The Social Security Administration (SSA) administers two programs that provide disability benefits for adults and children unable to work. The first program, Social Security Disability Insurance (SSDI), is like an insurance program that claimants may apply for if they have paid their Social Security taxes over time from paid work. If a claimant is eligible to apply for SSDI and is ruled disabled by the SSA, the amount of his or her monthly benefit is based upon their earnings record.
Claimants who are not eligible to apply for SSDI may be eligible to apply for the second program, Supplemental Security Income (SSI), which is payable to people with disabilities that keep them from working and who have limited income and resources.
Currently, the adjudicative process for both programs includes an initial decision after a written application is submitted by the claimant, a secondary reconsideration decision if the claimant protests an initial denial, and then a hearing - if requested by the claimant after a reconsideration denial - before an administrative law judge. The administrative law judges are part of an agency called the Office of Hearings and Appeals, which is separate and apart from the SSA.
People applying for either program wait a long time to have their claims adjudicated. It takes 18 to 24 months for a claimant to go through the administrative process and get a hearing before a judge. Should the administrative law judge deny the claim, the claimant may file a written appeal of the decision to an Appeals Council. Wait times for decisions from the Appeals Council vary wildly, from three months to two years.
Once the administrative process is exhausted, a claimant may appeal a denial to the federal court system via the U.S. District Court based upon the record made below.
If the claim is allowed, the SSA imposes a five-month waiting period for benefits from the date the claimant's disability begins. The SSA will only pay benefits back to one year before the date of application in SSDI cases and only from the date of application in SSI cases. In addition to monetary benefits, claimants are entitled to Medicare benefits if found disabled under SSDI or Medicaid benefits if found disabled under the SSI program.
Social Security pays only for total disability. The definition of disability under either program is the inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months.
To determine whether a person is disabled, the SSA has established a five-step, sequential evaluation. The first step is simply to determine whether the claimant is engaging in substantial gainful activity - that is, generally speaking, regular work for pay. If the claimant "worked" during any period in which he or she claims disability, benefits will not be provided.
If the claimant is not engaging in substantial gainful activity, under the second step the claimant must prove that he or she has a "severe" impairment or combination of impairments. An impairment is "severe" within the meaning of the Federal Code of Regulations if it imposes significant restrictions in the ability to perform basic work activities. An impairment can be physical or mental. As a practical matter, if the impairment imposes greater-than-minor restrictions on basic work activities, it will be considered "severe."
If the claimant has a "severe" impairment, the third step is to determine whether the impairment meets or medically equals the impairments, and elements therein, found in a set of medical criteria in an appendix to the applicable Federal Code of Regulations, entitled The Listing of Impairments.1 The elements to the listed impairments are precise and it is often difficult to prove that a claimant's impairment meets or equals a listed impairment. On the other hand, if it is proved that the impairment meets or equals a listing, the analysis stops and the claimant is found medically disabled.
If the claimant's impairment does not meet or equal a listing, the analysis moves to step four, at which point the claimant must show that he or she is incapable of doing any work that he or she performed in the 15 years preceding the date of the onset of disability. This specific work history is called a claimant's past relevant work.
If the claimant establishes that he or she cannot return to any past relevant work, the burden shifts to the SSA to establish that the claimant may make an adjustment to other work that exists in significant numbers in the national economy based upon the claimant's remaining ability to perform basic work activities, and his or her age, education and work skills. If it is not established that the claimant can successfully adjust to other work, the claimant qualifies for benefits.
Evidence at the administrative levels are received in the form of medical chart notes and tests, written reports, work histories, earnings histories and written lay testimony. At the hearing, the claimant may testify in person before the administrative law judge, along with other lay or expert witnesses. The administrative law judge may call expert medical or vocational witnesses to provide opinions on the record about medical impairments, work skills and potential work that exists given a claimant's impairments.
Attorney fees are strictly regulated by the federal government. An attorney may litigate a Social Security claim at the administrative level on contingency. Fees are limited to $5,300 or 25 percent of the claimant's back benefits, whichever is less.
1 20 C.F.R. Part 404, Subpart P, Appendix 1.
