The two programs administered by SSA -- Social Security disability (SSD) and Supplemental Security Income (SSI) -- have the same medical disability qualifications. Any person who files for disability must go through the same medical disability process to be found medically disabled for disability benefits.
In fact, disability examiners who make decisions on disability applications and reconsideration appeals make no distinctions between the two programs. The only time the two programs are considered separately is when an individual initially files their claim and the Social Security field office CR (claims representative) must determine whether they might qualify for SSD benefits based on work credits, or qualify for SSI disability based on need.
The medical disability evaluation process involves an application for disability benefits. During the application interview, Social Security claims representatives gather information about medical treatment sources, treatment dates, medications, testing, etc. They also get information about the types of work a person has had in the last fifteen years, which is what SSA refers to as the relevant work period.
How is a disability claim worked on?
After a disability application is taken at a Social Security field office, it is transferred to the DDS agency in that state. Immediately, the case is assigned to a disability examiner. Just as immediately, the examiner will begin to send out requests for the claimant's medical records.
The wait for these records constitutes the single largest delay on a case. However, once the records arrive--usually, this takes weeks or even months for all the records to come in--the examiner will be in a position to evaluate the fundamentals of the case.
Note: when a case is particularly strong, the examiner may not have to wait for all the records. The decision may be made with just some of the records if they do support a finding of disabled. This is also where a disability representative may provide some early benefit on a case by doing pre-hearing case development and attempting to win the claim without the need for a hearing and all the extra months of waiting which that entails for the claimant.
Looking at the records, the examiner will be able to determine if the claimant has a condition that is listed in the impairment listings and whether or not they meet the listing criteria. As we noted, this is usually not the case. The examiner will then review the records to get an idea of what the claimant's residual functional capacity is, i.e. what they can still do despite their impairment.
This is for the purpose of determining if the claimant may be approved on the basis of what is known as a medical vocational allowance. Essentially, a claimant is approved this way when the final determination is that they cannot be expected to return to work due to the severity of their condition(s) and the limitations that are caused by it.
Just to restate: the Social Security disability process requires that a person’s medical or mental conditions prevent them from performing any of their past jobs or any other kind of job they might be qualified to do considering their job skills, education, age, and functional limitations. If a person is prevented from doing any kind of substantial work activity, it is likely they will be medically approved for disability benefits.
However, there is more to Social Security disability benefit eligibility than a medical approval. Disability applicants must meet the non-medical requirements of one or both disability programs before their disability claim may be sent to a disability examiner (examiners make decisions on disability applications) for a medical determination.
Coverage for an SSD Claim
Every Social Security disability claim is based upon an insured status. Social Security disability is actually an insurance program that an individual’s earnings establish insured status for through their payroll deductions. Internal Revenue reported wages create an individual’s Social Security earnings record and each year an individual may earn as many as four quarters of coverage. These quarters of coverage, or work credits, determine if they are insured for Social Security disability benefits.
There are a few advantages to being insured for Social Security disability benefits. Sometimes, there are additional benefits payable for an individual’s children or spouses should they be approved for disability benefits. Additionally, most Social Security disability beneficiaries receive higher monthly disability benefits. If a Social Security disability beneficiary has a very low monthly disability benefit, it is possible that they may be entitled to both SSD and SSI. However, the amount they will receive will be no more than the SSI disability monthly earnings limit.
Coverage for an SSI Claim
If an individual does not have a sufficient amount of quarters of coverage to be insured for Social Security disability, they may still meet the requirements of the Supplemental Security Income disability program. SSI is a disability program designed to help individuals who have not worked, have not worked much, or who have worked too far in the past to be insured for Social Security disability. The SSI disability program has a program for disabled children as well (All disability claims for minor-age disabled children are taken through SSI).
SSI Eligibility requirements for SSI disability involve resource ("resource" is a term for assets that affect SSI) and income limits. In this way, SSI is like many other social help programs.
Claims representatives evaluate for SSI eligibility when they conduct their disability interviews. Resources for the purposes of an SSI eligibility determination might include but are not limited to vehicles, boats, motorcycles, pensions, bank accounts, stocks, bonds, 401Ks, land, homes, heir property, jewelry, or any other items that can be easily converted to cash.
Income for the purposes of being SSI eligible might include wages, unemployment benefits, workman’s compensation benefits, VA benefits, etc. Currently, Social Security allows an individual to have $2000.00 in resources and couples are allowed to have $3000.00 in resources. They exclude the home and land an individual or couple uses as a residence and the most expensive vehicle owned from this limit.
Income limits are not so concrete because they are variable to the number of children in the household. When an individual completes their interview, the claims representative will evaluate their household composition and determine if they are under the income limits for the SSI disability program.
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The national denial rate is quite high at 65%, one big reason for this is that many people do not get representation until they have been denied.
Many lawyers are partly to blame for this since it is very common for someone looking for a lawyer at application level for their SSDI or SSI claim to be told to "apply and call back when you are denied". Some lawyers(not all) do this because an attorney's fee is based on past due benefits and if the lawyer wins a case at application they feel the fee does not cover the work involved in handling a case at this level.
This approach should be avoided because it is very important that the case be handled properly from the beginning, not only to assure you have the best chance to win at application, but also to ensure that an application that was not properly done does not come back to haunt you at a later stage in the process. Approval rates are much higher at the initial application level.
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