Guidelines used to determination of SSA disability.
 

Under the authority of the Social Security Act, the SSA has established a five-step sequential evaluation process for determining whether an individual is disabled (20 CFR 404.1520(a). The steps are followed in order. If it is determined that the claimant is or not disabled at a step of the evaluation process, the evaluation will not go on to the next step.

At step one, the undersigned must determine whether the claimant is engaging in substantial gainful activity ( 20 CFR 404.1520 (b). Substantial gainful activity (SGA) is defined as work activity that is both substantial and gainful. "Substantial work activity" is work activity that involves doing significant physical or mental activities (20 CFR 404.1572 (a). " Gainful work activity" is work that is usually done for pay or profit, whether or not a profit is realized ( 20 CFR 404.1572(b)). Generally, if an individual has earnings from employment or self- employment above a specific level set out in the regulations, it is presumed that she has demonstrated the ability to engage in SGA (20 CFR 404.1574 and 404.1575). If an individual engages in SGA, she is not disabled regardless of how severe her physical or mental
impairments are and regardless of her age, education and work experience. If the individual is not engaging in SGA, the analysis proceeds to the second step.

At step two, the undersigned must determine whether the claimant has medically determinable impairment that is" (20 CFR) 404.1520 (c). An impairment or combination of impairments is "severe" within the meaning of the regulations if it significantly limits an individual's ability to perform basic work activities. An impairment or combination of impairments is " not severe" when medical and other evidence establish only a slight abnormality or a combination of slight abnormalities that would have no more than a minimal effect on an individual's ability to work (20 CFR 404.1521; Social Security Rulings ( SSRs) 85-28, 96-3p, and 96-4p). If the claimant does not have a severe medically determinable impairment or combination of impairment or combination of impairments, she is not disabled. If the claimant has a severe impairment or combination of impairments, the analysis proceeds to the third step.

At step three, the undersign must determine whether the claimant's impairment or combination of impairments meets or medically equals the criteria of an impairment listed in 20 CFR Part 404, Subpart P, Appendix 1 (20 CFR 404.1520 (d), 404.1525, and 404,1526). If the claimant's impairment or combination of impairments meets or medically equals the criteria of a listing and meets the duration requirement ( 20 CFR 404.1509). the claimant is disabled. If it does not, the analysis proceeds to the next step.

Before considering step four of the sequential evaluation process, the undersigned must first determine the claimant's residual functional capacity (20 CFR 404.1520 (e)). An individual's residual functional capacity is her ability to do physical and mental work activities on a sustained basis despite limitations from her impairments, In making this finding, the undersign must consider all the claimant's impairments, including impairments that are not severe ( 20 CFR 404.1520(e) and 404.1545; SSR 96-9p).

Next, the undersign must determine at step four whether the claimant has the residual functional capacity to perform the requirements of her past relevant work ( 20 CFR 404.1520 (f) The term past relevant work means work performed (either as the claimant actually performed it or as it is generally performed in the national economy) either as the claimant actually performed it or as it is generally performed in the national economy) within the last 15 years or 15 years prior to the date that disability must be established. In addition, the work must have lasted long enough for the claimant to learn to do the job and been SGA ( 20 CFR 404.1560(b) and 404.1565). If the claimant has the residual functional capacity to do her past relevant work or does not have any past relevant work, the analysis proceeds to the fifth and last step.

At the last step of the sequential evaluation process ( 20 CFR 404. 520 (g)), the undersigned must determine whether the claimant is able to do any other work considering her residual functional capacity, age, education, and work experience. If the claimant is able to do other work, she is not disabled. Although the claimant generally continues to have the burden of proving disability at this step, a limited burden of going forward with the evidence shifts to the Social Security Administration. In order to support a finding that an individual is not disabled at this step, the Social Security Administration is responsible for providing evidence that demonstrates that other work exists in significant numbers in the national economy that the claimant can do, given the residual functional capacity, age, education, and work experience ( 20 CFR 404.1512 (g) and 404.1560 (c)).

Please go to www.socialsecurity.gov to look up the sections and statutes. This is what the agency uses as guidelines. Hope it's not too long. If this has been posted before sorry.

To help a little more I have put the page up for 20 CFR 404.

http://search.ssa.gov/search?q=404&b...&proxyreload=1

If you find this to hard to understand let me know and I will try to explain it in a way you can understand it. This is very important though, and the reason why a lot of people get turned down.

Legalmania, I hope you don’t mind if I jump in. In my former life I was accused of sleeping with 24 CFR and the Federal Register under my pillow. It was my role to read and develop company (and occasionally industry-wide) policy, as it applied to changes to the CFR and other regulatory handbooks. That meant re-writing into language that could be understood by those who had to implement it. So, thought maybe I could make this a little easier to understand as well.

The five-step process starts with the Social Security (SSA) office. At Step One SSA determines if you are ‘technically’ eligible. If SSA determines you are technically eligible, your file will be forwarded to the Disability Determination Service (DDS) for your State. The DDS determines if you are “medically” eligible, by applying Steps Two through Five.

Step One – Substantial Gainful Activity (SGA): Are you participating in ‘Gainful’ work activity? If your earnings are below the SGA limit (for 2010 it is $1,000), you are not participating in ‘Gainful’ work activity. But are you participating in ‘Substantial’ work activity? If you are working and earning less than $1,000, the answer to this will generally be No. But if, for example, you are working for your friend 40-hours a week, but only getting paid $500/month, most likely your work activity will be considered ‘Substantial’. Also keep in mind this only applies to ‘earned’ income – money you get from working. It does not apply to ‘unearned’ income – money you get from sources like TANF (welfare), SSA for children, annuities, etc.

If you are earning less than $1,000 and are not participating in substantial work activity, your file will be sent to the DDS to determine medical eligibility. If you are participating in Substantial Gainful Activity, you will be denied at this step.

Step Two – Do you have an impairment (or combination of impairments) that ‘severely’ limits your ability to participate in Substantial Gainful Activity? At this step your medical records will be reviewed to determine if you have a physical or mental impairment that has been established by clinical findings, symptoms and/or laboratory tests - are you being treated by a doctor? And that impairment must limit your ability to function in a job. Your own statement of symptoms and inability to find work would not qualify as a severe impairment.

If you have a severe impairment, the DDS examiner will move on to Step Three. If the DDS examiner determines you do not have a severe impairment, you will be denied at this step.

Step Three – Is your impairment listed in the Blue Book, or does a combination of impairments meet the criteria of one of the impairments. And, is your condition expected to last longer than 12 months, or result in death. For example: It would probably surprise you to know that most cancers are not a listed impairment. But, the treatment can cause other symptoms, like neuropathy; or the medications may make it difficult to think, or shortness of breath may make it difficult to remain standing or walking, etc. The combination of those factors may meet the criteria for impairment. Before submitting your application, I would advise you read through the entire Blue Book, making note of every condition that applies to you. The combination of impairments may meet the criteria of impairment, where one impairment alone may not.

(Note: I have the Blue Book, other handbooks, and all required forms, in fillable/saveable format available on my blog at the link in my signature)

If the DDS examiner determines your impairment (or combination) meets the criteria established in the Blue Book, he/she will move on to Step Four. If not, you will be denied at this step.

Step Four – Can you do any jobs you did in the past 15 years? The purpose of Step Four is to determine if your impairment prevents you from performing any of the jobs you did during the past 15 years. When you receive the form ‘Adult Function Report (SSA-3373-BK)’ in the mail, you will know you are at Step Four. It is a 10-page form that asks you questions about how you function in daily living, and about your duties in your prior jobs. You will probably also get a Pain Questionnaire or Fatigue Questionnaire. Your answers will tell the examiner if you can do any past jobs with your current limitations. (This form is also available for download at my blog)

If the DDS examiner determines you are not able to do any past jobs, he/she will move on to the final step – Step Five. If, however, the examiner determines you are able of performing a job you did in the past 15 years, you will be denied at this step.

Step Five – The final step - Can you do any other jobs? Here the examiner will determine if you are capable of doing any job. Your age, education and past work experience factor into this decision. If you are under 50, the examiner will compare your abilities with jobs available in the national economy. If you were once a plumber, are you now capable of running a cash register at the local convenience store? If you are over 50, the examiner will use The Grid.

This is the final step. The examiner either determines you are unable to do any work, and you are approved. Or, the examiner determines you can run a cash register, and you are denied.

Good luck to anyone applying.

Thanks, I don't mind at all. I hope your weren't let go for sexual harassment of the Federal law books. I like to put it this way if you can't walk, sit or stand or can't remember for more than a hour ,get plenty of physical proof, also get mental proof as well. They like both physical and mental disabilities.

Appeal
 

Thanks for the information. My husband was diagnosed with syringomyelia in 07 and his symptoms have been progressively getting worse. He applied and was denied last year because the said he was still able to perform a job that he had 8 years ago as a master control operator for a TV station. He can no longer find a job like that, and in my opinion, couldn't perform that job if he had it. Anyway, he has a lawyer and appealed the decision, but we have been waiting for SSA to set a hearing date for almost a year. Any advice you could give would be greatly appreciated. Thanks

patience patience patience. It can take many more months of waiting for a hearing.

ALJ hearings
 

Oh Boy they can take a long time to come around.

My first SSDI hearing it took about 16 months. this time it has been almost 12 months so far. Still waiting. I live in alaska and i know each state is different. Alaska just opened a new Hearings office in anchorage in february. They are sopose to be able to run more people threw faster now.Sure hope so!

the whole process is way to long and when your sick you need help now!:eek:

Answers to your Questions.
 

I see a lot of questions being asked. You can get answers yourself right from the source. Go to http://www.socialsecurity.gov/SSA_Home.html, Click on questions up or down emblem. Then press go. There are a few topics to pick from. Here we want disability. This takes you to search by Keyword. Use the boolean system like children and disability or type in your question, then read. If you don't get the answer you want, use the search again. Some of the answers can get confusing, but basically it gives a simple answer.

Here is additional information on health care for the disabled.

http://www.socialsecurity.gov/presso...re-info-pr.htm

SSDI question
 

We have a question that we can't find any answers on SSA website. Since applied for SSDI can claimant receive EDD benefits under the Unemployment? Considering the fact that SSA takes from 4-8 months, to review the case and go through all the steps you described above, people have to have some sort of income to survive. What would you recommend?

Legalmania no longer actively posts here.

UE is a question of state law. Generally, your supposed to let your state UE officer know about your SSDI application. Most don't seem to feel there is a conflict, but some do.

More importantly, were you terminated due to health related reasons? Everyone needs very strong medical documentation, but those that apply after a general layoff might have an even tougher time getting approved right now, so make sure you have "all your ducks in a row."

the question was about SSA? would they care if you receive an UE benefits?
what if there was no termination involved? what if you left b/c simply couldn't handle the pain any more? and there is a WC case for that? and QME reports are supporting this?

Receiving concurrent WC and SSDI benefits is fine. Although, for many people it does not result in a large increase of monthly income. You're allowed to collect benifits from both, up to 80% of your gross income (they'll even go back a few years? Maybe even 5? if you had a decrease in income. I 'd have to look up the rule.) WC income is not taxed and at least in CA, has no COLA. SSDI is taxable, and has a slight COLA (cost of living adjustment) most years of 2-3% to keep up with inflation.

Again, different UE rules state different things and have different requirements. If you are required to actively be looking for work, someone at SS might question your honesty since with SSDI you're claiming to be unable to work.

Rules for WC and SSDI are very different. Is a QME report enough to prove qualification for SSDI? Highly unlikely. And all those reports WC generates by docs that have never met you to turn down meds and procedures? You'll have to provide overwhelming evidence for SS that you are unable to function at any job, making roughly $1000 per month.

I don't believe you can collect UE and WC at the same time.

If you live in CA, HI, NJ, NY or RI, they have short term disability insurance available, or if you have a private LTD insurance policy, than you should apply for that ASAP. Than you can apply for SSDI as well.

Thank you so much for all those details. You actually touched a little bit on everything. Unfortunately, there was no payments from WC, and QME reports are made only after the doctor's evaluation, and those are in person, at least once a year, for last 3+ years.
SSDI only allowed to apply after 12+ months of disability .So SDI exhausted.
And the concern was regarding the UI benefits, you mentioned about that.
However, the question is still open, how one can survive once Disabled (unable to engage in any gainful activities), SDI already exhausted, and no other source of income, or medical insurance???? How you can get a doctor to write a report, if no insurance available?
Do you know if SSDI has any programs that would allow that transition?

There is currently a bill introduced in Congress about passing legislation that makes it impossible to qualify for SSDI and UI in the same months. http://beta.congress.gov/bill/113th-...ouse-bill/1502

There are ALJ's that will not approve applicants for months that they are receiving UI. The ALJ may decide that you are not credible when you tell one government agency you are ready, willing and able to work and tell another government agency that you are unable to engage in substantial gainful activity because of a disability. But that is not yet law.

So, the answer about SSA is either not yet or depends. Pretty darn vague, I know.

If you read the Catch 22 sticky at the top of the forum, you'll get my long winded version of the economics issues. I'm a big proponent of LTD insurance now! Living paycheck to paycheck is very dangerous...

Approval can take YEARS.

If you have no income and few assets, you'll likely qualify for Medicaid.

You're claiming a WC injury, and yet you've never received TTD benefits? Are you expecting to receive a Permanent Disability Rating? Do you have a WC attorney?

SS doesn't give more weight to a QME report than your WC Primary Treating Physician. Are you receiving ongoing medical care? (I see my PCP at least 1x per month.)

VI've read elsewhere that the language of state's UE laws make a big difference. So, it can also potentially be a regional answer.

Thanks for keeping us updated!

Edit to clarify: So a person can currently go over 80% of gross by collecting UE and SSDI? And they can continue to collect UE after being approved for SSDI (not just backpay?) Ty!

The 80% rule applies to worker's comp and/or public disability benefits offset, not unemployment benefits. But that could change with new legislation which always takes a long time.