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In This Section

The Process

Introduction

When a person feels unable to work due to a physical or mental impairment and chooses to apply for Social Security disability benefits, a myriad of medical, psychiatric, psychological, legal, social, cultural and financial forces conspire. Below is information about the process.

To render a disability determination, the Social Security Administration employs a well known five step sequential analysis. Step 1 of the sequential analysis is the question: are you working? If a claimant is working and earning at a level of “substantial gainful activity,” s/he is, by definition, not disabled. At Step 2 of the sequential analysis, if the claimant is not working, a decision is then made as to whether the claimant has a “severe impairment.” This is essentially a de minimus standard to weed out frivolous claims. At Step 3, a determination is made as to whether the claimant meets or equals in severity a listed impairment. If s/he does, the claimant will be found disabled. After Step 3, but prior to Step 4, a determination as to the claimant’s “residual functional capacity” is made. Once “residual functional capacity” is established, at Step 4 a determination is made as to whether the claimant can return to her/his “past relevant work.” If the claimant can return to her/his “past relevant work,” unless a GRID rule applies, s/he will be found not disabled. If it is determined at Step 4 that the claimant cannot return to her/his “past relevant work,” at Step 5 a determination is made as to whether the claimant retains the “residual functional capacity” to perform any other type of work which exists in significant numbers in the regional or national economies.(See 20 CFR 404.1520).

Initial

After Social Security personnel complete the application process, the “initial” application is sent to Disability Determination Services (DDS), a state agency under contract with the federal government to make disability determinations. The DDS claims examiner assembles the claimant’s medical records, with the help of the claimant’s attorney if one is involved, and the case is sent to a DDS reviewing physician for a disability determination. The claim is then sent back to the local Social Security District Office for the issuance of a Notice of Initial Determination.

Reconsideration

If denied, the claimant has the right to file a “Request for Reconsideration,” at which time the file will be returned to DDS to a new claims examiner for additional development of the medical record, if necessary, and for a second disability determination by the DDS reviewing physicians. The file is then again sent back to the Social Security local District Office for issuance of a “Notice of Reconsideration.”

Hearing

If denied again at the reconsideration level, the claimant has the right to Request a Hearing before an Administrative Law Judge at the Office of Hearings and Appeals. The average delay from the filing of a Request for Hearing to the scheduling of the hearing varies but currently is approximately sixteen (16) to eighteen (18) months at the Providence Office of Hearings and Appeals. At the hearing, the ALJ often employs the services of medical and vocational experts to provide expert opinion evidence as to the claimant’s medical condition, residual functional capacity, and ability to work, including statistical data regarding the existence and incidence of jobs the claimant could perform, despite his/her impairment. After the hearing is held, the average processing time for the issuance of a decision is anywhere from one to six months.

Appeals Council

If the ALJ issues an Unfavorable Decision, the claimant can file a Request for Review with the Appeals Council. The Appeals Council is located in Falls Church, Virginia and handles Requests for Review of Unfavorable Decisions (at the hearing level) for the entire country. With rare exception, the Request for Review entails a written Memorandum of Law, alleging factual and/or legal errors.

District Court

If the Appeals Council affirms the ALJ’s Unfavorable Decision, the claimant has the right to file a complaint for relief in the United States District Court (USDC) for the district in which s/he resides.

Disability Service Improvement - DSI

It should be noted that the Social Security Administration has launched a pilot program in Region I (Rhode Island, Connecticut, Massachusetts, Vermont, New Hampshire and Maine) called “Disability Service Improvement” (DSI). DSI was launched as of August 1, 2006 and pertains to all initial claims filed on or after August 1, 2006. Under DSI, the Reconsideration level has been repealed and replaced with a review by a Federal Reviewing Official who works out of Falls Church, Virginia.

Additionally, under DSI, the Appeals Council has been repealed and appeal of an unfavorable Hearing Decision on claims filed on or after August 1, 2006 will lie directly in the federal courts. However, during the pilot phase of DSI, the existing Appeals Council will review 100% of ALJ Hearing Decisions for accuracy relative to claims filed on or after August 1, 2006.

These changes apply only to claims filed in Region I (Rhode Island, Connecticut, Massachusetts, Vermont, New Hampshire and Maine). For the rest of the country, the procedures set forth above remain in effect.

For more information regarding DSI, go to www.ssa.gov.