Social Security uses a strict definition of what it means to be “disabled” under the SSDI and SSI programs
There are literally hundreds of disability insurance programs in the United States. There are private insurance plans, typically obtained through an employer, there are railroad insurance plans for railroad employees, the U.S. Postal Service has its own disability insurance plan, and the Veteran’s Administration covers military veterans through the VA disability insurance program. Each of these programs has the same fundamental objective: to provide income to people who can no longer work due to a medical condition. However, each of these programs has their own definition of what it means to be “disabled” under their rules. They also have their own process for determining whether you meet their definition of being disabled. And, of course, the benefits are very different between one program and the next. For example, Social Security disability does not have a short-term disability program, nor do they have a partial disability system, such as is used in the VA disability program (in which veterans can be found 30% or 70% or 100% disabled, etc.). In Social Security disability, you either meet the definition, or you do not. If you do meet the definition, you receive all benefits until such time as you no longer meet their definition of being disabled. This is why understanding the definition of being disabled under SSA rules is critical. The only definition of what it means to be “disabled” that matters to us and our clients is Social Security’s definition.
Social Security’s Definition of Being “Disabled”
Social Security defines disability as the inability to engage in substantial gainful activity (SGA) due to a medically-determinable physical or mental impairment(s) that has lasted or is expected to last for a continuous period of at least 12 months or result in death.
So, let’s break that definition down because there are many important components to it.
“You must not be able to engage in substantial gainful activity (SGA).” This means you cannot have the ability to work above a specific income level. In 2015, the income level is $1,090 per month. This is a pre-tax (or gross) number. So if you are working above this SGA level, your claim will be denied automatically. It does not matter how sick you are, how strong your medical evidence is, or how difficult it is to pay your bills. You will be technically denied if you are earning wages above the SGA level. There are two exceptions to this SGA rule. First, if you incur medical expenses directly as a result of your work, these expenses can be deducted from your monthly wages to determine if you exceed SGA. Second, if your employer is making accommodations for you in the work place such that the work you are actually performing is not competitive in nature, this can also impact whether you exceed the SGA income rule. But, in the vast majority of claims, if you are working above SGA, your claim will be denied. This SGA test is also utilized by SSA to determine if current beneficiaries (people who receive disability benefits) should have their benefits terminated if they return to work.
“Due to a medically-determinable physical or mental impairment.” This means your allegations must be supported by medical evidence that substantiates your allegations or, as Social Security puts it, your impairment must “result from anatomical, physiological, or psychological abnormalities that can be shown by medically acceptable clinical and laboratory diagnostic techniques.” If someone complains of back pain, but he has no evidence demonstrating the underlying cause of the back pain, the claim will have very little chance of being approved because it is not medically-determinable. It is important to note, as the term above suggests, that Social Security will review all physical and mental impairments as long as they are supported by medical evidence. Oftentimes, a claimant will suffer from heart problems and bipolar disorder, so SSA will take both into consideration when they evaluate your claim. Again, only if these are supported by relevant medical evidence.
“That has lasted or is expected to last for a continuous period of at least 12 months or result in death.” This is what Social Security calls the Duration Requirement. Basically, the symptoms must have lasted or be expected to last 12 full months. For example, if you have your hip replaced and you will be out of work for 6 months, but the prognosis is that you will be back to normal in 6 months, you would not meet Social Security’s definition of being disabled because the duration requirement of 12 months is not expected to be met. If, however, you have a hip replacement and you are not expected to walk again for two years, you would meet the duration requirement. If you have a medical condition that is expected to result in death, you meet the duration requirement, again assuming the medical condition is well-supported with medical evidence.
Social Security’s definition of being “disabled” is specific. However, it is not detailed enough to understand whether you might meet the definition. In addition to understanding SSA’s definition of being disabled, it is also important to understand the process they use to determine if you meet their definition, as well as understand the five step sequential evaluation process they employ. While the definition of being disabled is fairly straightforward, in practice it is much more complex.