It’s apparent to every individual who decides to file for social security disability or SSI disability that an applicant must have an impairment of some kind, either physical or mental in nature, or a combination of impairments (that may be physical, mental, or both). Furthermore, the great majority of applicants for SSD and SSI benefits realize that the strength of an adult’s claim will hinge on the extent to which their ability to engage in work activity will be affected.

However, few disability claimants typically have any concrete idea as to how the social security administration, through its use of judges and claims examiners, actually makes the determination as to whether or not a claimant can work.

The answer is actually fairly simple. Disability adjudicators, the individuals who make decisions on claims (judges and examiners) evaluate a claimant’s medical records to ascertain if their impairment is severe. The records are also evaluated in an attempt to learn how the claimant’s condition functionally limits them and interferes with their ability to perform work activity. By rating a person’s current abilities and limitations, and then comparing this rating to what was required in the jobs previously held by the claimant, social security can determine whether or not a return to past work is possible. Social security also uses the claimant’s work history information and their medical information to determine if the claimant might be found capable of performing some other type of work, assuming they cannot return to their past work.

However, one overriding factor in this process is whether or not the claimant worked and received earnings (or is currently working and receiving earnings) at the substantial gainful activity level. As this segment explains, SGA is a monthly earnings limit that cannot be exceeded by anyone filing for disability or receiving disability benefits. The amount is indexed to the cost of living and, therefore, does change annually.

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The ultimate determination of whether or not a claimant will receive SSI disability benefits (after filing a claim, and perhaps filing multiple appeals) will rest on the claimant’s medical records. However, it’s not really as simply as that. A claimant’s records need to establish that the claimant has functional limitations (the reduced ability to engage in various activities of daily living) that basically make it impossible for the claimant to work and earn what social security refers to as substantial gainful activity, i.e. a substantial and gainful income.

This segment of Disability Audio describes briefly how a claim is initially worked on by a disability examiner at disability determination services. Of course, the very first task that the examiner will accomplish will be to request the claimant’s medical records. So, it becomes obvious at the outset that the information contained in those records are the core of a claimant’s case. And for that reason, claimants need to provide accurate lists of their various medical treatment sources. Because in far too many cases, claimants do leave off information about various sources of treatment and doing so can potentially disadvantage a claim by giving the disability examiner less information with which to work.

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It’s not uncommon for individuals who are filing for disability, under either the title II social security disability or title 16 SSI disability benefit program (or both if their application is concurrent) to wonder if they can receive benefits for partial disability, or if they can receive temporary disability benefits.

In either case, the answer is no. Social security uses a definition for disability, and for the approval of claims, that requires that a claimant be so affected by their condition that they are rendered unable to work and earn what is referred to as a substantial gainful income. For the social security administration, this standard of disability equates with total disability.

That does not mean, of course, that an individual who is filing for disability, or an individual who is actually receiving disability benefits, cannot work and earn income at the same time. In actuality, a claimant can work in either situation as long as their gross monthly earnings do not exceed the allowable limit set for that particular year. However, having said that, an individual who is filing for disability may wish to consider the fact that disability adjudicators (disability examiners at the first two levels of the system, and disability judges at the hearing level) are human beings and very often (or most often) their decisions have a subjective component to them.

That being the case, the fact that a claimant is continuing to work may influence how they are rated in terms of functional capacity, as well as the outcome of a case. This may be even truer when it comes to disability claims that are predicated, for the most part, on mental allegations.

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This post focuses on providing a basic explanation of how the social security disability and SSI disability process works. The post does not address the disability appeal process (typically, when I do this, I focus on the first level appeal, the request for reconsideration, and the second level appeal, the request for a disability hearing before an administrative law judge), but, rather, discusses how claims are typically initiated (by calling a local social security office) and, subsequently, what happens after.

To recap, after a disability application is taken by a social security employee known as a CR, or claims rep, the claim is sent to the disability determination services agency in that particular state (in most states, the agency actually is called DDS, but in other states it goes by the moniker “Bureau of disability determination” or “Disability determination Unit” or “Disability determination division”). Once received at that agency, the case is given to a disability specialist, also called a disability examiner, who will handle the task of evaluating both the claimant’s medical history–via records that are gathered from the the sources that are indicated by the claimant at the time of application–and also the claimant’s work history.

Most claimant’s can easily guess why medical records will need to be obtained from their various treatment sources. However, some may not be entirely clear as to why information regarding their work history and individual jobs needs to be gathered. Well, the answer is simply this: the SSD and SSI disability programs issue decisions that are both medical and vocational in nature.

In other words, to receive disability benefits in either program, the federal government does not require that an individual be completely physically or mentally incapacitated (they must be 100% disabled, but as you’ll see, disabled and incapacitated are not necessarily the same thing). Instead, the social security administration requires that, in addition to lasting a minimum of 12 months, a claimant’s condition must simply be disabling to the extent that they cannot engage in their past relevant work (certain jobs performed within the past 15 years) and, additionally, cannot engage in other forms of work that they might, under normal circumstannces, be able to switch to based on their age, education, and acquired working skills.

To make this type of medical-vocational determination, of course, the social security administration, through the disability examiners who process claims for it in the various state agencies, must be able to A) determine what a claimant’s current physical and mental limitations are and B) must be able to compare these rated limitations to what was required of a claimant in their past jobs, as well as compare these limitations to other jobs for which the claimant might ordinarily be suited to take up.

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Though an individual will usually file a claim for social security disability or SSI disability at a local social security office, the case itself (and by this we mean the evaluation of an individual’s medical records and work history), is not actually worked on by the social security administration. In actuality, a social security office will simply take a person’s claim and then send it off to an entirely separate agency where the case will be examined and decided by a disability examiner.

Disability examiners do not have medical training; but, they are trained to review medical records to look for signs of an individual’s loss of functional ability. For instance, a claimant who applies for disability may allege on their disability application that they have a shoulder injury or pain in their lower back. However, the allegations of such complaints will mean little to a decision-maker unless the medical records that are being read and evaluated actually indicate (or lead the examiner to conclude) that the claimant has loss of function such as, for example, a reduced ability to reach, to lift, to bend, to sit, to stand, etc.

Loss of function, and a claimant’s remaining level of function (known as residual functional capacity) allow disability examiners to decide whether or not a person filing for benefits actually has the ability to go back to work, either in one of their former jobs or in some form of other work.

Obviously, to make this assessment, a social security disability claims examiner needs access not only to a claimant’s medical records but also information regarding their work history. By reviewing the work history, a disability examiner can learn more about the duties and physical and mental requirements of the claimant’s former jobs to determine if they can return to one of these jobs. By reviewing the work history, a disability examiner can also learn if the claimant has job skills that might allow them to perform some other type of work.

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