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Eligibility for Social Security Disability Insurance

The following is an excerpt of a transcript in which a Virginia lawyer discusses eligibility requirements for Social Security disability insurance and the complications that can arise in the application process. If you have have been injured or have fallen ill and can no longer work or support yourself, contact his Virginia law office to schedule a free, initial consultation. If you have already applied for benefits and been denied, an attorney can talk to you about the appeals process. For a general overview, refer to this page.

What is SSDI, and what are the eligibility requirements for obtaining SSDI?

Answer: SSDI is Social Security Disability Insurance. This is an insurance benefit available through Social Security that protects individuals who have paid into the Social Security system, and have become disabled and are unable to work due to a medically determinable impairment. Part of your withholdings on your federal taxes pay into Social Security and part of it is to protect you for when you retire, but it’s also to provide for disability benefits. The eligibility requirements include needing to have worked enough years or enough periods of years to work up what are known as “work credits,” and you need a specific number of credits to be eligible for benefits, depending on how old you are and how long you’ve been in the workforce. The other requirements are that you need to have a disability that prevents you from being able to work, but the way Social Security terms it, it prevents you from being able to engage in any “substantial gainful activity” for a period of a year or longer. Either you need to have been out of work for a year or longer, or a physician or medical professional has to expect it will keep you out of work for a year or longer. There are no income requirements. A lot of people worry that if they’re married and their spouse makes money that they’re not going to be eligible for SSDI, but that doesn’t come into play with an SSDI claim.

What are some of the most common reasons why an individual might be rejected from an SSDI claim?

Answer: There are a whole host of reasons. Not having enough credits is one big one, but also if Social Security finds that you’re not disabled under their rules, for example if a doctor says you can keep working at the position you have now, that’s not sufficient, and it needs to be in the medical records. Another problem is if somebody has been waiting for years. They might have what Social Security finds to be a medically-determinable impairment, but it might not be substantiated in the medical records within the time window when they were eligible to apply. There’s a concept known as “a protective filing date” that buys you a little bit more time, if you get the ball rolling with the Social Security Administration, but it’s a last resort, and I would definitely encourage people to seek assistance as soon as they think they may have a claim. A lot of the time people get rejected after they initially apply on their own, but the review process is a multi-tiered process.

If someone gets a denial at the first level, that doesn’t mean that all hope is gone, that doesn’t mean that they have no chance of being found disabled. They can file for reconsideration. At that stage, Social Security will likely have the person examined by one of their doctors. It’s an independent doctor that will evaluate the patient, especially for someone who doesn’t have a primary care physician or someone who doesn’t have a medical history in the record, for example if they didn’t have health insurance, or wasn’t able to afford health care. A lot of the time, unfortunately, it’s a socioeconomic factor. People don’t necessarily prioritize doing a yearly checkup if they feel like they’re healthy, and then when they find out they’re not it can really be problematic. Another question is if the medical substantiation is there, within the window of time during which they would have been eligible. Another thing that happens is that people apply, they put some information on there, and then maybe their FICA earning summary from the Social Security Administration doesn’t match up with what they’ve been telling Social Security. If you claim that you have been out of work for a period of time, but have actually held a job and have been working that whole time, you’re not going to be eligible, because your medical impairment must prevent you from engaging in substantial gainful activity for a full year. If Social Security can see on your earning summary that you have been engaging in substantial gainful activity, that would be an issue for your disability claim.

All of this needs to be done with the mindset of trying to get back to work, and they do have periodic reviews for that purpose, because someone may be found disabled at one point in their life, but continue with treatment and therapy and get better, and be able to return to the workforce. That is something to keep in mind, but you’ve got to follow your doctor’s orders. If a doctor says not to work, that will be in the medical record. Sometimes physicians don’t explain functional limitations in language that SSA looks for, such as limits on your ability to do certain things, such as lift, push, climb stairs, etc. A “residual functional capacity” form can be filled out for physical and mental activity, and this helps to explain your functional limitations in a way that translates to the factors considered by the Social Security Administration. A lot of the time that makes the difference between a successful claim and one that’s not successful – having the physician go that last step of putting things in terms of inability to work and the functional limitations.

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