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How Disability Determination Works – Behind the Scenes

How Disability Determination Works – Behind the Scenes

by Barbara Prokasy

Since I am retired from a Social Security Disability Determination Services office, I would like to share with you how determination works.

The Social Security office does not decide if you are disabled, but they have set up their standard(s) of what constitutes disability. This is what you must qualify for and meet in order to receive a disability check. Claimants must apply at this office if they feel they are disabled, or a family member can apply if the claimant is unable to do so.

Below is kind of a summary on disability information and how Social Security bases your inability to work:

"Disability under Social Security is based on your inability to work. You will be considered disabled if you are unable to do any kind of work for which you are suited and your inability to work is expected to last for at least a year or to result in death.

Social Security benefits will not begin UNTIL THE 6th FULL MONTH OF DISABILITY. This "waiting period" begins with the first full month after the date we decide your disability began.

Once a decision on your claim is reached, you will receive a written notice from the Social Security Administration. If your claim is approved, the notice will show the amount of your benefit and when payments start. If it is not approved, the notice will explain why."

The rules in the Social Security law for determining disability differ from those in other government and private programs. They will be affected if you are also eligible for workers’ compensation or from certain federal, state, local government, civil service or military disability programs. Total combined payments to you and your family from Social Security and any of these other programs generally cannot exceed 80% of your average current earnings before becoming disabled.

Social Security does not pay for partial disability or for short-term disability. If you are receiving disability benefits and reach age 65, they become retirement benefits and the amount remains the same. The amount of your monthly disability benefits is based on your lifetime average earnings covered by Social Security. You may continue to earn money, but will STOP if you work at a level they consider "substantial" — an average of $500 or more a month.

Disability benefits for children are available to many who suffer some form of mental retardation, others from various childhood conditions. I, myself, don’t think HSP is anything Social Security would pay disability for unless the child was using a wheelchair (or other assistive device) or had another disabling problem along with HSP to contend with. Each case is different. For more information on this, ask Social Security for the booklets, SSI (Publication No. 05-1100) and Social Security and SSI Benefits for Children with Disabilities (Publication No. 05-10026). They are free. These can be picked up or sent to you through your local Social Security office, or you can call 1 (800) 772-1213 on their toll-free number.

And, should you be able to qualify, you will be automatically enrolled in Medicare after you have been getting disability benefits for two years.

After an application is made it is assigned to a case worker. The folder is put together at their office stating the claimant’s disability. In this folder placement is made of any doctor reports, testing, hospitalizations, etc. the claimant may have brought in, their birth certificate, wages earned, contacts to be called if necessary (family, friends) and names of the doctors they have already seen, time seen, addresses, etc., etc., etc. After all this is finalized, the case is then sent over to the Disability Determination Services for processing.

There it is again assigned to what is referred to as an "examiner". The examiner gives the case to a technician (which is what my role was), and they quickly review the claim and request information from the doctors the claimant indicated they had seen along with any testing to confirm their allegation(s). Sometimes forms must be sent out to the claimant or family (such as for seizures). The claimant cannot "see" what is happening to them or know how long the seizure lasts. Therefore, a family member needs to fill out this information. And, sometimes the claimant is a child so the teacher has to be sent forms to be completed. Some claimants may have as many as 15-20 doctors which have to be contacted. Normally, a case may take upwards to three months to complete if the claimant responds to all requests promptly and their doctors agree to send in the testing which has been done. Some doctors may have nothing on the claimants. I’ve seen cases that have taken over a year to process. The claimant keeps calling in with new allegations, or goes in for more operations, etc. and every one must be thoroughly processed before a determination is allowed. What takes so long is just receiving the information so a decision can be made. Doctor offices and hospitals are well known to just taking their time in looking and getting something out in the mail for their disabled patients. They work first with their on-hand patients.

After all the doctors, hospitals, whatever have been contacted and reports received, the examiner will review the case to see if a determination can be made. Most of the time there will not be any recent testing done because most of the people who apply cannot or do not have the money to see doctors. (A lot of street people apply.) When this occurs, and in most cases it does, the Determination office must contact one of the state doctors and set up an examination for the claimant. Sometimes the claimant must be scheduled for an x-ray before the doctor will see them. This may take another month-six weeks before the examination is made and the doctor’s report is received. Many claimants make up some excuse at the last minute as to why they cannot go to the examination, so another one has to be made. If they cannot (or will not) make three in a row, they are automatically denied for lack of cooperation.

When receipt of all possible information has been received the examiner will read through the case and make a decision according to the rules of Social Security. The case will then be reviewed by their supervisor. If the supervisor feels the determination is correct, it will then be reviewed by a staff doctor according to the particular field (mental, physical, etc.) of the allegation(s). If not, the case is given back to the examiner for further work. If it does go into staffing, the staff doctor will have to sign the case indicating it has been thoroughly reviewed by them.

At this point many people have come to the same decision. If the staff doctor or the supervisor felt something else needed to be checked before this point, the case would have been sent back to the examiner for further action. BUT, before the folders are sent back to the respective Social Security offices, every day a random number are chosen to be sent to the District Office for review. Occasionally, the reviewers in this office feel a correct decision has not been made at the Determination office, and it is sent back for further testing or whatever (That’s a black mark against the Determination office and highly frowned upon!). Therefore, everything possible is done beforehand in judgment so this does not happen.

In order to received Social Security benefits, one must be so ill they will be dead within a year, or so physically or mentally disabled that they can no longer do any kind of work like they were trained to do. In our cases, we do not qualify until it is shown we need some kind of an assistive device in order to ambulate and get around in (walker, wheelchair). Some of you may have other handicaps which may qualify you at an earlier time.

So, Social Security applications are not seen by one person. I know there have been rumors saying, "You have to apply three times before you can get it". That’s silly and just nonsense. I’ve seen thousands of cases in my time with the Determination office. For those that claim this, they are only trying to get the $$$. They are not truly disabled. For a laugh for you folks, some claim a swollen toe and bad hangnails, or one even claimed he had the flu, his girlfriend had walked out on him, and he had no car. Some may feel they are disabled, and even their doctor claims they are……but they have to meet the Social Security rules. They are the ones who pay out the money. There are many who just don’t quite make it but will in another year or so. Those are the ones who have to apply, and then go back at a later time and reapply. Some diseases just take their time until the victim is ‘truly disabled’. When this happens disability will go back to their first onset date.

For details about social security disability, click here.

For a White Paper regarding a structural model of Social Security’s Determination Process, click here.


Saturday, September 8th, 2012