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Social Security Disability Benefits: The Basics

The Social Security disability benefit system is perhaps the most confusing of all the federal bureaucracies a citizen may be required to confront, either as a person filing a claim for benefits or as a health professional required to provide medical evidence to support such a claim. Understanding a few basic principles about how the system works will help to demystify the process and avoid unnecessary delays in providing much-needed benefit payments to disabled claimants. What follows is simply a thumbnail sketch of the system, focusing on three important concepts - When is a person "disabled" for Social Security purposes? What benefits are available for one who is disabled? And what hoops must a person jump through to begin receiving benefits?

When Is A Person "Disabled" For Social Security Purposes? The essence of a "disability" under Social Security rules is the inability to work. Generally, if a physical or mental condition causes a person to be unable to do any kind of work for which s/he is suited (given the person's age, education, and work experience) and the disability is expected either to last for at least one year or to result in death, then that person will be considered disabled for Social Security purposes.

In deciding if an applicant is disabled, the Social Security asks five questions:

Is the applicant working? - if so and his or her earnings average more than $500 per month, s/he generally will not be considered disabled.

Is the applicant's condition "severe"? - the answer to this question depends on the extent to which the condition interferes with basic work-related activities.

Is the applicant's condition found in SSA's list of disabling impairments? SSA keeps a list of impairments that are so severe that they automatically warrant a finding of disability.

Can the applicant do the work s/he did previously? - if an applicant's condition is severe, but not as severe as any listed impairment, the SSA must determine if the condition interferes with the applicant's ability to do the work s/he did in the last 15 years.

Can the applicant do any other type of work? - if the applicant cannot do the work s/he did in the last 15 years, the SSA evaluates whether s/he can do any other type of work, considering the applicant's age, education, past work experience, and transferable skills. What Benefits Are Available For A Disabled Person? Social Security administers four separate benefit programs for individuals with disabilities - Social Security Disability Insurance (SSDI), Supplemental Security Income (SSI), Disabled Widows and Widowers benefits (DWB), and Disabled Adult Child Benefits (DAC). The medical requirements to prove disability, as well as the process for making disability determinations, are the same under each program. The primary difference among the programs is that eligibility for SSDI, as well as the calculation of benefits, is based upon the applicant's prior participation in the Social Security system (i.e., working and paying Social Security taxes). Eligibility and benefit calculation for SSI, on the other hand, depends upon financial need. DWB and DAC benefits are based on the Social Security payment record of another person: a deceased spouse for DWB, and a parent who is deceased or receiving Disability or Retirement Insurance Benefits his or herself for DAC.

A person who is eligible to receive SSDI will automatically be enrolled in Medicare after receiving 24 months of benefits. Medicare has two parts - hospital insurance (which is free for SSDI recipients) and medical insurance (which requires a monthly premium). A person who is eligible to receive SSI payments qualifies for Medicaid.

What Steps Must A Person Take to Obtain Disability Benefits? A person who becomes ill or injured and, as a result, is unable to work should take the following steps to apply for disability benefits:

1. Obtain appropriate medical care for the illness or injury. Appropriate medical information documenting the condition is essential.

2. File an application with any Social Security office. Just when to file a claim can be a tricky question because of the requirement of proof that the disability must prevent a person from working for at least one full year. Applications may be filed by phone, mail, or in person. If the applicant has questions about completing the application or about the claims process, it may be helpful to consult with a representative from Lighthouse Social Security Services, concentrating in Social Security disability law.

3. The application will be sent to a Disability Determination Services (DDS) office. Based upon the application and available medical data, DDS will decide if the applicant qualifies. If the information provided to DDS is insufficient, the applicant may be asked to undergo an examination. Although DDS uses qualified physicians, these exams are sometimes criticized for being quick and superficial, perhaps because DDS is allowed to pay very little for them.

4. Once DDS makes a decision, SSA will adopt that decision and the applicant will receive a written notice - if the claim is approved, the notice will show the benefit amount and the month payments begin; if the claim is denied, the notice will state why.

5. In most cases, an initial claim for benefits is denied. Three levels of administrative appeal are available:

First, a request for reconsideration - this will be decided by a different team than the one that issued the initial determination. Very few reconsiderations result in a different decision.

If the claim is still denied, the applicant may request a hearing before an administrative law judge (ALJ). Although some people choose to have legal counsel from the initial filing of a claim, representation by an Disability Associate experienced in Social Security law is most important at the administrative hearing.

If the ALJ denies the claim, the applicant may request a review by the Social Security Appeals Council. After all administrative appeals are exhausted, the claimant may file an action in federal court. The time limit for each level of the appeal process, including administrative appeals and court actions, is 60 days from the date the applicant receives an unfavorable decision.

Applying for disability benefits can be a frustrating ordeal, but it need not be overwhelming. Simply knowing what to expect at each stage of the process and, where necessary, seeking the advice of competent medical and Social Security Disability professionals, can reduce anxiety - that and a good dose of patience.

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