Are you, like 70% of those who apply, wondering why Social Security denied your claim for disability? How do they determine if you are disabled? They don’t know you. Well, Social Security has a definite system for determining disability under their rules. This last part is key. You may have been found disabled by the state, by your doctor, and even the DMV, but that doesn’t mean that you will pass the Social Security Disability 5-Step Sequential Determination Process.
I am not on Social Security disability, but I worked seven years for a Social Security Disability attorney, three of which were spent as the department trainer, and I have helped hundreds of people obtain their disability benefits. Before Social Security will decide if you are medically disabled under their rules, Social Security will determine if you are technically eligible. To learn more about technical eligibility, click here: Technical Eligibility.
This article is not to serve as any kind of advice, but just to provide a layperson’s example of how Social Security determines disability. I will do my best to answer any questions for you, but if you need an attorney, please contact the National Organization of Social Security Claimants’ Representatives (NOSSCR) to find an attorney to help you. https://www.nosscr.org/
Definition of Disability
Social Security has a very specific definition of what they consider to be a disability: “the inability to do 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.” (https://www.ssa.gov/OP_Home/cfr20/404/404-1505.htm) There are three parts to this definition:
- Vocational: the inability to do any substantial gainful activity
- Medical: by reason of any medically determinable physical or mental impairment
- Durational: 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
They determine if you meet this definition by going through a sequential 5-step process.
Step 1 is where Social Security looks at Substantial Gainful Activity (SGA). They put a price on SGA — for 2018 the amount is $1180/month. This means that if you go to work and earn $1180 or more a month (gross, before taxes are deducted) then you are automatically determined to not be disabled under their rules.
You can have any amount of unearned income (unless you are applying for SSI), but you can not exceed the $1180 earned for 2018. The amount goes up a little every year, but it is not really enough to live off, just enough to be found not disabled. I agree that this is unfair, but write to your congressperson.
This is just the beginning of the vocational determination. You cannot be approved at step 1, but you can be denied.
Step 2 is where Social Security starts to look at your medical conditions. Step 2 determines if your impairment or combination of impairments is “severe.” There are two parts to this determination:
- Is your condition expected to end in death, has it lasted 12 consecutive months, or is it expected to last 12 consecutive months?
- Do you have a diagnosis from an M.D. or a D.O.?
The important part about number 1 is that if your condition is not expected to end in death, that it has to have lasted or be expected to last a continuous period of 12 months. You can’t break one leg and then six months later break the other leg and expect to be found disabled (most likely). Chances are that the first leg will heal, and then the first injury will not have lasted a consecutive 12 months.
The important thing about number 2 is that you must have a medical doctor establish the condition. Later in steps 3 through 5, they will look at all of your medical records to determine how severe your impairment or combination of impairments is, but in order for it to be considered medically determinable, they need a doctor to sign off, someone who is licensed and has gone to medical school — an M.D. or a D.O. They will look at other types of doctors for certain conditions, such as an O.D. for vision problems, but they will not accept a therapist’s recommendation that you have depression. Go see a psychiatrist.
You cannot be approved at step 2, but you can be denied.
Step 3 is the first step at which you can be approved. At step 3 Social Security determines if your impairment or combination of impairments is severe enough to meet one of their listings of impairments: https://www.ssa.gov/disability/professionals/bluebook/AdultListings.htm.
To meet a listing, you have to be pretty sick. For example, if you have ESRD and are on either peritoneal dialysis or hemodialysis, then you automatically win under listing 6.03: Chronic Kidney disease with chronic hemodialysis or peritoneal dialysis. Listing 6.03
Your dialysis clinic will complete form CMS-2728-U3 and fax it to the Social Security Administration, and Social Security will find you disabled as of the date that you started dialysis. If you want to be found disabled before the date that dialysis started (it will still take 5 months to payments to begin under SSDI), then you may have to go to steps 4 and 5.
You can be approved at step 3, but you cannot be denied.
Between step 3 and step 4, Social Security does what is called a determination of your residual functional capacity (RFC). This is basically what can you still do, now that you have these severe impairments. There are 5 basic levels of RFC.
- Heavy: you can do jobs like a construction worker or other heavy labor intensive jobs.
- Medium: you can do some lifting, but mostly you are just on your feet all day long. Most nursing jobs fall under medium.
- Light: you can be on your feet most of the day, but you don’t have to do much lifting. Most teaching jobs are considered light work.
- Sedentary: you can sit at a desk all day long. These jobs mostly involve using computers and phones.
- Less than Sedentary: this isn’t an official level of RFC, but it is where you want to be to win your disability case. Most people who are limited to sedentary work but have difficulty using their hands because of carpal tunnel or arthritis fall under this category. Once again, Social Security looks at a combination of impairments to decide if you meet their rules for disability.
The above categories are what are known as exertional limitations, but there are also non-exertional limitations which can take you down to the less than sedentary level. Non-exertional limitations include carpal tunnel, arthritis, depression, anxiety, asthma, and a host of others.
You can be neither approved nor denied at the RFC determination. The RFC is used to determine vocational factors in steps 4 and 5.
Step 4 is where Social Security looks to see if you can perform any of the jobs you had during the last 15 years that were over the SGA level and that you worked at long enough to become proficient at them. This can also included work that you did that was not for profit, but that if you were payed for it, you could have earned over the SGA amount for that month.
Step 4 is relatively easy to get over. The majority of people that leave their jobs due to a disability do so just because they can no longer perform that kind of work now they they have a mental or physical impairment. There are a rare few that don’t want to go back to an old job, but according to Social Security, if your medical records say that you are healthy enough to do an old job from the last 15 years, then you are not disabled under their rules.
My advice is that if you can work, you should continue to work, as the amount that you will receive from Social Security is not a lot anyway. I would love to just be able to sit at home and write all day long, but I checked, and I would only receive around $1300 a month if I claimed disability today. Many people receive much less, and the maximum you can receive is around $2500 per month, and that is only if you have been earning about $120,000 a year before you became disabled and you were paying full Social Security taxes.
You cannot be approved at step 4, but you can be denied.
In the final step of the sequential disability evaluation process, Social Security looks to see, based on your RFC, if you can perform any other work in the national economy. Social Security has matrices of different RFC levels to determine whether you are approved or denied based on your age, education, and prior work experience; however, most people fall in between two of the RFC levels, and they also don’t account for non-exertional impairments, so these matrices (or grids) are rarely used.
This is the hardest step to overcome, and it is the only step where you can be either approved or denied. If you have been denied by Social Security for Disability benefits, there is a good chance this is the reason why.
This article was not meant to be exhaustive, as there is much more to talk about in each of these 5 steps. This article was simply meant to be a (very) brief overview of the Social Security 5-Step Sequential Disability Evaluation Process.
Please leave me any questions you have in the comments below, and I will do my best to research and answer them. If you have been denied once or twice, you still have a good chance of winning your case. I will discuss the lengthy appeals process in another article, but your best bet would be to obtain an attorney who specialized in Social Security Disability.
One additional note: I am not sponsored by any Social Security attorneys. I just know a lot, and I know how confusing the process can be for claimants (people like you). It is my hope to share some of my knowledge and do some good for someone in the world.