Healthy workers don’t like to think about becoming ill or disabled and being incapable of working for long stretches of time. It seems so far-fetched. But the reality is, a 20-year-old worker has a 30 percent chance of becoming disabled at some point before retirement age. Private insurance may help with immediate medical expenses, but the Social Security Administration (SSA) maintains a disability insurance program as well as a supplemental security income (SSI) program, intended to help workers weather long periods of disability.
The Social Security disability program is funded through payroll taxes imposed on both employers and employees, and benefits can be applied on either a temporary or permanent basis, depending on the nature of the disability. Generally, a worker can qualify to receive disability benefits if he or she:
- Suffers from a condition, mental or physical, that prevents his or her engagement in “substantial gainful activity”
- Suffers from a condition that is expected to last at least 12 months, or that is terminal
- Is under 65 years of age
- Has worked roughly five of the ten years prior to the onset of the disability (for younger workers, this requirement is scaled back proportionately)
When applying for disability insurance, medical evidence is required to substantiate the claim, clearly demonstrating the applicant’s inability to work. It is important that an applicant keep all medical records related to treatment of the disabling condition, such as laboratory test results, names and dosages of all medications taken, all records and reports from doctors, therapists, hospitals, caseworkers, and other health care providers, and all contact information for health care providers who have been involved in treatment. Also, the applicant needs to provide specific information on the work her or she did, so the that SSA’s case worker can make a determination on the applicant’s ability to work.
SSA case workers follow a five-step process to determine eligibility:
1. If an applicant is working and earning a certain minimum amount of money each month (in 2010, $1,000 per month; this figure is adjusted annually, and special rules apply to blind persons), then the application is rejected.
2. The case worker must determine if the medical condition is “severe,” meaning the disability must limit the applicant’s ability to perform basic activities such as sitting, walking, or remembering instructions.
3. The applicant’s condition must be listed on the SSA’s “List of Impairments.” If not, the severity of the applicant’s condition will be reevaluated to determine whether it belongs on this list.
4. The case worker will determine whether the applicant is prevented from doing the work he or she was doing before succumbing to disability. If the applicant can still perform this job, then he or she is ineligible for benefits.
5. The SSA will determine if the applicant can perform any other kind of work. Only after concluding that the applicant is incapable of performing any gainful work will an application be accepted.
This process can take a long time, and refusals are common; initial determinations show an acceptance rate of only 30-40 percent, though many applications that are initially rejected are later accepted through a four-stage appeals process. And while initial determinations might be made in 90 days, depending on backlog, an appeals hearing — the third stage in the appeals process — can take longer than a year of waiting time. Because of these frustrations, most applicants — as many as 90 percent — find representation to manage the application process on their behalf, whether a trained specialist or a lawyer. Fees are set by law: currently 25 percent of the retroactive dollar amount awarded, not to exceed $6,000. No fees can be charged for claims that are ultimately rejected.
Once a claim is approved, disability payments are made monthly, beginning during the sixth full month after the date on which the disability began. The benefit amount is calculated based on the applicant’s previous earnings. The SSA case worker will work through this calculation, but if the applicant has representation in filing the claim, that person will ensure that the applicant gets the full amount he or she is entitled to. And, in case of the applicant’s death, family members may be eligible to continue receiving benefits, for instance a spouse over the age of 62 or an unmarried child under the age of 18.
Supplemental Security Income (SSI) is an additional program administered by the Social Security Administration, providing assistance to low-income persons who are either elderly (65 years or older), blind, or disabled. Benefits are offered based on need rather than work history, but benefits are capped, unlike social security disability benefits, which are based on previous earnings. Eligibility requirements for SSI are similar to those for regular social security disability.
We all hope that we will never have to face the prospect of not being able to work for long periods of time because of a disability, but it is reassuring that the Social Security Administration provides a safety net.