In trying to determine if a person is entitled to social security benefits, it can be helpful to know a little bit about how the Social Security Administration (“SSA”) and Administrative Law Judges (“ALJ’s”) working for SSA make decisions about any given claim. For purposes of this post, we will restrict our discussion to claims for Social Security Disability Insurance benefits, also known as Title II benefits, for adults.
The standard for disability is the inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment or combination of impairments that can be expected to result in death or that has lasted or can be expected to last for at least 12 consecutive months. That definition is a mouthful, to say the least, so to make their decision, SSA breaks it down into a sequence of smaller determinations. Before they can get to that process, SSA has to determine that a claimant is “insured” for purposes of SSDI benefits. Insured status depends on a person’s work history and when they became disabled. If a person is insured, federal regulation requires SSA to engage in a five-step sequential evaluation. (20 C.F.R. 404.1520 (a)).
Step 1: Substantial Gainful Activity.
At step one of the evaluation, SSA determines whether a person is currently engaging in substantial gainful activity. Generally, this means that SSA wants to know if a person is still working – whether they are doing something that involves significant physical or mental activities and whether it is the type of activity normally done for pay or profit. If someone is working and earning a certain amount each month, SSA will consider them to not be disabled, regardless of any disability. In other words, a person who might otherwise be disabled will not be able to receive benefits while they are currently engaging in substantial work. (20 C.F.R. 404.1520 (b)).
Step 2: “Severe” Medically Determinable Impairment
At step two, SSA determines whether a person has a “severe” impairment or combination of impairments. Impairments are “severe” if they significantly limit a person’s ability to perform basic work activities. In almost every case, they are “medically determinable” if a doctor has diagnosed someone as having that impairment. In practice, any impairment is “severe” if it imposes any more than a minor limitation in someone’s ability to work. SSA considers all impairments, including symptoms like pain or fatigue, in determining whether a condition is “severe.” (20 C.F.R. 404.1520 (c)).
Step two is also where SSA figures out whether an impairment meets the durational requirements – whether it has lasted or is expected to last for more than 12 months, or is expected to result in death. In other words, even if a condition is debilitating, but it has not and is not expected to last more than a year, or result in death, it does not meet the standard for disability. (20 C.F.R. 404.1521).
Step 3: The Listings
Step three is where SSA determines whether a claimant meets any of the “Listings.” The Listings are descriptions of certain conditions and the impairments they cause. They are contained in yet another regulation – 20 C.F.R. Part 404, Subpart P, Appendix 1. They can be long or short, and some incorporate findings of certain tests. For example, here is the listing for “Loss of Visual Efficiency”:
2.04 Loss of visual efficiency.Visual efficiency of the better eye of 20 percent or less after best correction.
If an impairment or combination of impairment meets a Listing, a claimant should be found disabled and benefits awarded. What it means to “meet” or “medically equal” an impairment can be very complicated, particularly when the Listing gets more involved, and it may be helpful to talk to an attorney about whether your condition might meet a listing or what kind of evidence should be gathered to make that case. If someone does not meet a listing, that does not mean that benefits should be denied. It merely means that SSA or the ALJ has to proceed to steps four and five.
Step 4: Past Relevant Work
Most social security cases, at whatever level, are won or lost at steps four and five of the process. Step four is where SSA determines whether someone can do the work they used to do – their “past relevant work.” Before that, SSA tries to find out that person’s ability to do work, considering their impairments – their “residual functional capacity.” If, as a result of their impairments, a person is no longer able to do the work they used to do, the process proceeds to step five. If, however, SSA or the ALJ finds that someone is still able to do their old work, they will find that the person is not entitled to benefits. (20 C.F.R. 404.1520(f)).
Step 5: Any other work
Finally, if someone is found to not be able to do their past relevant work, SSA or the ALJ must determine whether they can do any other work in the national economy, considering that person’s age, educational background, work experience and, of course, impairments. To make this determination, ALJ’s may consult with vocational experts. During a social security hearing, a claimant has the opportunity to cross-examine the vocational expert, and an attorney can assist you. If, however, a person makes it all the way to step five in the analysis and SSA or the ALJ finds that they are not able to engage in other work as a result of their impairments, that person is entitled to benefits, possibly including back benefits. (20 C.F.R. 404.1520 (g)).
There are many rules and nuances that apply to each of these steps. If you have applied or are considering applying for social security benefits, you should consult with an attorney.