Learn how Social Security Disability laws apply to your claim and how the disability evaluation process will be used to decide if you are disabled.

How does the Social Security Administration apply Social Security Disability Laws to determine if I am disabled?

To determine whether you are eligible for benefits, your claim will undergo a series of five reviews in a specific order set by Social Security Laws.

The 5-Step Disability Evaluation

Step 1: Evaluating Your Insured Status and Your Work Activity

First, before your claim is evaluated medically, your local Social Security office will review your Social Security Earnings Record to determine whether you have enough work credits to be insured for Social Security Disability.

If you are insured, Social Security will review any work you have done after the disability date you are claiming. Part of Social Security’s definition of disability is “the inability to engage in any substantial gainful activity,” so the work you have performed after your claimed date of disability will be reviewed to determine if it is substantial.

Disability Determination Services

If you have not worked since the date you are claiming disability or your work is not “substantial” or it was an unsuccessful work attempt, your claim will be sent to a state agency, called Disability Determination Services. This agency, DDS for short, has been contracted by Social Security to decide whether you are disabled according to Social Security Disability rules. 

Medical Documentation for Your Disability Claim

To apply Social Security’s definition of disability to your claim, DDS needs documentation of your physical or mental impairments. This documentation must come from medical professionals defined by Social Security as acceptable medical sources. Social Security regulations say that you are responsible for providing medical evidence to support your claim; however, DDS may help you by requesting medical records from your doctors, hospitals, clinics, and pharmacies. They will also request a statement from your physicians. Because you are ultimately responsible for submitting the necessary information and because your treating physicians’ statements are considered to be very important in the claim evaluation process, you should let all your doctors know that a report will be requested and what it will ask for.

Following Up and Getting Help

It’s also a good idea to contact the Disability Determination Services periodically to see what information, if any, they may still be waiting for. This will allow you to follow up with the medical providers to get the requested information released. Here’s where having a lawyer who is experienced in Social Security is a real asset! He or she can contact your doctor to clarify Social Security’s questions. This in turn will help the doctor prepare a report that fully addresses the points to be evaluated by DDS. Having an attorney assume these tasks will also relieve you of some of the burden of pursuing your claim. When you are not feeling well, this can be very desirable.

Additional Disability Proofs

Sometimes statements from care providers, employers, social workers, and other health care providers such as chiropractors and naturopaths can add important information about your limitations. Even statements from relatives, neighbors, and friends may be helpful. You or your attorney will need to gather these statements and submit them to DDS because typically DDS will not request them. 

What to Do If You Are Asked to Attend an Examination

If DDS does not receive enough information to determine the extent of your limitations, they will ask you to attend a medical or psychological evaluation. This is called a Consultative Examination. The examination will be at no cost to you. If your treating physician is qualified and willing, he may perform the examination; otherwise, you will see a doctor you haven’t seen before. The examination is for evaluation only, not for treatment. If you are asked to go to a Consultative Exam, it is extremely important that you attend and cooperate fully. If you do not, it is likely your claim will be denied.

Once the Disability Determination Services has received all the medical information that is needed or that is available, they will take your claim through the remaining four steps to decide whether you are disabled.

Step 2: Is Your Medical or Psychological Condition Severe?

The first step is to evaluate whether your condition is severe. By this, Social Security means that you are significantly limited in your ability to do basic work activities. If they determine that your condition is not severe, your claim will be denied.

Step 3: Does Your Condition Meet the Social Security Disability Listings?

If DDS finds that your condition is severe, they will move on to the third step, which is to evaluate whether your condition is so severe that it is included in Social Security’s List of Impairments. It’s important to note that to be placed on the List of Impairments an illness or injury must be accompanied by certain signs or symptoms. If your condition meets or is comparable to a listing, DDS will determine that you are disabled. 

Step 4: Are You Disabled from Work You Have Done in the Past?

If your condition does not meet a listing, the evaluation will move to the fourth step, which is to evaluate whether you can perform work that you have done in the past. In this step, DDS reviews your limitations and capacities and compares them to the physical and mental requirements of your former work. If you cannot perform work you have done in the past, the evaluation will move to the next step.

Step 5: Can You Work in a New Occupation

If you cannot do work you have done in the past then your claim will be evaluated to determine whether you are able to perform work that you have not done before. In this step, DDS looks at your limitations and capacities, your education and training, and your work history to see if you have skills and knowledge that can be transferred to other work you are physically and mentally able to perform.

How this step is applied depends in part on your age. If you are age fifty or older more consideration is given to your age and education in answering the question of whether you have the ability to begin a new occupation. How much over age fifty you are and how much education you have, especially advanced education, play into that analysis and even more so when you reach age fifty-five.

In this step, regardless of age, if it is determined that you cannot perform work that is new to you, you will be found disabled and your claim will be approved.

When applying for disability benefits will I have to see a Social Security doctor?

Social Security will only send you to a doctor for a Consultative Examination if the medical records and other information you submit when applying for disability are not enough to make a decision on your claim.

Your Responsibility to Prove Your Disability

If you are asked to go for an examination, you will receive a letter from the Disability Determination Services, which is the agency responsible for reviewing your claim. The letter will give you the name and contact information of the examining doctor, the time of the appointment, and how to confirm that you will attend. It is very important to your claim to confirm the appointment by the date given and to attend the examination on time and cooperate fully. If you fail to do so, your claim is likely to be denied.

When a Psychological Examination Is Required

A psychological consultative examination may be ordered even when your own psychiatric records are sufficient for approval of your claim. This occurs when more information is needed to determine whether your mental illness will keep you from using your benefits to take care of yourself by paying for your basic needs of shelter, food, and basic clothing before other expenditures or whether you need to have a representative payee to manage your benefits for you.

Sometimes people who are applying for benefits based on a physical condition ask, “Why am I being asked to see a psychiatrist? I’ve never been treated for an emotional problem.” Certainly, that situation can be confusing, but Social Security has a reason for asking you to attend a psychiatric evaluation. Here are a couple of them: If the information in your claim file doesn’t support the physical disability you claimed and you reported physical symptoms that could be caused by a psychiatric illness, then Social Security wants to find out whether you qualify for benefits based on a mental illness. This most especially will occur if your chart notes mention, even in passing, that you are depressed or anxious. 

The Doctor, the Purpose, and the Cost for the Examination

Social Security arranges and pays for the consultative examination. The doctor to whom you are sent is not actually an employee of the Social Security Administration. Social Security asks a qualified doctor as close as possible to your home to perform the examination. Your own attending physician may even be asked to perform the consultative examination if he is qualified to do independent exams and is willing. A final note: the appointment has been set because you are applying for disability and it is for evaluation only, not for treatment.

Why are my education and work experience factors in deciding whether my application for disability will be approved?

Your education and work history are important and will affect your Social Security application for disability.

Meeting the Disability Listings

If your medical or psychiatric condition is so severe that it meets Social Security’s Listing of Impairments, the Social Security Administration will not review your education or work history when evaluating your application for disability. Nor will your education or transferable skills from work experience be considered if you are able to return to a past occupation.

When Your Education and Work History Affect Your Disability Claim

If your condition does not meet the Listings, which is often the case, then Social Security evaluates whether or not you are disabled by comparing your physical and mental capabilities to the mental and physical demands of work you have done in the past. If you are unable to perform past occupations, that’s when your education and work experience come into play. If your education and transferable skills from past work prepare you to work in an occupation that is within your health limitations, you are not disabled according to Social Security law and your claim will be denied. On the other hand, if you do not have the education and experience to work in a new occupation that you can physically or mentally perform, your claim will be approved. How education and experience are factored into the evaluation is affected by your age, depending on whether you are under age fifty, age fifty through age fifty-four or age fifty-five or older.

You can see from this that it is important for you to answer carefully and completely Social Security’s or your attorney’s questions about your work history. When listing your duties, be sure to list all your duties, describing the physical and mental demands of each and why you cannot meet those demands now.

Age and the Social Security Disability Evaluation

Disability Determination Services, the state agency that Social Security hires to determine whether you are disabled, evaluates your claim to decide whether you meet the Social Security qualifications for getting disability benefits by moving through a progressive set of requirements that are always applied in the same order. Your claim can be approved or denied at any one of the steps.

When Age is Not a Factor

The first evaluation after assessing any work you are doing is to determine whether you have a severe condition. If you do, your claim is then evaluated to see if your condition meets or is comparable to the List of Disabling Impairments. Neither of these reviews considers your age. If your condition does not meet List of Impairments tests, then your claim moves to an assessment of whether you are able to do work that you have done before. If the answer is “yes,” then you are not disabled, regardless of your age.

When Age Becomes a Factor

If you can’t do any of the kinds of work you have done in the past, your claim goes on to the next step, which is to evaluate whether you can do a type of work that you have not done previously. Education and work experience is considered in assessing the ability to move into a new occupation. At age 50, age is also considered in determining the ability to sustain work in a new occupation and at age 55, more advanced age is given even greater consideration in determining whether a claimant can move into a new occupation.