How does the Social Security Administration (SSA) Define Disability?According to the Social Security Act, the definition of disability is the "inability to engage in any substaintial or gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or has lasted or can be expected to last for a continuous period of not less than 12 month" (www.ssa.gov).
Social Security Disability Insurance (SSDI)
SSDI is a federal disability insurance program designed for individuals who have worked enough to earn sufficient "work credits." Under this program, monthly payments are based on the individual's earning record, which is on file with the Social Security Administration. SSDI provides you monthly cash benefits and Medicare entitlement to those who are blind or disabled.
SSDI benefits can be paid retroactive back to the original date of a disability, if a claim was filed at that time. If you do not have enough work credits to qualify for SSDI then you may be eligible for SSI.
Supplemental Security Income (SSI)
SSI is a federal financial assitance program which provides monthly payments to individuals who either never worked or have insufficient credits on their earnings record to qualify for SSDI. SSI recipients are typically required to have limited financial resources and assets that do not exceed $2,000 for one person and $3,000 for a couple. In 2004, the basic SSI benefit program will pay according to Federal Poverty Guidelines which are re-calculated each fiscal year.
These programs are administered by the Social Security Administration and the disability criteria are the same for both. In order to qualify for SSI or SSDI, an individual must have impairment or a combination of impairments that preclude substantial gainful work activity that is expected to last continuous period of 12 months or longer or that is expected to last in death.
Each individual who applies for SSDI is also screened for SSI benefits. SSI payments may be available during the usual 5-month waiting period before SSDI cash benefits begin. Benefits become payable the month after the application is filed with regardless of when the disabiity began. There is no retroactive benefit under SSI. Those eligible for SSI may also be automatically eligible for Medicaid benefits. For those who receive SSDI approval, they will begin receiving monthly cash benefits after five full months of waiting.
The SSA can make a determination of "presumptive disability" for SSI benefits. Presumptive Disability allows SSA to pay up to six months of SSI payments before they make their disability determination, based on the finding that there is a high probability that the applicant is disabled. SSA does not provide for presumptive payments to individuals applying for SSDI benefits (www.alsa-stl.org).
The SSA has an expedited procedure for processing terminally ill cases to ensure that a favorable decision can be made expeditiously. The code word for this type of case is "TERI" case. This type of case needs to be flagged or noted some way by the claim representative so that the case can move expeditiously to the Disability Determination Section (DDS). There is no cash benefits paid to the family if the claimant expires during the waiting period or while a disability decision is being established. The individual's medical records or pathology report must reflect that the claimant is terminally ill or about to expire in six months or less (www.alsa.stl.org.
The Disability ProcessMost Social Security disability claims are initially processed through a network of local Social Security Administration (SSA) field offices and State agencies called Disability Determination Services (DDS). The field offices obtain applications for disability benefits in person, by telephone, by mail or by filing online. The application and related forms ask for a description of the claimant's impairment(s), treatment sources and other information related to alleged disability. The field office is responsible for verifying non-medical eligibility requirements, which may include age, employment, marital status or Social Security coverage information. The field office then sends the case to the DDS for evaluation of disability.
The DDS office is fully funded by the Federal Government, but the State agency is responsible for developing medical evidence criteria and rendering the initial determination as to whether or not a claimant is disabled or blind under the law (www.ssa.gov/disability/determination.htm).
Usually, the DDS tries to obtain evidence from the claimant's own medical source first. If that evidence is unavailable or insufficient to make a deteremination, the DDS will arrange for a Consultative Examination (CE) to obtain additional information needed. After, all the medical evidence is compiled, the Adjudicator/Claims Examiner is the person that makes the disability decision, and he/she determines if the claimant will be approved or denied. Then, the DDS returns the case to the field office for appropriate action. If the DDS found the claimant to be disabled, SSA computes the benefit amount and will began paying cash benefits to the claimant.
DDS takes into account the age, education and work experience of the claimant in addition to the medical records and the residual fuctional capacity to determine whether the claimant is "disabled" under the SSA'a rules.
It is much more likely that a claimant over age 55 will be approved for SSDI/SSI because it is assumed that a claimant over age 55 cannot adjust or be retrained to a completely different line of work.
How do you file your disability claim?If you become disabled, you should file for disability benefits right away. You can do this by calling or visiting your local Social Security office. There are federal government listings in your local phone book or you can call a toll free number from anywhere in the United States by calling 1-800-772-1213 or if you have access to the internet by visiting Social Security Online at www.ssa.gov.
You can shorten the time it takes to process your claim if you have the following medical vocational information when you apply:
- Medical records from your doctors, therapists, hospitals, clinics, and caseworkers
- Your laboratory and test results
- The names, addresses, phone and fax numbers of your doctors, clinics and hospitals
- The names of all medications you are taking
- The names of your employers and job duties for the last 15 years
- Submit a copy of your most recent tax return along with a recent pay check stub
- A letter from your attending physician that includes the phrase as written: "...will be unable to work for 12 months or longer"
Be aware that many disability applicants, up to 60% of all filed, are denied for the first time. Do not give up! You have the right to appeal this denial and can do so very effectively with the proper medical documentation(s) such as: physician's notes, history and physicals, consultations, MRIs, cat scans and pathology reports. Include other pertinent information that would indicate a decline in your condition as well as any side effects to medications (memory loss, fatigue, nausea, etc.). Do not file a new application after a denial. Appeal the original decision.