Understanding How the Social Security Administration Evaluates A Claim for Social Security Disability or SSI Benefits

Modern Social Security card.

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When someone applies for Social Security Disability Insurance benefits or SSI (Supplemental Security Income), the Social Security Administration follows a five-step sequential evaluation for determining eligibility (20 CFR 404.1520(a)).  This process is followed regardless of the level of decision, i.e. Application, Reconsideration, or Hearing Before an Administrative Law Judge.  The adjudicator follows the steps in order and if the claimant is or is not disabled at a step of the evaluation, then the process stops and a determination is made.  This is the process used for adult claims.  The process used for determining the eligibility for Childhood SSI will be discussed in an entry in the future.  The five steps are as follows:

1.         Whether the claimant is engaging substantial gainful activity?

     The general rule is that a claimant cannot engage in full-time employment and be approved for Social Security Disability or SSI.  Substantial gainful activity (SGA) is work that is both substantial and gainful.  Each year the Social Security Administration determines a level of earnings considered SGA.  That information is maintained on the Social Security Administrations website:  http://www.ssa.gov/oact/cola/sga.html.  A claimant should not automatically assume that if she is working and earning below SGA, that she will be safe in terms of the disability application.  The decisionmaker could still decide later that the work is evidence of ability to perform certain categories of work and thus find that the claimant is not disabled further down the sequential process.  

2.         Whether the claimant has a medically determinable impairment that is “severe” or a combination of impairments that is “severe” (20CFR 404.1520(c))? 

     An impairment or combination of impairments is severe if it limits an individual’s ability to perform basic work activities.  Case law has generally required only minimal limitations of work activity in order for an impairment or combination thereof to be considered severe.  If the claimant receives regular medical treatment for a condition or several conditions, then this hurdle should be overcome. Very few claims are denied at this step of the sequential process.

3.         Whether the claimant’s impairment or combination of impairments meet or medically equals the criteria of an impairment listed in 20 CFR Part 404, Subpart P, Appendix 1, commonly known as the “Listings” (20 CFR 404.1520(d), 404.1525, and 404.1526)?

     If a claimant’s impairment(s) meets or equals a listed impairment in Appendix I, then the Social Security Administration will find that person disabled without considering age, education, and work experience.  The Listings describe each of the major body systems impairments considered severe enough to prevent an individual from doing any gainful activity.  Each body system has an introduction followed by the specific Listing.             

     The introduction contains important information on how to use the Listings in that body system, as well as specific criteria for establishing a diagnosis.  The Listings follow and they contained detailed objective medical and other findings needed to satisfy the criteria for that Listing.  The Social Security Administration will find that the claimant’s impairment(s) meet the Listing when it satisfies all of the criteria of that specific listing. 

     Most of the listed impairments are permanent or are expected to result in death.  Medical equivalence of a Listing can also be achieved.  Medical equivalence can be found in three ways: 

            1) if an impairment exists that is listed, but the findings do not meet all of the criteria, but the claimant has other findings related to the impairment that are at least of equal medical significant to the required criteria;

            2) an impairment is not listed, but are closely analogous to a listed impairment; or

            3) the claimant has a combination of impairments none of which meet a listing, but the finding in total are analogous to listed impairments.

      Most claimants do not meet Step 3 of the process and are evaluated at the “Vocational Steps” described below.

 4.         Whether the claimant has the residual functional capacity to perform the requirements of his or her past relevant work (20 CFR 404.1520(f))?   

     At this point in the process (necessary also for Step 5), the Social Security Administration’s decision maker must determine the claimant’s residual functional capacity (RFC) (20 CFR 404.1520(e)).  A claimant’s RFC is her ability to do physical and mental work actiivites on a sustained basis despite limitations from her impairments.  The decision maker must consider all of the claimant’s impairments, including those that are not severe (20 CFR 404.1520(e) and 20 CFR 404.1545; SSR 96-8p).

      The regulations allow consideration of work performed within the past 15 years (20 C.F.R. §§ 404.1565(a); 416 965(a)).  The work is defined as heavy, medium, light or sedentary, and skilled, semi-skilled, or unskilled and the Dictionary of Occupation Titles and the Selected Characteristics of Occupations from the Dictionary of Occupational Titles provides the SSA with this information about past relevant work (20 C.F.R. §§ 404.1566(D), 416.966(d)).  This is also the first step that really looks at Residual Functional Capacity (RFC), which signifies what a claimant can do despite his or her physical and/or mental limitations (20 C.F.R. §§ 404.1545, 404.1561, 416.945, 416.961).  RFC is used in determining whether a claimant can do past relevant work, and if not, whether the claimant can perform any available work under Step 5. 

      Again, the burden of proof is on the claimant to show he or she cannot perform his or her past relevant work.  The reason must be due to exertional and/or nonexertional restrictions and limitations relating to the medically determinable impairments and not from being fired or inability to be hired (20 C.F.R. §§ 404.1566(c), 416.966(c)).

    If the claimant can perform his or her past relevant work, then the inquiry stops and non-disability is determined.  If the claimant cannot perform his or her past relevant work, then usually the claim moves on to Step 5.  An exception exists where a claimant with marginal education who has worked at unskilled, arduous work for 35 or more years can no longer return to that work (20 C.F.R. §§ 404.1562, 416.962).

5.         Whether the claimant is able to do any other work considering her residual functional capacity, age, education, and work experience?  

     If the claimant is able to do other work, she is not disabled.  If the claimant is not able to do other work and meets the duration requirement (has lasted or expected to last at least one year), she is disabled.  Although the claimant generally continues to have the burden of proving disability, a limited burden of going forward with the evidence shifts to the Social Security Administration.  In order to support a finding that a claimant is not disabled at this step, the Social Security Administration has to provide evidence that demonstrates  ther work exists in significant numbers in the national economy that the claimant can do, given the residual functional capacity, age, education, and work experience of the claimant (20 CFR 404.1512(g) and 404.1560(c)). 

      In determining whether a successful adjustment to other work can be made, consideration should be given to the Residual Functional Capacity, age, education, and work experience in conjunction with the Medical Vocational Guidelines, 20 C.F.R. Part 404, Subpart B, Appendix 2.  These are commonly referreded to as “The Grids.”  If the claimant can perform all, or substantially all, of the exertional demands at a given level of exertion, the Medical Vocational Guidelines direct a conclusion of either “disabled” or “non-disabled” depending upon the claimant’s specific vocational profile (SSR 83-11).

     When the claimant cannot perform, substantially, all of the exertional demands at work of a given level of exertion and/or has non-exertional limitations, the Medical Vocational Guidelines are used as a framework for decision making unless they are ruled to direct a conclusion of disabled without considering the additional exertional or non-exertional limitations (SSR 83-12; 83-14).  If the claimant has solely non-exertional limitations, Section 204.00 of the Medical Vocational Guidelines provides a framework for decision making (SSR 85-15).  If the claimant has a Residual Functional Capacity to perform a full range of sedentary work considering the claimant’s age, education, and work experience, a finding of “non-disabled” would be directed.  However, if the full range of sedentary work has been significantly compromised, the Vocational Grid Preamble, Section 201.00(h) of Appendix 2 to Subpart B of Part 404, provides that a finding a “disabled” is not precluded for even younger individuals.  Thus, additional limitations or non-exertional limitations can create a substantial erosion of the sedentary occupational base so there would not be a significant number of jobs in the local, regional, or national economies that the claimant could perform. 

     Currently, about 75% of all applicants are denied benefits on their initial application.  Claimants have sixty (60) days to appeal the adverse determination or risk losing benefits.

      If you have or someone you know has applied for Social Security Disability or SSI or your claim has been denied, please call John Dreiser at the Law Offices of Tony Farmer and John Dreiser for a free case evaluation.  We can be reached at (865) 584-1211 or (800) 806-4611 or by e-mail at John@farmerdreiser.com, follow us on Facebook,  or through our website at www.farmerdreiser.com.  Our office handles disability claims throughout East Tennessee, including Knoxville, ChattanoogaKingsport, Bristol, Johnson City, Morristown, Maryville, Rogersville, Dandridge, Tazewell, New Tazewell, Jefferson City, Strawberry Plains, Sevierville, Gatlinburg, Loudon, Kingston, Halls, Maynardville, Crossville, Cookeville, Sweetwater, Lenoir City, Athens, Oak Ridge, Clinton, LaFollette, Lake City, Jacksboro, Bean Station, Cosby, Newport, White Pine, Mosheim, Wartburg, Sunbright, and Deer Lodge.


About farmerdreiser

Based in Knoxville, Tennessee, The Law Offices of Tony Farmer and John Dreiser provide comprehensive representation to injured victims throughout eastern Tennessee in personal injury, Social Security disability, and workers' compensation cases.
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