Social Security Disability Guide

Social Security Disability Guide

Overview

What is Social Security Disability, and how does it differ from workers' compensation?

Social Security Disability provides compensation to people incapable of working, if they meet certain requirements. The Social Security Administration, a division of the federal Department of Health and Human Services, runs the Social Security Disability program.

Social Security Disability has a different administrative procedure and different requirements for compensation than workers' compensation. One important difference between Social Security Disability and workers' compensation involves the cause of the disability. An individual can only receive workers' compensation if their disability resulted from a work-related injury or occupational disase. Social Security Disability does not require the disability result from work.

Effect of Workers’ Compensation

What happens if you receive Social Security Disability benefits and workers’ compensation benefits?

Social Security Disability and Permanent Total Disability

Payment of Social Security Disability and permanent total disability compensation under the Ohio workers’ compensation system reduces the amount of the permanent total benefit by 1/3.

When an individual receiving both disability benefits reaches retirement age, Social Security will automatically switch them to Social Security retirement and workers’ compensation permanent total benefits should return to the full amount.

For some people, it may make sense to switch over to Social Security retirement early.

Social Security Disability and Other Workers’ Compensation Benefits

Individuals receiving other forms of workers’ compensation [such as temporary total, for example], need to report those amounts to Social Security. Social Security considers the amount of workers’ compensation an individual receves in determining the amount to pay. Workers’ compensation benefits may reduce the social security disability payment.

When the workers’ compensation benefits terminate, notify Social Security so they will know to reinstate the full amount of Security Disability payments.

Eligibility Standards

What are the three eligibility requirements for Social Security Disability benefits?

A Social Security Disability claimant must establish all three of the following requirements in order to receive Social Security Disability compensation: (1) that the claimant is disabled; (2) the claimant’s disability meets the durational requirement; and (3) the claimant has disability insured status.

Disability Standard

What is the Social Security standard for disability?

An individual’s disability must have a certain length or severity for Social Security Disability eligibility. To satisfy the durational requirement for Social Security Disability benefits, the medical impairment which causes the disability must either (1) have lasted for longer than 12 months; (2) be expected to last for longer than 12 months; or (3) be expected to result in death.

Durational Requirement

What is the durational requirement an individual must satisfy for Social Security Disability?

An individual’s disability must have a certain length or severity for Social Security Disability eligibility. To satisfy the durational requirement for Social Security Disability benefits, the medical impairment which causes the disability must either (1) have lasted for longer than 12 months; (2) be expected to last for longer than 12 months; or (3) be expected to result in death.

Disability Insured Status

What disability insured status must an individual satisfy to be eligible for Social Security Disability?

A claimant must have disability insured status to receive Social Security Disability. An disabled individual without disability insured status may qualify for Supplemental Security Income.

Disability insured status has complex requirements which exceed the scope of this page. You can get the requirements from the Social Security Administration.

Basically, disability insured status requires that the claimant worked five out of the last ten years in covered employment. Covered employment means employment which results in payments being made to the Social Security Administration. However, in some cases (such as individuals just starting to work) another rule may apply.

Claim Procedure

What procedure does Social Security follow in processing disability benefit claims?

The process starts with the initial claim application, filed at the Social Security Administration's local district office closest to the claimant's residence. Social Security will then make an initial decision.

If the initial decision disallows the claim, the claimant can file a request for reconsideration within 60 days of the date they received the denial. The claimant can file additional evidence at this stage.

If Social Security again disallows the claim, the claimant can request a hearing within 60 days of the date the received the reconsideration disallowance. An Administrative Law Judge will hold the hearing. The claimant can submit new evidence before the Administrative Law Judge.

If the Administrative Law Judge decides against the claimant, the claimant can appeal to the Appeals Council within 60 days of the date they received the Administrative Law Judge’s decision. The claimant can submit new evidence at this stage, but it must relate to the time before the Administrative Law Judge’s denial.

If the Appeals Council refuses to review the case, or affirms the Administrative Law Judge’s denial, the claimant may appeal to the Federal District Court for the District where the claimant lives within 60 days of the Appeals Council decision. A claimant cannot submit new evidence at this stage.

Initial Application

How does Social Security process the initial claim application?

The claimant should file the initial claim at the local district office of the Social Security Administration located closest to their residence. Social Security considers the claim and makes an initial decision.

If Social Security disallows the claim, the claimaint will receive a letter which explains why. The claimant can file for reconsideration within 60 days of the date they received the denial.

Reconsideration

What happens on reconsideration?

If Social Security denies the claim on the initial consideration, the claimant must request reconsideration within 60 days of the date they received the disallowance. A different person than the one who made the initial decision considers the reconsideration request.

A claimant can file additional evidence with the request for reconsideration, or even after they file the request for reconsideration. In most cases submitting additional evidence at this stage is helpful.

If Social Security denies reconsideration, the claimant can file for a hearing before an Administrative Law Judge (ALJ) within 60 days of the date they received the denial.

ALJ Hearing

What happens at the Administrative Law Judge hearing?

If Social Security again disallows the claim after the request for reconsideration, the claimant can request a hearing in front of as an Administrative Law Judge (ALJ). The hearing provides an opportunity for the ALJ to question the claimant to better understand the effect of the disabling condition.

The claimant can file the request for hearing with the local Social Security District Office within 60 days from the date they received the reconsideration disallowance.

In an unusual case, such as where death may result, a claimant can ask the ALJ for an expedited hearing (a hearing sooner than normal) by explaining the need for an expedited hearing in writing.

Five-Step Evaluation

What is the five-step evaluation which the Administrative Law Judge applies?

The Administrative Law Judge [ALJ] uses a five step process to decide whether to award Social Security Disability benefits. The ALJ will ask the questions in order and will stop if any of the answers result in a finding of "disabled" or "not disabled."

The ALJ considers:

  1. Is the claimant engaged in substantial gainful activity? [If "yes" the claimant cannot be disabled].
  2. Does the claimant have a "severe" impairment? [This means that the impairment must limit the claimant's ability to work.]
  3. If the claimant has a severe impairment, the ALJ determines whether the impairment is so severe as to meet or equal the requirements of a "listing." [The listings are a list compiled by the Social Security Administration of types of impairments which are so severe that if an impairment is included on the listings, it means that the claimant is automatically considered disabled, without considering the claimant's vocational ability to work.]
  4. If the claimant has a severe impairment which does not meet the requirements of a listing, does it prevent the claimant from returning to their prior employment? [If the impairment does not prevent the claimant from returning to their prior employment, the claimant is not disabled. Prior employment refers to past relevant work -- generally work done for a significant period of time within the past fifteen years.]
  5. If the impairment does not meet the requirements of a listing, but does prevent the claimant from performing their prior employment, does the claimant have the ability to perform other work available in the national economy? [If so, they are not disabled.]

The claimant must demonstrate items 1 through 4 on the list above. If the ALJ proceeds through the process to step 5, then the Social Security Administration must demonstrate that the claimant can perform other work. The Social Security Administration uses a vocational expert at the hearing to discuss whether the claimant can perform their prior job or any other employment in the national economy. If the ALJ decides against the claimant, the claimant may appeal to the Appeals Council within 60 days of the date they received the ALJ's decision.

Vocational Evidence

How does the Administrative Law Judge use vocational evidence, and what are the grids?

The last step of the sequential evaluation process requires the Administrative Law Judge (ALJ) to consider the claimant's ability to work if they cannot return to their prior employment.

The Social Security Administration has adopted a set of regulations (known as the grids) to help make this determination. The grids apply age, education, work history and physical ability to work and automatically reach a conclusion on whether the claimant could work. [You can find more information about the grids on the Social Security Administration's web site].

If the ALJ determines that a claim fits within the grids, the ALJ will look at the grids and reach the result they compel without considering further evidence.

However, if the claimant does not fit within the grids, the ALJ may also have a vocational consultant testify what work, if any, the claimant can do.

The vocational expert clarifies issues concerning the claimant's work experience. This expert classifies the claimant's past job(s) in terms of skill and exertional level. Skill level may range from unskilled to semi- skilled to skilled. Exertional levels include sedentary, light, medium, and heavy.

The vocational expert also explains whether the claimant has obtained job skills in their previous work experience that could transfer to other jobs. Frequently, an ALJ will ask the vocational expert a hypothetical question. The vocational expert should be asked "Assuming the disabilities and restriction testified to by the claimant at the hearing are true, are there jobs available that the claimant is capable of doing?"

Appeals Council

What happens on the appeal from the Administrative Law Judge’s decision to the Appeals Council?

A claimant can appeal an unfavorable Administrative Law Judge’s (ALJ) decision to the Appeals Council. The claimant must request the Appeals Council review within 60 days from the date they received the Administrative Law Judge’s decision.

The Appeals Council considers only the written record. A claimant can submit additional medical information. However, any additional medical evidence must deal with the time period prior to the denial. A claimant should submit additional evidence with the request for review, or as soon after as possible. A claimant can submit additional medical evidence by sending a letter to the Appeals Council attaching the additional medical evidence and asking that it be made a part of the record and considered in the case.

When appealing to the Appeals Council, a claimant (or their representative) should send a letter to the Appeals Council outlining the reasons the ALJ’s decision was wrong and why the ALJ should have found the claimant disabled.

The Appeals Council may (1) send the case back to arrange for additional medical evidence; (2) send the case back to the ALJ to consider further points; or (3) reverse the ALJ. Or the Appeals Council may decide that the ALJ decision was correct.

If the Appeals Council refuses to consider the case or upholds the denial the claimant may appeal to the Federal District Court.

Appeal to Court

What happens on the appeal from an unfavorable Appeals Council decision to federal court?

If the Appeals Council refuses to review the case or affirms the Administrative Law Judge’s denial, the claimant then has only 60 days to appeal to the Federal District Court for the geographical area where the claimant lives.

It is recommended that a lawyer represent the claimant in court, although a claimant can act as their own representative.

The federal court does not hear any witnesses or take new evidence. The court must confine its review to the record made up by the Social Security Administration (including the transcript of the hearing before the Administrative Law Judge).