But, how does Social Security really evaluate a case?
Social Security reviews cases using the five-step sequential evaluation process to decide is a person is disabled. Here are the 5 questions that make up the sequential evaluation process:
- Does your impairment keep you from being able to perform a substantial gainful activity (SGA), generally full-time, competitive, work?
- Is your impairment severe? AND, is your impairment expected to remain severe for at least 12 months?
- Does your impairment “meet or equal” one of Social Security’s “Listing of Impairments?” A listing of medical conditions, acceptable medical evidence, and the severity necessary for an impairment to be considered disabling. There are separate listings for adults and for children.
- Does your impairment prevents you from being able to perform any job you performed over the last 15 years which was also a substantial gainful activity?
- Does your impairment prevent you from being able to perform any other type of work which exists in substantial numbers of the national economy?
Let’s take these one at a time:
Step 1: Engaging in a Substantial Gainful Activity (SGA)
A.k.a.: Are you working?
Even you have a clearly disabling condition, if you are able to work at a substantial gainful activity level (SGA), you are not disabled.
Example, you may be limited to crutches or a wheelchair, but you force yourself to work a full time, competitive, job. Under Social Security regulations, you are not considered disabled.
Because you are able to work, you do not qualify for Social Security disability benefits.
There are exceptions to this:
- If you are working full time, but your medical expense, which let you work, are so high that your pre-tax income is still below SGA threshold, then your Impairment Related Work Expenses (IRWEs) make your work not SGA. So, you case should not be denied at step 1.
- If you are working at an SGA level, but the work is not competitive: you either got a job through a friend or family member and you not held to the same standards as another worker in the same position, or if you are being paid a “subsidy” — the value of your work is $600 a week, but you are being paid $800 a week.
Step 2: Severity
For an impairment to be severe, it has to cause more than a minimal effect on your ability to perform daily activities?
Example: many people have asthma. However, asthma is not always disabling. Asthma is often well controlled with medications. When it is not well controlled, it may be a severe impairment.
As a Colorado lawyer, I do not see Social Security deny a lot of cases because they do not believe a impairment is severe. However, every once in a while, this comes up. Having a “severe” condition is a pretty low standard and it is usually fairly easy to show that a condition has more than a minimal effect on daily activities.
The second part of this is more difficult. The condition has to be expected to remain severe for 12 months or longer.
If you are denied because Social Security does not think your condition will be disabling for 12 months, it is called a “durational denial.”
I often see a durational denial, where there has been a traumatic accident (such as a car accident) or in cases of disability during the recovery period following serious surgery (such as a back fusion).
Social Security accepts that there will be a healing period where you may not be able to work. But, unless you can convince Social Security that your condition will remain disabling for 12 months, you may be denied.
Step 3: Listing Level Impairment
This is the “short-cut” step. If you have a condition which is contained in the Social Security Listing of Impairments AND the medical findings match what is required for your listing, you may be found disabled without Social Security considering the last two steps. This is “meeting a listing.”
You can also be found disabled at this step if your condition “equals a listing.” Equaling a listing means that while your condition may not be mentioned in the Listing of Impairments, it is just a severe AND has the same findings as a listed impairment.
In my experience with individuals who have already been denied once, the chance of meeting or equaling a listing level impairment is small. But, it is always worth considering.
Step 4: Ability to Perform Prior Work
If you are able to perform any of the past work you have done at a substantial gainful activity level, over the last 15 years before your disability began, Social Security can deny you.
Example: If you previously performed very physical work (construction work or nursing), but you also did worked as a manager for a few months, you may be denied based on your ability to still be able to perform the management job. This may apply even though it is not your most recent work, the employer is no longer in business, or if you cannot get hired for that type of work any more.
Keep in mind that this is just a general overview. Every case depends on its specific circumstances. Also, there are a number of issues around this step including whether you worked long enough to learn the job.
Step 5: Ability to Perform Other Work
Even if you are unable to perform any of your past jobs, you can still be denied if there are other jobs you can still perform which exist in substantial numbers in the national economy.
This is a very complicated area where many cases are won or lost. The rules at this step change depending on your age group (18-49, 50-54, and 55-60).
- If you are under 50, the rule of thumb is that you have to prove that there is no work in the national economy that you can still perform.
- If you are over 50 years old, the rules get a bit easier, but you still have to eliminate most kinds of jobs to win your case.
This is just a quick rundown of the five-step sequential evaluation process. There are exceptions and corollaries to this but I just want to quickly state the steps that Social Security goes through in evaluating a disability claim.