How Does the Social Security Administration Define Disability
The Social Security Administration (SSA) defines the term “disability” as the “inability to engage in any substantial gainful activity (SGA) by reason of any medically determinable physical or mental impairment(s) which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months.”
SGA is a term used to describe the level of work activity an individual can put forward and how that activity impacts their income.
The SSA identifies “substantial work” as anything involving a significant amount of physical and/or mental amount of work. Substantial work does not need to be done on a full-time workload; a part-time workload can be analyzed under SGA.
The SSA identifies “gainful work” as any of the following:
- Work that is done for pay or profit.
- Work that is typically done for profit.
- Work intended for profit, even if a profit is not made.
Under this definition, the SSA offers two programs for individuals to seek disability. They include the Social Security Disability Insurance (SSDI) program which is under title II of the Social Security Act (Act) and the Supplemental Security Income (SSI) program which falls under title XVI of the Act. Both programs are federally funded and recognize the same definition of disability. While they have many similarities between them, they do differ in some regards.
How are Disability Payments Determined?
Under SSDI, disability payments are made out to individuals who are “insured” under the Act, with payments determined by the individuals’ and their employer's contributions to the Social Security trust fund as required by the Federal Insurance Contributions Act (FICA).
With SSI, payments made to individuals are based on need. SSI payments are made to eligible individuals and their dependents under the age of 18.
SSDI Eligibility and Benefits
SSDI benefits individuals who are insured, disabled or blind, and may extend to some family members if they are eligible. Documentation required for application includes recent wage information in the form of W-2s, paystubs, and other documents showing work and wage history. Payment is determined by the “date of onset” or when the individual became disabled.
SSI Eligibility and Benefits
With SSI, individuals who benefit include those who come from low-income households as well as individuals who are disabled, blind, and/or elderly. While the monthly benefit amount is established by congress annually, states have the ability to offer additional monetary support. For example, North Carolina offers between $97 and $887 per month (amounts differ on a claimant’s specific situation). Meanwhile, states including Arizona, Arkansas, Georgia, Mississippi, Tennessee, and West Virginia do not offer additional assistance.
Unlike the SSDI program, SSI bases payments on need and takes into consideration an individual's income, their living arrangements, and the personal resources they have access to. These are the key factors taken into consideration when determining payment. The date of eligibility used by SSI is the protective filing date or PFD. This date is established when the applicant or the case manager overseeing the applicant contacts the SSA to make their intention of applying for disability.
The definition of “disability” is the same for both the SSDI and SSI programs. However, when it comes to other government and private disability programs, the criteria for disability may change.
Although SSDI and SSI only cover people with permanent disabilities, sometimes a recipient’s medical condition does improve to the point where they no longer qualify as disabled. What happens then? Roger Drake, a California disability attorney with the law firm Drake & Drake in Calabasas, explains that such individuals would have to pay back benefits if their payments exceed the disability period. According to Drake, this most commonly happens when claimants appeal a disability review. “If the Social Security Administration finds medical improvement no longer entitles you to disability benefits and you appeal that determination, the agency will continue to pay monthly benefits throughout the administrative appeal process.” Drake continues, “If you do not win that appeal, however, the SSA will ask for that money back.” Drake describes two ways to avoid this. The first, he says, is to ask SSA to stop paying you benefits during the appeal process. The second, according to Drake, is to ask for a waiver of the overpayment.
Children Who are Disabled
The federal government also observes disability in children. Children under 18 can claim disability under title XVI if they meet any of the following criteria:
- Have a medically determinable mental and/or physical impairment that severely limits their functionality,
- Their impairment is expected to cause death or,
- Their impairment has lasted or is expected to last for an extended period of time no less than 12 months.
The Social Security Administration defines “medically determinable impairment" as “an impairment that results from anatomical, physiological, or psychological abnormalities that can be shown by medically acceptable clinical and laboratory diagnostic techniques.”
This impairment needs to be backed by medical evidence; a statement about the impairment and symptoms observed are not enough.
Although payments can continue for a lifetime, the SSA may check in occasionally to follow up on an individual’s disability. Attorney Drake explains that this does not typically happen for older claimants, but for claimants under age 55, he says the SSA may schedule continuing disability reviews every few years. “They will ask for your current medical providers, medication, and impairments,” says Drake. “This is why,” he continues, “it is important to continue to get medical treatment even after qualifying for Social Security Disability benefits so you have evidence to show you are still disabled.”
How to Apply for Disability
The application process for both SSDI and SSI is the same, but they have different application forms. With either application, applicants will typically start the process through their local Social Security field office or state agency. State agency offices are typically referred to as Disability Determination Services (DDS). These offices will process initial disability claims.
Additionally, these offices will determine eligibility by collecting medical evidence, income, resources, and living arrangement information. These offices are also tasked with uncovering whether an individual fits the criteria of a disabled individual under SSA’s definition.
After making a determination on an individual's application, the state offices will refer the case back to field offices for the appropriate action. Individuals have the ability to appeal decisions once they reach the field offices. Additional information on the application process can be found on the SSA’s official website.
While some government healthcare programs get targeted for fraud by applicants who don’t qualify for benefits, this doesn’t happen often in either SSDI or SSI claims, according to attorney Roger Drake. By the time an individual is awarded benefits, he says, several government analysts, doctors and lawyers have reviewed the file, so there is little room for fraud. “The reality is we see the opposite,” says Drake, “where deserving claimants are denied benefits.”
Indeed, more than two-thirds of applications are initially rejected by the SSA. An experienced disability benefits attorney can prove helpful in ultimately obtaining benefits, whether on an initial application or after going through a series of motions for reconsiderations, hearings and appeals. As frustrating as it may seem, this is one area where persistence pays off.
