You’ve worked hard to pay into the Social Security system. Now, you have an injury or illness that prevents you from working. You should be able to collect disability benefits, but the criteria to qualify are confusing. The right attorney can make all the difference.
As you’ll see, while the Social Security Administration (SSA) has guidelines regarding qualifying disabilities, ultimately, whether you qualify is highly individualized. That’s why it’s so important to speak with an experienced Social Security Disability lawyer who can analyze your individual situation and explain your rights and options.
What is the SSA “Blue Book” of impairments?
The Social Security Administration’s Listing of Impairments, also known as the “Blue Book,” is a list of medical criteria that the agency uses to evaluate adults for disability. The categories of medical conditions included in the list are:
- Musculoskeletal disorders
- Special senses and speech disorders
- Respiratory disorders
- Cardiovascular conditions
- Digestive disorders
- Genitourinary disorders
- Hematological disorders
- Skin disorders
- Endocrine disorders
- Congenital disorders that affect multiple body systems
- Neurological disorders
- Mental disorders
- Cancer
- Immune system disorders
The listing of impairments plays an important role in SSDI claims, but it’s important to know that this is a guideline, not a set of hard and fast rules. Put another way, you can’t just look up your illness or injury on the list and find out whether you qualify. Rather, whether you qualify for SSDI is based on how your medical condition (or combination of medical conditions) affects your ability to work.
What is the substantial gainful activity (SGA) standard?
To qualify for SSDI, you must have a medical condition that prevents you from engaging in substantial gainful activity. This is a certain level of monthly income that changes every year (note that SGA only includes income earned from labor, not passive income).
If your actual income is higher than the SGA threshold, then your SSDI claim will almost certainly be denied. But even if your current income is below the threshold, if the Social Security Administration believes you could be earning more than the threshold, they will likely deny your claim. This might be the case if you are engaging in volunteer or unpaid work that you could do for pay. It may also be the case if the SSA thinks your medical condition isn’t severe enough to prevent you from working.
Here, again, the outcome of your case depends on highly individualized factors. The same medical condition could be manageable for one person and utterly crippling for another. It depends on the severity of your symptoms, the way your body responds to treatment, and the nature of the work you are trained and experienced to perform.
What are presumptive conditions for SSDI?
Certain conditions are considered “presumptive” disabilities, generally because they are quite severe. Presumptive conditions include:
- Loss of a leg at the hip.
- Total deafness in at least one ear.
- Total blindness in at least one eye.
- Immobility without a wheelchair.
- Stroke (at least three months ago) that has caused difficulty walking or using a hand or arm.
- Cerebral palsy.
- Symptomatic HIV/AIDS.
- Spinal cord injury (SCI) that renders you unable to walk independently.
- End-stage renal disease (ESRD).
- Amyotrophic lateral sclerosis (ALS)/Lou Gehrig’s Disease.
- A terminal illness requiring hospice care.
Presumptive conditions aren’t guaranteed to be qualifying disabilities, but they do qualify for faster approval and payment. However, you still need to prove that you have a qualifying disability under the usual criteria.
How age affects your qualifying medical condition
Another key factor in whether you qualify for Social Security Disability is your age. While all adults under 65 can qualify for SSDI if their work history and medical condition are significant, adults over 50 have an easier time qualifying because of the way the SSA looks at impairment.
If you are under 50, the Social Security Administration looks at whether you can engage in any substantial gainful activity, regardless of your current level of training or experience. In other words, if you could realistically pursue retraining and change jobs to accommodate your disability, then you likely will not qualify for SSDI.
However, if you are over 50, the SSA does not expect you to pursue as much retraining because you are closer to retirement age. At that stage of life, the SSA looks at whether your medical condition prevents you from doing the job or jobs that you are already trained and experienced to do. Depending on the type of work you do and the type of medical condition you have, this means you might qualify for SSDI even if you could theoretically get a different job with retraining.
How to prove you have a qualifying medical condition
Ultimately, to qualify for Social Security Disability, you need a medical condition that prevents you from engaging in substantial gainful activities and is expected to last at least 12 months. You also need to prove that you have engaged in medical treatment and followed your doctor’s instructions and that even with treatment, your condition stops you from working. The Social Security Administration needs to know when your condition began so that they can determine a start date for your benefits.
This all must be proven with medical evidence. According to SSA regulations, you need to prove this using objective medical evidence from an acceptable medical source; that is, a qualified physician.
Medical records you may need to provide include:
- Doctor’s diagnostic reports.
- Treatment records.
- Progress notes.
- Other medical records.
You don’t necessarily need to include these documents with your initial application for Social Security Disability. If you list your doctors, hospitals, and other medical providers in your application, the Social Security Administration will reach out to your medical sources and request the records they need. However, providing the records up front can get your claim processed faster. In addition, you have certainty that the SSA will review exactly the documents you want them to see.
What to do if the SSA says your medical condition doesn’t qualify
If the Social Security Administration says you don’t have a qualifying medical condition, you have 60 days to request reconsideration. If you do so, a different medical consultant and claim examiner will review your file and make a new determination. You can submit additional medical evidence on reconsideration to be taken into account as well.
If the SSA reaches the same decision on reconsideration, the next step is a hearing before an administrative law judge (ALJ). The ALJ will review medical evidence and testimony about your condition and may ask questions about your injury or illness and how it has affected your ability to do your job. The ALJ will then reach a decision.
If the ALJ hearing doesn’t get your claim approved, then there are additional levels of appeal as well. At each stage, you need to meet strict deadlines and legal requirements in order to move your claim forward. And at each stage, it’s important to have competent legal representation to protect your rights and interests.
How a Social Security Disability attorney can help
Proving you have a qualifying condition is the key to obtaining SSDI benefits. While your doctor plays a key role in creating the required medical documentation, your lawyer also plays a crucial role by gathering and presenting those records in a manner that the SSA will find convincing.
An experienced Social Security Disability lawyer understands the qualifying medical conditions and knows what types of documentation are needed to get a claim approved. If there is a dispute regarding your qualifying medical condition, your attorney can represent your interests in hearings and appeals.
If you need help proving your medical condition to qualify for Social Security Disability benefits, you need the right attorney to handle your claim. Disability lawyers offer free consultations and work on contingency, meaning you don’t have to pay out of pocket. Contact a Law.com Premier Attorney in your area today.
