It seems like it would be a straightforward question whether someone with an injury or illness who can no longer do their job should be eligible for Social Security Disability Insurance (SSDI) benefits. But the decision-making process of the Social Security Administration (SSA) – the federal agency responsible for administering Social Security programs – must follow complicated federal laws and regulations in its processing of SSDI claims.
Definition of disability
Many people assume that disability for purposes of SSDI eligibility is like the definition used in workers’ compensation or private disability insurance, but it is quite different. To be considered disabled and eligible for SSDI (or SSI), a claimant must have a severe physical or mental medical impairment (or combination of impairments) expected to last at least 12 months or result in death.
The condition must prevent the claimant from engaging in “substantial gainful activity” (SGA), meaning the person cannot earn more than a minimal monthly wage because of the limitations from their impairment. SGA changes in concert with national average wage levels. In 2021, the monthly SGA amount for a nonblind person will be $1,310.
So, the bottom line is that the person can work if they earn less than the monthly SGA amount and still be considered eligible for SSDI.
The five-step evaluation process
The SSA uses a five-step process to analyze whether a claimant is disabled for purposes of SSDI:
- Is the claimant working, meaning earning more than the allowed monthly SGA level? If yes, then not disabled. If no, continue.
- Is the claimant’s medical impairment severe? A severe impairment interferes with “basic work-related activities” like sitting, standing, carrying, making decisions, following directions, displaying appropriate work behavior and others. If not severe, then not disabled. If severe, continue.
- Does the claimant’s medical impairment meet or equal a listed impairment? The SSA has established a list of diagnoses that are so debilitating that if a claimant has the symptoms the SSA requires to meet a listed impairment or if the condition as manifested by the claimant is equally severe to the listing, the claimant is automatically found disabled. If the claimant’s condition meets or equals a listing, they are disabled. If it does not, continue.
- Considering the limitations and restrictions on physical and mental work activities caused by the claimant’s impairment (the reduced work ability is “residual functional capacity” or RFC), can they return to “past relevant work”? If yes, not disabled. If no, continue.
- Considering the claimant’s RFC, education, work experience and age, could they adjust to another kind of work sufficiently available in the economy? If yes, not disabled. If no, disabled and eligible for benefits (so long as nondisability eligibility requirements also met).
This only introduces a complicated process. A disability attorney can answer questions about your medical and work situation and whether it is likely to meet SSDI requirements.