Social Security Disability Insurance & Legal Eligibility
A person who has a serious, relatively long-term disability that interferes with their ability to work may be able to receive Social Security Disability Insurance benefits through the Social Security Administration. Eligibility for SSDI benefits involves two types of criteria. First, a claimant generally must have accumulated a certain amount of work credits, which are based on wages or self-employment income. An employee can earn up to four credits per year. To get SSDI benefits, they typically will need 40 work credits, including 20 credits from the last 10 years ending with the year when their disability began. However, a younger person may need fewer credits to be eligible.
The other set of criteria involves whether the claimant meets the definition of disability provided by SSA regulations. The agency has developed a five-step sequential evaluation process to review this medical requirement, although many cases are resolved without proceeding through all five steps.
The Five-Step Sequential Evaluation Process
The first step in the sequential evaluation consists of deciding whether the claimant is engaging in substantial gainful activity. This generally means that they are earning more than a certain amount of income per month. If they are engaging in substantial gainful activity, they are not considered disabled and are not eligible for benefits, regardless of how severe their condition may be.
If the claimant is not performing substantial gainful activity, the evaluation moves forward to the second step, which involves considering the medical severity of their impairment. They must have an impairment that significantly limits their physical or mental ability to perform basic work activities. Moreover, their condition must meet the duration requirement, which provides that the condition must have lasted or be expected to last for at least 12 months, or to result in death. The SSA will find that a claimant is not disabled if their condition is not medically severe or does not meet the duration requirement.
If the claimant’s condition is medically severe and meets the duration requirement, the evaluation will proceed to the third step. This involves deciding whether the claimant’s condition meets the criteria of an entry in the Listing of Impairments, which is a manual that classifies impairments according to the body systems that they affect. If it meets the criteria of an entry, they likely will qualify for SSDI benefits. They also likely will qualify for benefits if their condition is medically equal to a listed impairment, which means that it is equal in severity and duration.
If a condition does not meet or is not medically equal to an entry in the Listing of Impairments, a residual functional capacity assessment must be conducted. This will shape the fourth and fifth steps of the sequential evaluation. A residual functional capacity assessment determines the maximum work that a claimant is still capable of performing, despite any physical and mental limitations that affect what they can do in a work setting.
The fourth step involves asking whether a claimant can still do their past relevant work, based on their residual functional capacity assessment. Past relevant work must have been performed in the last 15 years, have involved substantial gainful activity, and have lasted long enough for the claimant to learn how to do it. If they can still do their past relevant work, they are not eligible for benefits. If they cannot do their past relevant work, the evaluation will proceed to the fifth and final step.
This last step involves asking whether the claimant can adjust to other work, taking into account both their residual functional capacity and their age, education, and work experience. If the answer is yes, they are not eligible for benefits. If the answer is no, they will receive SSDI.
Appealing a Denial of SSDI Benefits
Many claimants get a denial of an initial claim reversed upon review. The SSA provides three stages of administrative appeals. The first stage is a reconsideration, in which people who did not review the initial claim will take a fresh look at the claimant’s eligibility. A claimant also may provide more evidence in support of their claim.
If a claimant does not get benefits through a request for reconsideration, they can ask for a hearing before an Administrative Law Judge. The ALJ will review documents in the case file and listen to the testimony of the claimant and witnesses. Many denials are reversed at this stage. If the ALJ finds that the claimant is ineligible, they can appeal to the SSA Appeals Council. This is the last stage of administrative appeals. A claimant can take their case to federal court if they receive a denial from the Appeals Council.
