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Am I eligible for social security benefits based on my disability?

In order to be found disabled under Social Security rules, your disability must be expected to last at least 12 months.  You must also be found disabled under a five-step analysis that Social Security applies to disability applicants. You may only be found disabled at steps 3 or 5.

Step 2: Severe Impairment

Step 3: The Listings

Step 4: Past Relevant Work

Step 5: The Grids

I have applied for benefits but have been denied.  Can I appeal the decision?

Step 1: Substantial Gainful Activity (SGA)

Step 1 asks if you are engaged in substantial gainful activity.  If yes, you are not disabled.  If no, go to step 2. 

What is substantial gainful activity (SGA)?

SGA: Involves significant and productive physical or mental duties and is done (or intended) for pay or profit.  20 CFR § 404.1510. Basically, if someone can work and earn a certain amount of money, then that person is no longer disabled.

With SSI benefits, any amount of money earned is going to affect the amount of benefits as well. SGA amounts increase with increases in the national average wage index.

SGA Amounts: A person who is earning more than a certain monthly amount is ordinarily considered to be engaging in SGA.  The monthly SGA amount for 2012 is $1,010 (net). (If you receive benefits because you are blind, the SGA amount is $1,690.)

At the same time, the SSA does not want to prohibit disabled people from attempting to return to work.

Trial work period:  After a person becomes eligible for disability benefits, the person may attempt to return to the work force. As an incentive, the SSA provide a trial work period in which a beneficiary may have earnings and still collect benefits.  A person may work for 9 months (in a 5 year period) and still be considered disabled.  Once the person earns over $720 (in 2012) the trial work period is triggered.

Step 2: Severe Impairment

Step 2 asks if you have a severe medically determinable impairment.  If no, you are not disabled.  If yes, go to step 3. 

When is an impairment severe?

To meet this definition, you must have a severe impairment(s) that makes you unable to do your past relevant work or any other substantial gainful work that exists in the national economy.

Severe:  If you do not have any impairment or combination of impairments which significantly limits your physical or mental ability to do basic work activities, the SSA will find that you do not have a severe impairment and are, therefore, not disabled. The SSA will not consider your age, education, and work experience.   Although that information will be relevant at a later step. However, it is possible for you to have a period of disability for a time in the past even though you do not now have a severe impairment.

Step 3: The Listings

Step 3 asks if your impairment(s) meet or equal a listing. If you meet a listing, you are disabled. If not, go to step 4.

What are the listings of impairments?

You can find the listing of impairments in the Appendix 1 to Subpart P of  20 CFR 404. The lisitings define impairments considered severe enough to prevent an individual from doing any gainful activity. The Part A listings contain medical criteria that apply to the evaluation of impairments in adults age 18 and over. Part B defines impairments and required medical criteria for children.

In order to be found disabled, you must meet or medically equal a listing.  20 CFR § 404.1526. You can also find the listings of impairments for both adults and children on the SSA website.

How do I medically equal a listing?

Medical equivalence: Your impairment is medically equivalent to a listed impairment if it is at least equal in severity and duration to the criteria of any listed impairment.

Combination of impairments: If you have a combination of impairments, no one of which meets a listing, the SSA will compare your findings with those for closely analogous listed impairments.  Then combination of impairments might be medically equivalent to a listing. In order to meet a listing, you will need to provide Social Security with copies of all of your medical records.

How do I show that I meet a listing?

You must make sure that you provide all of your medical records to the Social Security Administration so that your disability can be properly supported and evaluated. Your impairment must result from anatomical, physiological, or psychological abnormalities which can be shown by medically acceptable clinical and laboratory diagnostic techniques.  A physical or mental impairment must be established by medical evidence consisting of signs, symptoms, and laboratory findings, not only by your statement of symptoms.  20 CFR § 404.1512.

Step 4: Past Relevant Work

Step 4 asks if, given your impairment(s), you can do your past relevant work.  If yes, you are not disabled.  If no, the go to step 5.

What is past relevant work?

Past relevant work is work that you have done in the last 15 years. 

Step 5: The Grids

Step 5 asks if, given your impairments, there is any work available in significant numbers that you can do.  If yes, you are not disabled.

What is the grid?

In evaluating whether or not you are disabled at step 5, the administrative law judge will refer to the “grid.” The grid is located at Appendix 2 to Subpart P of  20 CFR § 404. You can also find the grid in Appendix 2 on the SSA webiste.

The grid utilizes a number of factors to determine whether or not you are disabled at Step 5. The grid uses your residual functional capacity, age, education,  and prior work experience in order to determine whether or not you are disabled under the regulations. You will need to establish that through you physical limitations, you are unable to perform work in the national economy.  Physical ability will include your ability to stand, lift, walk, sit, push, pull, etc.  You can also testify to your subjective pain.

At the hearing, a vocational expert may be present to give his or her opinion regarding any jobs that may be available in the national economy.  See the Dictionary of Occupational Titles. Any mental impairments will take the individual outside of the grid.  The grid is not equipped to deal with mental disabilities and nonexertional impairments.  20 CFR § 404.1569a.

How do I file an appeal?

After an applicant submits the application, the SSA will first make an initial determination denying or granting benefits.  Generally, most applicants are denied at this stage. 

The applicant then has 60 days (plus 5 days for mailing) to request a reconsideration of that decision.  This is another administrative review.  Generally, at this stage, the applicant will be required to attend a consultative evaluation from a doctor contracted with the SSA. You can find the Form SSA-561, Request for Reconsideration on the SSA website.

If the decision on reconsideration is still to deny benefits, the applicant has 60 days to request a hearing before an ALJ.  This hearing may be in person or by video conference. At the hearing the ALJ will evaluate your claim based on the 5 step process discussed above. You will be given the opportunity to present updated medical records and will be allowed to testify about your physical and mental limitations. The form to request the ALJ hearing may also be found on the SSA webiste.

If you are unhappy with the ALJ’s decision, he or she can request that the decision be reviewed by the SSA’s Appeals Council.  This review is simply an appellate review of the judge’s decision to determine if that decision is supported by evidence and is consistent with the law.   The opportunity to submit additional evidence is limited.

If the Appeals Council affirms the ALJ decision, the final step is to seek judicial review in Federal District Court.  A federal judge will act in an appellate capacity, reviewing the decision of the SSA to determine whether it is supported by substantial evidence and whether it is consistent with the applicable law. For more information on the SSA appeals process you can visit the SSA website.