Aspects of Disability Decision Making: Data and Materials

A. How Disability Determinations Are MadeThe Definition of DisabilityThe Social Security Act defines disabilityas the inability to perform any substantialgainful activity by reason of any medically determinablephysical or mental impairment which canbe expected to result in death or which has lastedor can be expected to last for a continuous periodof not less than 12 months. The definition is thesame for adults in both the Disability Insurance(DI) program and the Supplemental SecurityIncome (SSI) program.Under the SSI program, children under age 18may be found disabled and eligible for benefits.To be eligible, children must have a medicallydeterminable physical or mental impairment (orcombination of impairments) that causes markedand severe functional limitations and that can beexpected to cause death or that has lasted or canbe expected to last for a continuous period of notless than 12 months.When enacted, the Social Security disabilityprogram was structured essentially as an earlyretirement program. Benefits were limited tothose individuals aged 50 and over, computed ina manner analogous to retirement benefits, andbased on a finding that the inability to work wouldbe of a “long-lasting or indefinite duration.” Theunderlying premise was that if a person has a disability,he or she is unemployable. This model hasresulted in a definition of disability in which theprimary eligibility requirement is the inability towork due to a medically determinable physical ormental impairment. While subsequent amendmentsremoved the age limitation and establishedthe 12-month duration requirement, the basicdefinition equating disability and inability to workcontinues.The Sequential EvaluationAs a result of Social Security’s unique definitionof disability, adjudicators must routinelyconsider the interaction of complicated medical,legal, and vocational concepts. The 5-stepsequential evaluation process that SSA requires alladjudicators to follow is a deceivingly simple schematicfor a process that, because of the diverseimpact of impairments on individual humanbeings, is extraordinarily complex.At each step of the sequential process adjudicatorsmust obtain and consider more and differenttypes of evidence. At the first step adjudicatorsneed only consider whether the individual is workingand the gross amount of earnings that he orshe is earning. At step 5, the last step, adjudicatorsmust look at non-medical evidence of eligibility,medical evidence, and vocational evidence. Eachstep of the process requires adjudicators to makeprogressively more complex judgments and makeprogressively difficult assessments of increasinglysubjective factors. Although not a formal step inthe sequential evaluation process, the 12‐monthduration requirement is considered at every step ofthe sequential evaluation process except the firstone. With the exception of SSI statutorily blindindividuals, any severe or disabling impairmentpreventing an individual from working must havelasted or be expected to last for at least 12 continuousmonths, or the impairment must be expectedto result in death.Adjudicators follow the five sequential evaluationsteps in the order shown below.1. Is the individual engaging in substantialgainful activity (SGA)?If the individual is working and grossing anaverage of $1,010 2 or more a month (or performingsubstantial services if self-employed), the claim isusually denied without considering medical factors.The amount of earnings used to determineif an individual is engaging in substantial gainfulactivity is established by regulation and is updatedperiodically.According to SSA’s work-oriented definition ofdisability, an impairment is significant only to theextent that it prevents work. By engaging in SGA,an individual with an otherwise severe medicalcondition has demonstrated that he or she is notdisabled by SSA rules.2. Does the individual have a severe impairment?Once the claimant has established that heor she is not presently engaging in SGA, the nextstep in the process is to establish the existenceof a severe medical condition. Fundamental tothe disability determination process is the statutoryrequirement that to be found disabled, an22012 SGA limit for non-blind individuals. Substantial gainfulactivity is limited to $1,690 for blind individuals.Aspects of Disability Decision Making: Data and Materials 83