SSDI: Medical Eligibility for Benefits

The journey to applying for disability can be long and confusing for someone with a chronic illness. Even harder if that chronic illness is something that is not shared by very many people. When I first applied for SSI benefits, I was excited that Behcet’s Disease is actually on the list of recognized diagnoses. After two denied appeals and hiring an attorney, I learned that your most prominent diagnosis is not always the one that is best to put forth to the ADJ judge.

To qualify for disability benefits (either SSDI or SSI), you must prove you have a severe, medically determinable impairment that limits your functioning to such an extent that you aren’t able to work. Disability Determination Services (DDS, a state agency that evaluates disability claims for the SSA) analyzes each disability claim with a five-step evaluation process.

Step 1: Substantial gainful activity

Substantial gainful activity (SGA) is the term SSA uses to describe work activity and earnings. Under SSA’s rules, work does not have to be fulltime to be “substantial,” because it is based on monthly earnings. For 2017, SGA is considered $1,170 gross per month for a non-blind individual and $1,920 for a blind individual. If you are making over this amount when you apply for disability, your application will be denied because, under SSA’s Step 1 evaluation, you are still able to work substantially.

Step 2: Severity and durational requirement

There are two criteria that must be satisfied to get past Step 2: medical severity and duration. An impairment or a combination of impairments is considered “severe” if it significantly limits an individual’s physical or mental abilities to perform basic work activities. Then, the severe impairment must have lasted or must be expected to last for a continuous period of at least 12 months, or be expected to end in death.

Step 3: Listing of Impairments

SSA’s Listing of Impairments describes the medical conditions, severity and evidence required for an impairment to warrant a finding of disabled. Listings for adults and children are separate, both organized according to body systems (musculoskeletal, senses, respiratory, cardiovascular, etc.).

Read More: The most common lists of eligible medical diagnoses.

If your condition meets or equals a listing’s requirements, SSA can find you disabled at this step, and will not move on to Step 4 or Step 5. To meet a listing requirement, your condition must be the same as the criteria of a listed impairment. To equal a listing requirement, your condition must be equal in severity and duration to the criteria of a listed impairment. Generally, people use an “equals to” argument in one of the following circumstances:

  •     Your impairment does not meet one or more of the medical criteria specified in the listing.
  •     Your impairment does meet all of the criteria, but one or more of the criteria is not as severe as specified in the listing.
  •     Your impairment is not described in the listing but may be as severe as an analogous impairment.
  •     You have a combination of impairments, none of which meet a listing, but the cumulative total of your impairments could equal one or more listings.

Note: My attorney actually decided that the diagnoses that were most likely to win me benefits were my chronic complex migraines and my psychiatric diagnoses: bipolar disorder and anxiety. These are, of course, worsened by my Behcet’s Disease and my fibromyalgia, but according to my “expert”, they are the ones most easily understood and proven in the ADJ setting.

Step 4: Past Relevant Work

At this step, SSA will determine if you are able to complete any of the work you performed in the prior 15 years. This only applies to work you performed that was above SGA. You also must have performed the work long enough to learn it, which depends on the nature and complexity of the work. If you had five jobs in the past 15 years, but only three were above SGA, SSA would only analyze the three above-SGA jobs. If your current physical abilities fit into the requirements of a past job, SSA can decide that you can still do that job and deny you disability.

Step 5: Ability to Perform Other Work

If you are unable to perform any of your past relevant work, SSA may still find that you can perform other jobs in the regional or national economy, resulting in a denial. This step is where SSA issues the largest number of denials. It can be relatively easy for SSA to find some work in the national or regional economy you would be capable of performing. SSA will consider your medical conditions, your age, education, past work, and any transferable skills you may have. If you cannot adjust to any other work, your claim will be approved.

This five-step analysis applies if you file for Social Security Disability Insurance, Supplemental Security Income, child’s insurance benefits, and widow’s or widower’s benefits. The five-step process makes the analysis of every disability case uniform across the country, regardless of age, diagnosis or jurisdiction.

Up Next: Special References for your SSA Disability Case

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