Basic Eligibility for Disability Benefits.
To be awarded Social Security disability benefits, an applicant must be found medically eligible by proving all of the following:
- The condition, physical or mental, must be severe enough to have a significant effect on the applicant’s ability to do basic work-related tasks.
- The condition must have lasted, by the time a disability determination has been rendered, one full year, or it must possible to make a projection that the condition will last one full year.
- The condition must be severe enough that it prevents the applicant from working and earning a monthly amount equal to what is known as SGA, or substantial gainful activity.
An applicant must also be eligible for the SSDI program by virtue of having worked and paid Social Security taxes for many years or for the SSI program by having low income and assets. Learn more about financial eligibility guidelines for SSDI and SSI.
The Decision-Making Process
Claims for both SSDI and SSI are processed in the following steps.
- A disability claim is taken by Social Security; typically, this occurs at a Social Security field office or over the telephone.
- After the disability interview has been conducted, the appropriate paperwork has been completed, and the claim has been entered into the system, it is then transferred to a state agency (Disability Determination Services, or DDS), where it is assigned to a disability examiner.
- The disability claims examiner has the responsibility of making a medical determination on the case. To do this, the examiner will begin the process of gathering the claimant’s (applicant’s) medical records by contacting doctors’ offices. This process may take weeks or even months. Once the records have been gathered, the examiner will, in consultation with medical and mental consultants (physicians and psychologists who are assigned to the examiner’s work unit at DDS), examine the case to determine the following:
- Whether the claimant’s symptoms and test results meet or equal the requirements of a disability listing.
- The nature of the claimant’s past work.
- The requirements of the claimant’s past work.
- The claimant’s mental or physical limitations that exist as a result of their condition.
- Whether or not the claimant can return to the past work, based on current mental or physical limitations.
- Whether or not the claimant can perform other types of work.
Claimants who are found to be unable to perform their past work and are also found to be unable to perform some type of other work will be found disabled and thus eligible to receive Social Security disability or SSI disability benefits.
Important Factors in the Disability Determination
The most important two things in a disability case are a person’s medical records and work history.
Medical records are key to proving a case. Your medical record should contain both objective evidence like test results but also your doctor’s subjective opinion on the specific tasks you can and cannot do. Claimants should provide exhaustive detail regarding the history of their medical treatment at the time of the application (and they should also do this when appeals are filed). Additionally, claimants whose cases are being processed and who have obtained recent medical treatment should report this treatment to the DDS claims examiner (or administrative law judge if your case has reached an appeal hearing) so that they have the latest medical information. (Learn more about medical evidence for a disability claim.)
A person’s work history can play a large role in deciding the outcome of a case because whether you can work your prior job depends on what skills and functions it requires. For this reason, claimants should provide full and detailed information regarding their work history when they are asked to complete and return work activity questionnaires. The skills involved in your prior job will also be taken into account when the claims examiner decides whether you can be expected to do another type of job. For more information, see our section on how Social Security decides if you can do past work or other work.