Disability Determination – The Five Step Process

After the claimant has filed an application with the Social Security Administration (SSA), the SSA writes to the medical providers of the claimant to fax or upload all relevant medical records to their office. After a reasonable time this file is evaluated by a department of SSA called the Disability Determination Service (DDS). The DDS has specially qualified personnel and medical doctors who can understand and interpret the medical record.

If a claimant is eligible and insured according to Social Security criteria, then the disability claim is examined through a five step process by the DDS:

 

  1. Income

     

    What is the average monthly income? Is the claimant engaged in Substantial Gainful Activity?

    Is the person applying for disability benefits, earning an average income that exceeds the limit established by Social security Administration (SSA) as Substantial Gainful Activity (SGA)?

    Example – Average monthly income should be less than the following:

    Year Disabled Blind
    2017 $1170 $1950
    2018 $1180 $1970
    2019 $1220 $2040

    There are many if’s and but’s as to what constitutes an income, and certain deductions … impairment related work expenses (IRWE) are allowed in its calculation.

    There is also the issue of unsuccessful work attempt (UWA) that should not be considered in calculating SGA.

    If the claimant has income exceeding SGA level, then stop here, the claimant is not disabled, otherwise go to step 2.

    Link to SSA webpage: SGA

  2. Severe Impairment

     

    Is the medical impairment severe, and will it result in death, or, is it expected to last more than 12 months?

    The impairment must be medically determinable, that is, supported by medical records. Doctors do not make the diagnosis of severe impairment, they diagnose medical conditions, … and they may have opinions as to whether the condition is expected to get better, or deteriorate further, or result in death.

    This step requires interpretation of medical records, and DDS has qualified persons to do that. As a practical matter severity of medical impairment needs to be obvious from the medical record.

    If the medical condition interferes with activities of daily living and interferes with activities required at work, then it is not frivolous … and if it is not frivolous then it is severe.

    The activities are sitting, standing, walking, lifting weights, coordination, understanding, remembering, executing tasks, etc.

    If the impairment is not severe, or will not last more than 12 months, then stop here, the claimant is not disabled, otherwise go to step 3.

  3. SSA Listed Impairments

     

    Does the medical impairment meet or equal a listing in the published list of impairments

    Social security Administration has published a listing of medical impairments including objective criteria and other findings that will determine disability. If the claimant’s medical record contains those specific tests and findings that are same or very similar to those listed then the claimant is considered to have met the impairment listing and is considered disabled.

    SSA: Impairment listing for adults

    If the impairment meets or equals a listing then, stop here, the claimant is disabled, otherwise go to step 4.

  4. Past Relevant Work

     

    If the claimant has severe medical impairment, then the impairment affects claimant’s functional residual capacity (FRC). Given the limitations in functional capacity can the claimant still perform past relevant work?

    Past relevant work is work that the claimant has done in the past fifteen years. The physical demands of the easiest work done is compared to the current residual functional capacity.

    A guess is made by the DDS by comparing the physical demands of that specific past relevant work with the physical requirements of that work as listed in the Dictionary of Occupational Titles (DOT)

    SSA-POMS: Past relevant work

    If the claimant can do that, then the claimant is not disabled.

    If the DDS determines that the claimant can not do any of the past relevant work, then it goes to step 5.

  5. Any Other Work

     

    If the claimant did not lose at step 4 then DDS has to show that there is other work that the claimant can do with their limited capacity.

    DDS follows its published Medical-Vocational Guidelines, popularly known as the “grids”. It takes into consideration claimant’s age, education, skills, and work experience, to see if there is other work that the claimant can do, and if such work exists in sufficient numbers in the US economy.

    If DDS decides that there is such work that can be done by the claimant then the claimant is not disabled, otherwise the claimant is disabled.

    If the disability claim is denied then the claimant can follow the appeal process and request for a hearing by the Administrative Law Judge (ALJ)

    SSA: How to appeal


SSA presentation of the five step process (pdf)