Social Security Disability Eligibility: Are You “Disabled”?

There is a lot of confusion about social security disability insurance benefits. But one thing is for certain: getting social security disability benefits is not an easy road.

We all have an idea of what we think it means to be “disabled”: we generally believe we know it when we see it. This is, however, not always the case.

Consider world-renowned astrophysicist and cosmetology Stephen Hawking, who died in 2018.  Hawking was wheelchair bound early in life due to a motor neuron disease related to amyotrophic lateral sclerosis (ALS).  As he lost more and more motor function, Hawking eventually could only communicate via small cheek movements translated into speech by a sophisticated machine.

Americans unfamiliar with Stephen Hawking  would  doubtless view his iconic pictures – frail, unable to hold his head up and looking like a rag doll tossed in his wheelchair – and consider him “disabled”.

On the other hand, many of us know a person receiving social security disability that to us appear anything but disabled. While it is true that there are many who receive social security disability benefits that should not have been approved, it is more likely that the outward appearance of these disability recipients does not reflect their actual limitations and that they in fact are unable to work.

Entitlement to social security disability insurance benefits is not based on a claimant’s appearance.  Rather “disability” is a precise legal definition under the Social Security Act.  But before we consider that definition of what it means to be “disabled”, let’s consider some prerequisites to social security disability insurance entitlement.

Legal Status in US

To be eligible for social security disability insurance benefits, a disability claimant most be a United States citizen or national, or fall within specific classifications of an “Alien” ( a legal term for a noncitizen).

Insured Status

Social security disability insurance (SSDI)  is just what it says:  insurance.  It is insurance coverage for disability that you pay for via your FICA taxes.  Insurance requires that you pay your premiums  Therefore, you must have “insured status” for SSDI via payment of FICA taxes..

Insured status is a two part test.

1. you have earned at least 20 QCs during the last 10 years (“recent coverage”), and
2. you are fully insured.

For most Americans who have worked all their lives there is no problem with insured status – particularly the “fully insured” test.  But the “recent coverage” can be problematic for those who have not worked for a long time.  That is, those who have not worked at least 5 of the last 10 years may have a problem with meeting the “recent coverage” leg of the insured status test.   Those who file, fail to appeal, and refile repeatedly for social security disability insurance are in particular danger of losing their insured status.

Definition of “Disabled” under the Social Security Act

In most cases, insured status for social security disability insurance benefits is not a concern.  The main issue in a disability case is whether the person meets the legal definition for disability under the Social Security Act.  Here is that definition:

“The inability to engage in any substantial gainful activity (SGA) by reason of any medically determinable physical or mental impairment(s) which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months.”

But here is a more understandable summary of what the Social Security Act means by “disabled”.

Who decides if I am “Disabled”?

As you have already guessed, the social security administration determines whether your medical condition imposes such significant restrictions on your ability to perform work-related activity that your condition fits the definition of “disabled” under the Social Security Act. Folks here in Texas are often confused if not angry when they file a claim for social security disability benefits at the suggestion of their physician and still get turned down.  “My doctor says that I am disabled – how can they say that I am not”!

Other sources and decision determining disability do not necessarily mean that social security will find someone disabled under the social security act.  Those sources include:

• Favorable disability finding under a Short Term or Long Term Disability Policy;
• Favorable disability rating from the Veteran’s Administration;
• High workman’s compensation rating;

It should be noted, however, that these other favorable disability finding, and the supportive opinions of treating physician’s is very important evidence for social security.  Social security regulations provide that they must consider these types of evidence and get good reasons if they disregard them.

Key Social Security Disability Regulations: How the Social Security Act definition of “Disabled” is  Really Determined

Those not familiar with administrative law might assume  that the language from the Social Security Act defining “disability” that I cite in quotes above would be what social security decision-makers and Administrative Law Judges refer to day-in, day-out in deciding disability cases. That assumption would be wrong.  Social security has created pages and pages of regulations designed to implement the Social Security Act.  In determining disability, social security uses the regulation at CFR § 404.1520. “Evaluation of disability in general” referred to as the 5-step  Sequential Evaluation Process. This graphic illustrates how the Sequential Evaluation Process.    The Kaiser Permanente Foundation also has a good graphic on the steps social security follows in determining qualification for social security disability insurance or supplemental secure income benefits.  Also, take a look at our Frequently Asked Questions about social security disability.