Category: Proving Disability

The Disability Decision Making Process

Understanding the Social Security disability evaluation process is important because it helps us understand how to prepare a better claim.

The Application

The first step in the disability process is for us to submit an application. On the application we include information about the doctors you seen, the medical tests you have had, procedures you have had, and medications you are taking. We also include information about your work history and your education. 

Once we submit the application it goes to the local Social Security office. At that office they make some technical determinations in your case. For example, they look at your work record to determine whether you have worked for long enough to qualify for disability insurance benefits. They also look at whether you are currently working (if you are doing substantial work, you are not disabled) and whether you meet the income and asset requirements for SSI.

If you meet the technical requirements for disability, they will send your claim to a state agency called the Disability Determination Services, or “DDS.” Once your claim gets to DDS it is assigned to a person called a Claims Examiner. The Claims Examiner is the person who will make the decision about whether you meet the medical requirements of disability.

The Claims Examiner

When the Claims Examiner gets your claim, that person will review the application and request the medical records from the medical sources you have listed. When those medical records are received, the Claims Examiner will write a short, usually one page, summary of those medical records. Then the Claims Examiner will send the claim to a different person at DDS called a Medical Consultant.

The Medical Consultant

The Medical Consultant will review your medical records and make a list of limitations in what Social Security calls “Basic Work Activities.” Basic work activities are the basic things that you need to do to be able to do any job. For physical activities, basic work activities include things like sitting, standing, walking, lifting, carrying, bending, kneeling, climbing stairs, and other similar activities. For mental activities, basic work activities include things like being able to remember and follow simple instructions, being able to get along with supervisors and coworkers, being able to work without being distracted by or distracting others, being able to maintain normal standards of hygiene and dress, and being able to maintain normal schedules.

A normal list of limitations in basic work activities will look something like this.

This person can occasionally lift 20 pounds and frequently lift 15 pounds. He can stand and/or walk about six hours in an eight hour workday. Likewise, he can sit for about six hours in an eight hour workday. He can occasionally (up to one third of the workday) climb ramps/stairs, ladders/ropes/scaffolds, balance, stoop, kneel, crouch and, crawl. He can reach overhead with both arms occasionally. He can do simple, routine work with occasional contact with others.

Making the Decision

After creating this list of limitations, the Medical Consultant will send the case back to the Claims Examiner. The Claims Examiner will then compare the list of limitations with the physical and mental requirements of the work that you have done in the past 15 years, called past relevant work. If the Claims Examiner determines that you can do any of your past relevant work, then you will be found not disabled. If you are determined to not be able to do any of your past relevant work, then the Claims Examiner will compare the list of limitations to all other work available anywhere in the national economy. If the Claims Examiner finds other work available your claim will be denied. If, on the other hand, there is no other work available you will be found disabled.

There are a couple of special situations to be aware of regarding age. If you are age 50 or older and you have never done a sit-down type of job and you don’t have the skills for a sit-down type of job, Social Security does not expect that you will work a sit-down job in the future. Therefore, even if you are found capable from a physical and mental standpoint of a sit-down type of job, Social Security will not require that you return to that job and will instead find that you are disabled.

Similarly, at age 55 if you are limited to what is called light work, which is work that requires standing on your feet for about 6 of 8 hours and lifting 20 pounds occasionally during the workday, and you have only done heavier manual labor types of work, Social Security will find that you are unable to return to other work and award disability.

Understanding this process, helps us to understand what sources Social Security looks to to determine your eligibility for disability benefits and what information Social Security is looking for in those sources.

How To Build a Better Claim

First, the primary source of information for Social Security about your disability is the medical records. That means that your limitations should be documented clearly and completely in those medical records.

Second, Social Security will be looking for limitations in basic work activities in those medical records. That means that you should make sure to discuss with your doctor how your medical conditions limit your ability to do daily activities such as cooking, cleaning, shopping, and interacting with others. The more specific and detailed the examples your doctor writes into the medical records the better.

If for example, you are over the age of 50 and your past work has all been truck driving, you will need to establish in the record that you are now limited to lifting less than 20 pounds occasionally and you are limited to standing/walking for less than six of eight hours. That means that you want to provide your doctor with examples from your daily activities that establish these limitations.

On the other hand, if you are under the age of 50 you will need to establish that you are unable to sustain any activities for an eight-hour workday sufficient for you to work. For example, if you have depression that keeps you from leaving the house several days a month you will need to establish that limitation in the medical record to show that you are unable to maintain normal schedules. If you have back pain that requires you to lay down for several hours during a normal eight-hour work., You will need to establish that in the medical records.

Using these simple techniques can substantially improve the quality of the evidence Social Security relies on determine your disability. Of course, having this information will not guarantee that you will win your case. However, having this information will definitely help you build a better claim and make your chances of winning much higher.

Social Security Disability Defined

Social Security does not define disability in the same way that many of us think about disability. For Social Security, the only kind of disability that matters is a disability that leaves you unable to perform any work activity. This definition is one of the most strict definitions of disability in American law.

The law specifically states that an individual must be not only unable to do his previous work but cannot, considering his age, education, and work experience, engage in any other kind of substantial gainful work which exists in the national economy, regardless of whether such work exists in the immediate area in which he lives, or whether a specific job vacancy exists for him, or whether he would be hired if he applied for work.

Social Security’s definition of disability is really a hypothetical definition. Rather than focusing on whether work exists in your area that you could perform and actually be hired for, the definition requires Social Security to look at whether jobs exist in the national economy. It is possible to be found not disabled because Social Security believes there are certain jobs available in the national economy, even though those jobs do not exist in your community, state, or region.

Many people who live in rural areas or who have a limited ability to travel ask what does Social Security expect a person to do? The answer is that Social Security does not have any expectation. Instead, Social Security simply requires that you meet its definition of disability to be eligible for disability benefits.

The law does require that Social Security consider all of your impairments in combination. And impairment refers to a limitation on your ability to perform basic work activity. Basic work activity includes things like sitting, standing, walking, bending, pushing, pulling, lifting, and carrying four physical impairments and things like following instructions both written and oral, getting along with coworkers and supervisors, maintaining attention, maintaining concentration, maintaining appropriate pace, working independently, maintaining appropriate appearance, and maintaining regular schedules for mental impairments. If your conditions do not impair your ability to do these basic work activities Social Security will consider you not disabled.

What does this mean for how Social Security evaluates your case and what you can do to help prove your disability? Social Security looks first to the medical records to determine how your conditions impair your ability to perform basic work activity. The best way to make Social Security aware of how your conditions impair your abilities is to discuss those impairments with your medical provider. It is also important to ask your medical provider to document those impairments, because such documentation is usually not part of the normal medical documentation process. If you don’t document your impairments, Social Security will be left to guess at what those impairments are.

Although Social Security’s definition of disability is very strict, if your condition significantly impairs your ability to perform work activity and you have been, or will be, unable to work for a significant period of time, you should consider filing for disability.

Medical Record Accuracy

Social Security is increasingly relying on computer systems to evaluate disability. These systems both check the accuracy of decisions and try to identify claims that can be approved earlier in the process. However, they rely intensively on natural language searches of the medical records as well as coding done by SSA employees. Recent proposed rule changes will make SSA even more reliant on medical records for disability assessment, as opposed to opinions from your doctors. With this in mind it is extremely important for you to be aware of problems with the accuracy of medical records and to know what needs to be documented in your records.

Most people assume both that their doctors write down the necessary elements to establish symptoms and diagnosis and that they write those things down accurately. Multiple studies of medical record accuracy have established that this is simply not true. For example, one study found that that emergency room doctors failed to diagnose mild traumatic brain injury when the elements were present 56% of the time. Powell, Janet M., et al. “Accuracy of mild traumatic brain injury diagnosis.” Archives of physical medicine and rehabilitation 89.8 (2008): 1550-1555. Another study found that medical providers were particularly poor at documenting symptoms and medication side effects in schizophrenia patients, especially when those patients were severely ill, black, or perceived as non-compliant (meaning that the patient did not follow the medical provider’s recommendations for treatment). Cradock, Julie, Alexander S. Young, and Greer Sullivan. “The accuracy of medical record documentation in schizophrenia.” The journal of behavioral health services & research 28.4 (2001): 456-465. The problems with accurately documenting medication side effects, dosage, and drug allergies have been documented in multiple studies. A study from 1989 found that “Medical records are being distorted and fashioned to keep clinically important but sensitive personal information about patients from public view. To comply with standards of care and a reimbursement system blind to biologic diversity, medical records are being forced to address only the technical side of care.” Burnum, John F. “The misinformation era: the fall of the medical record.” Annals of Internal Medicine 110.6 (1989): 482-484. This study cautioned against what has now become a reality of modern life, over-dependence on medical records for legal determinations such as eligibility for disability benefits.

The problems shown by these and other studies are particularly relevant to those seeking disability benefits because the disabled are generally very poor and have a difficult time complying with treatment recommendations.

So, what can you do to improve your own medical records.

The first thing to do is have a conversation with your doctor to let him or her know that you are applying for disability and that as a result you will need complete and accurate documentation of your symptoms and documentation. Social Security has very specific requirements for diagnostic documentation and the only way for those requirements to be met is for your doctor to make sure they appear in the medical records. You will also need to have your doctor document the extent and nature of your disability with specific descriptions of your functional, especially work-related, limitations. For example, if you have a back condition it is essential that your doctor describe any difficulties you have with activities such as walking, standing, sitting, lifting, carrying, concentration problems due to pain, etc.

The next thing to do is to be open and honest with your doctor about your symptoms every time you go. Many people will assume that since they have told their doctor once they don’t need to do so again. The problem is that Social Security needs to see how your condition affects you over a long period of time. If your limitations are not documented consistently throughout your record, Social Security is very likely to find that your condition is not as severe as you say it is.

Next, help your doctor by documenting your symptoms yourself. For example, you can keep a journal or calendar that keeps track of both how often you have symptoms and how severe they are. If you have depression it is a good idea to document those periods when you have severe depression that keeps you from functioning. Then you can take that documentation with you to your doctor’s visits to make sure they are aware of how limiting your depression is. Often times Social Security judges will think you are lying if you tell them you have very severe symptoms despite taking medications or seeing a doctor regularly. They think the doctor would take further action like changing your medication if you were really that bad off.

Lastly, make sure you document any difficulties you have obtaining medical care. If your doctor prescribes a medication that you can’t afford, make sure to let the doctor know you can’t afford it and have the doctor write that down in your records. The same is true for any other medical treatment such as a surgery or a recommendation for physical therapy, and any other reason you don’t get treatment such as unacceptable side effects or transportation problems.

Taking these steps will not guarantee that you will be approved for benefits, but they will go a long way to helping you prove your claim.