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[IP] Info about Social Security Disability Process

Hi all,
This is long, but is some good, basic, understandable info for those who
have not dealt with SSA and its disability claim process.  At the bottom,
are some comments-ok, necessary disclaimer: NOT legal advice/information-
based on years of experience dealing with the SSA (professionally and

 Marj; Mike; and "Ace, the PP" (portable pancreas)

(exerpt from http://www.lad.org/TPJ/10/socsec.html )

"The Social Security Disability Process
Recent Changes and What the Future
Holds with the Re-engineering of Government

Social Security Disability, SSI and the Manner in Which Disability
Evaluations Are Processed
Congress has defined disability under both the Social Security Disability
Insurance (SSDI) and Supplemental Security Income (SSI) programs as 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 twelve months."1 The Social Security Act
further provides that an individual shall be determined to be under a
disability only if his or her physical or mental impairment or impairments
are of such severity that the individual is not only unable to do his or her
previous work but cannot, considering age, education, and work experience,
engage in any other kind of substantial gainful work which exists in the
national economy, regardless of whether such work exists in the immediate
area in which the claimant lives, or whether a specific job vacancy exists,
or whether the claimant would be hired if applied for work.2
The Social Security Administration has developed a five-step "sequential
evaluation process" for evaluating disability claims under this statutory
standard.3 The first step determines whether a claimant is engaged in
"substantial gainful activity" (SGA).4 If engaged in SGA, the claim is
denied.5 If not engaged in SGA, the second step in the sequence is a
determination of whether the claimant has a medically severe impairment.6 If
the claimant does not have an impairment or combination of impairments that
exceeds this medical-severity threshold, the claim is denied.7 If the
claimant does have a medically severe condition, the evaluation proceeds to
the third step to determine whether the claimant has an impairment that
meets, or is equivalent in severity to8 one of the presumptively disabling
medical conditions defined in the SSA's "Listing of Impairments."[NB
amputation of a limb due to diabetic complications is one of these]9 A
claimant who has a condition in this catalog or list of impairments "is
conclusively presumed to be disabled and entitled to benefits."10 If the
claimant does not have such an impairment, the evaluation proceeds to the
fourth step to determine whether the impairment prevents the claimant from
performing past relevant work.11 Past relevant work denotes work that
amounted to SGA that lasted long enough for the claimant to learn it, and
that was performed in the last 15 years.12 If former work can be performed,
the claim is denied.13 If former work cannot be performed, the fifth and
final step of the sequence is a determination of whether the claimant can
perform other work, taking into consideration age, education, and prior work
At the fifth step of the process, if the claimant is unable to perform other
work, the claimant will be found eligible for benefits.15 Under settled
precedent in all twelve courts of appeals, the claimant has the burden of
proof in the first four steps of this process.16 Upon the claimant's proof
of inability to perform past relevant work, the burden shifts to the Social
Security Administration to demonstrate the availability of other work that
exists in substantial numbers in the national economy. The agency meets its
burden of proof at step five of the sequence in one of two ways. One way is
through the testimony of a vocational expert on specific jobs available in
the economy that are within the claimant's capabilities. However, the Social
Security Administration has developed medical-vocational guidelines that
"relieve the Secretary of the need to rely on vocational experts" and
authorize administrative notice of the availability of other work for
claimants with certain medical-vocational profiles. Because parts are
displayable as a simple chart or tables, the medical-vocational guidelines
are commonly called 'the grid'. The Supreme Court has upheld the grid's
The disability application process begins with the filing of an application
for SSDI or SSI at one of the SSA's district offices (DO).17 The file is
then sent to a state Disability Determination Service (DDS) under contract
to the SSA to make the disability determination.18 The DDS obtains available
medical evidence from the claimant/s hospital records and treating
physicians19 and sometimes orders a consultative evaluation by a private
physician. A DDS medical consultant and disability examiner jointly make the
disability decision.
If the DDS denies the claim, the claimant may pursue a "three-stage
administrative review process."20 First, the application is reviewed de novo
by the DDS in a process known as "reconsideration."21 Second, if the
reconsideration is denied, the claimant is then entitled to a hearing before
an Administrative Law Judge (ALJ) of the SSA's Office of Hearings and
Appeals (OHA).22 Third, if the ALJ's decision is unfavorable, the claimant
may seek review by the Appeals Council (AC) of the OHA.23 If the AC denies
the request for review, the claimant may then seek judicial review in
federal district court.24
The statutory standard of federal court review of SSA disability decisions
is the "substantial evidence" standard.25"

***With Social Security Disability, it's not just the diagnoses that count,
but how the conditions/illnesses interfer with you doing SSA's definition of
"substantial, gainful employment" (SGA) for at least a continuous12-month
period or (morbid) with the expectation of death.  ***Also, there are
specific criteria as to quarters of coverage needed for SSDI based on your
age at the time you apply unless you're only applying for SSI as a disabled
person. SSI uses income/assets standards (benefit levels may be enhanced by
states).   ***In some states, you apply for SSI at the SSA office, in others
you apply at a DSS or Human Resource Agency office.  Either way, an SSI
disability application gets reviewed under the same disability standards as
a Social Security Disability Insurance-SSDI-application, and a check will be
made to see if you might qualify for SSDI.

There is a waiting period even if SSA finds you eligible for SSDI (benefits
start in the 6th month from the date that you're found diabled; if you are
found to have been disabled more than 6 months from the date of approval
then benefits begin immediately; Medicare eligibility is after 2 years
unless you require dialysis).  Some former co-workers now are saying it
appears SSA may be utilizing the ADA (Americans with Disabilities Act) to
show how employers could do modifications for people to work.  Also, SSA may
require you to be seen by one or more of their doctors (can be located hours
from where you live so you may have to fight this as a hardship with need to
be seen by a doctor closer to home) who may have no training or true
knowledge of the conditions you have, but more or less will eye you over and
ask for you to do some mundane stuff.

If approved under SSA disability standards, you will be asked about
accepting vocational training.  This can become a gray area if you decline
unless your declination is supported by medical evidence.  There also are
requirements which may require periodic reviews of your disability status
both for SSDI and SSI as well as annual review to show you continue to meet
SSI income/assets standards.   Your opinion is sought as to whether the
diability is better, same, worse, and you will need to supply names of any
doctors you've seen, clinic visits, hospitalizations, since the diabled
finding or last review.   At least this process became easier a few years

As noted, even though it may be felt that you can't do your current or
former work, Social Security could state that you should be able to do some
sort of other position (they having a myriad of job title listings).  It
could be an unusal job title and any job in this title could be located
hundreds of miles away (my favorite: man lost both hands, couldn't do his
old construction job, Social Security told him he could load foam rubber
into a machine since he didn't need hands to "pick" it up though  "plants"
doing this were hundreds of miles away).  It also doesn't matter whether any
employer with this job title would hire you or whether it would provide you
with a commesurate income level compared to other jobs you've had.

The first and best resource is a doctor/doctors who are willing to put in
writing why you can't work (preferably showing this in your medical record
with notations such as "[your name] continues to be unable to hold
employment because [reason]), and be willing to complete thoroughly any
forms required by SSA-can often do this by dictating info in a call to a tel
number SSA provides to the doctor.  SSA will contact MD's, hospitals, etc,
for info so it's important that the info show abnormal results/problems
which would have a negative impact on someone working as defined by the SSA

Also, when you do the forms for SSDI, make sure you are specific as to why
you believe you can't work.  A very simple example:
    stress of [specific tasks] would cause blood sugar to become erratic so
that: hyperglycemia with concern for DKA was         happening which
required more frequent blood/urine testing, adjustment of treatment,
hypoglycemic episodes occurring         [any MD/EMT/ERvisits or especially
hospitalizations for DKA/hypoglycemia are important], more frequent doctor
visits,         days missed from work, inability to do assigned job duties
[formal employer job description could be important], negative     changes
in  medical problem(s)/diagnosis of [new problem(s)], how you were/are
unable to perform normal household             duties, and if true that your
MD(s) told you to stop working making sure you can provide documentation of
this or MD(s)     willing to put into writing that he/she verbally told this
if it's not written in your medical records!!!).
SSA has a phrase that gets bantered around: "end organ damage" meaning
demonstrable, negative, physiological changes.
Remember, parttime work, or even a lot of involvement with a hobby that
could produce decent income might be considered evidence of the ability to
do SGA for SSA purposes.

You have to give you education history.  You will have an opportunity to
define in detail what job duties you have/had with any training received. Of
particular import: any lifting, weird hours, unusal job tasks, etc.
Although they primarily look at your last 15 years work experience, they
will want to know any job you've had since you started to work since this
could give a clue to other training/job skills.  They also want to know what
you do around the house, hobbies, how you spend your day.....

If you are working at the point you're considering SSDI you will be denied
unless you can prove that you were given medical advice to have stopped
working many months/years before (see below).   Check out whether you could
be eligible to apply for an employer's disability pension plan/state
disability plan.  SSA initially will deny applications made while someone
still works unless there's been a "crisis" situation.  For a basic example:
severe Diabetic Retinopathy with almost total vision loss which is not
expected to resolve with adequate return of vision (again, that 12 month
period)to do job tasks, and where the person is/has used sick leave /non-pay
status benefits to meet the waiting period or you can show MD record
documentation that MD or MD's told you not to work with reasons spelled out,
beginning many months before your application .  Little known info is that
if you do work after being told not to, can provide proof of being told not
to work with why, and your health status declines (again, need long and good
documentation of this), then your employment shouldn't be held against you,
but instead could be evidence of the inability to do substantial, gainful
Should SSA find initially that you are not disabled under the SSA standards,
there is an appeals process (Kathy B.can attest to this) which can be
lengthy.  Sometimes it can seem quite arbitrary how SSA sets the date of
disability onset.
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