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First Impressions: What a Claims Examiner Determines About Your Adult Social Security Disability or Supplemental Security Income Claim in the First 15 Minutes 

 

From Disability ESP Newsletter, V5, Issue 1  

 

According to the Social Security Administration,

“… Disability for an adult is based on your inability to work because of a medical condition.  To be considered disabled:

·           You must be unable to do work you did before and we decide that you cannot adjust to other work because of a medical condition.

·           Your disability must last or be expected to last for at least one year or to result in death.

Social Security pays only for total disability.  No benefits are payable for partial disability or short-term disability.

For adults, we use a five-step evaluation processto decide whether you are disabled under Social Security. The process considers any current work activity you are doing, and your medical condition and how it affects your ability to work.”

In light of this definition, I thought it might be useful as an ex Social Security Disability Examiner (DE) to share with you what I did within the first fifteen minutes after a new claim was received on my desk for processing.

[Do keep in mind that the Disability Determination Service (DDS) offices are separate from the office that accepted your claim. The Social Security local Field Office generally accepts your claim and makes certain non-medical and non-vocational determinations on your eligibility, prior to forwarding your claim to the DDS office. The DDS office houses the claims examiners who make decisions on whether you are medically and/or vocationally disabled. So if your claim reaches the DDS office, it generally means that you have passed all the other non medical/vocational requirements, such as financial eligibility, etc.)

The Cheat Sheet

 As a disability examiner for the DDS office, I created a one page cheat sheet that I used which contained a list of the core factors that would determine how easy or how hard it would be to approve an individual’s claim for disability benefits. Yes, contrary to popular belief, the examiner does not begin your case trying to decide how to deny your claim, but instead is trained to do all that is possible under Social Security Disability law to approve your claim in the quickest manner possible, even given the limitations of the system.

Core Requirements

Core things that I looked at in the first fifteen-minute review of an application/claim for disability benefits included: age, education, work history, diagnosis (es), whether the claimant was alleging a physical disability or a combination physical / mental disability, and whether the diagnosis was one that could automatically be allowed benefits, or whether it was one which could be expected to resolve itself within one year. Also noted on my cheat sheet were the date of the last medical exam or treatment the claimant had received, and whether the claimant had a regular treating physician and /or psychologist.

My cheat sheet also included whether the claim was for regular Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI). If it was for SSI (or a combination of SSDI and SSI), and the claimant had a severe impairment that was obviously disabling, I could at that moment expedite the claim to allow the claimant to get benefits immediately through the Presumptive Disability procedure. This option allows benefits to be paid for up to 6 months while an examiner processes an SSI claim and gathers medical and vocational evidence necessary to document and prove disability.

Another peculiarity about SSI claims is that the examiner has less leeway in asking claimants directly to help them get the information needed to prove their disability. I suppose the assumption was that people with fewer resources somehow can not assist you in getting documents. (I generally ignored this erroneous assumption on the part of the SSA, and instead assumed that applicant’s applying for SSI should be given the same chance as everyone else in assisting in the process of information gathering, and in fact, they may have an even greater incentive to assist a claims examiner.)

With that said, let’s take a brief look at each of these separately.

[Next: Factors Considered Including Age, Education, Work History and Diagnoses]

 
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