Martin on Social Security
Part 2 – Topics
Disability Benefits
Claimant Categories
§ N 100. Disabled Worker Claiming Disability Insurance
Social Security disability insurance benefits are paid to disabled workers who meet a special insured status test and apply for benefits. Benefits are not paid until the individual has met the Act’s disability standard for 5 months. However, this 5 month waiting period does not apply to individuals who have previously received disability benefits or to those who have had a recognized period of disability within the past 5 years.
[Supporting and Elaborating References] [Related Sections: Part 1 - Part 2]
§ N 200. SSI Disability Benefit Claim
Individuals who meet the Social Security disability standard, whether or not they have the insured status necessary for disability insurance benefits, are potentially eligible for Supplemental Security Income (SSI) disability benefits. To qualify they must have income and assets falling below the SSI limits.
Entitlement to Social Security disability benefits is not necessarily inconsistent with eligibility for SSI because Social Security benefits for individuals with low past earnings can be less than the SSI income limit.
Since SSI benefits do not require insured status or, indeed, any past work, they are available when a currently disabled adult cannot establish the onset of disability while he or she met the insured status test for Social Security. They are also available to young adults and children.
In Sullivan v. Zebley, 493 U.S. 521 (1990), the Supreme Court held that the regulations limiting child SSI disability benefits to those who had a listed impairment or the equivalent violated the statutory provision extending benefits to children who suffer for impairments of “comparable severity” to those which would establish disability in an adult. Regulations responding to Zebley were issued by the Agency in February 1991. A Social Security Ruling based on Zebley, SSR No. 91-7, was issued in August 1991. These provisions gave children claiming SSI who do not meet or equal a listing a further opportunity to show disability, through a process largely analogous to the residual functional capacity assessment in adults.
The Act was amended in 1996 to eliminate the language supporting this element of individualized assessment of children.
Rev. 9/96
[Supporting and Elaborating References] [Related Sections: Part 1 - Part 2]
§ N 300. Disabled Widow(er) Claiming Survivors Benefits
Surviving spouse benefits are normally limited to those age 60 or over and spouses caring for eligible children. However, disability can drop the age threshold for a surviving spouse from 60 to 50 years old. To qualify, however, the disability must have commenced within seven years of the insured worker’s death or last receipt of mother or father benefits.
The test of disability applied to surviving spouse claimants has historically been somewhat stricter than the standard applied to disabled workers. The different standard was removed by a 1990 amendment to the Act with the result that the tests are now the same.
[Supporting and Elaborating References] [Related Sections: Part 1 - Part 2]
§ N 400. Older Child Claiming Social Security Because of Disability
Entitlement to family benefits as a child of an insured worker normally ends at age 18. However, an older individual, otherwise entitled to such benefits, can qualify if the individual is disabled and that disability began before age 22. This provision makes it possible for an adult to receive child benefits. As is true of child benefits generally, such disabled adult child benefits are not available until an insured parent dies or starts drawing old-age or disability benefits.
Rev. 11/05
[Supporting and Elaborating References] [Related Sections: Part 1 - Part 2]
§ N 500. Claim for a Period of Disability Earnings Record Freeze Apart From Benefit Claim
The Act provides that a continuous period during which an individual is disabled will be dropped from benefit and insured status calculations. Such a “disability freeze” applies to calculations for all types of benefits. It can apply to survivors benefits based on the earnings of a deceased worker who never sought disability benefits before his death. To be eligible for a determination that such treatment applies the individual must meet a special insured status test, the period of disability must last at least 5 months, and the individual (or a representative) must file an application while disabled or within 12 months after the disability ends.
The time within which an application must be filed is increased to 36 months in certain cases. Because of the “disability freeze” individuals can delay applying for disability insurance benefits until long after becoming disabled so long as they can establish that the onset of disability occurred while they still met the insured status test for those benefits.
[Supporting and Elaborating References] [Related Sections: Part 1 - Part 2]
Context of Disability Issue
§ N 600. Claim Resting on Initial Finding of Disability
The critical issue in most disputed claims for disability benefits of all types is whether the individual meets the appropriate standard of disability at the time of application or within a relatively short time before. Title II disability benefits can be paid for a period of eligibility extending prior to the filing an application, but that period cannot be more than 12 months. Consequently, while the “disability freeze” provisions allow an application to be filed long after the onset of disability, retroactive benefits will not reach back more than a year.
Rev. 11/05
[Supporting and Elaborating References] [Related Sections: Part 1 - Part 2]
§ N 700. Claim Focusing on When Person Became Disabled
Entitlement to Title II disability benefits critically depends on exactly when an individual who is currently disabled and who was disabled at the time of filing a benefit application became disabled. That is because entitlement depends on meeting an insured status test. Unless the individual becomes disabled while still holding insured status (which would give rise of a period of disability, thus preserving insured status) benefits are unavailable. Since the insured status test requires quarters of coverage in the period immediately before the onset of disability, a disabled individual who ceased working because of health problems some time before meeting the Act’s standard of disability may not qualify for benefits unless those health problems reached the Act’s standard before the absence of earnings caused insured status to be lost. Moreover, a claimant who at one point met the Act’s standard while insured but then experienced medical improvement may not qualify for benefits because of the need to show that the current period of disability began while the person had insured status.
Less often and less critically the issue of when the claimant became disabled can go to the issue of when entitlement began. Since Title II disability benefits can only be paid for 12 months prior to application such disputes involve much smaller stakes.
Establishing an “onset date” prior to the first time the claimant sought medical attention is difficult but not impossible. Social Security Ruling SSR No. 83-20 deals with this problem.
Rev. 3/95
[Supporting and Elaborating References] [Related Sections: Part 1 - Part 2]
§ N 800. Issues of Terminating Disability Benefits – In General
Unlike Social Security benefits that rest on attainment of a certain age or the death of an insured worker, disability benefits rest on a condition that can be reversible. The definition of disability requires only that a disability be expected to last a year. Consequently, benefits can be paid in cases where an end to disability is foreseen. But whether or not foreseen, an end to disability ends entitlement to disability benefits and leads to termination of benefits for the claimant and any dependent family members.
The difficulty of the disability determination also increases the likelihood that new evidence will cast doubt on an initial determination of eligibility. Such a reversal of position which is possible though less likely with other types of benefits can also lead to termination and perhaps even a conclusion that benefits have been overpaid.
Disability beneficiaries threatened with termination have an option to continue payments through the hearing stage, subject to having those payments treated as overpayments should the hearing decision by the administrative law judge (ALJ) affirm the termination.
[Supporting and Elaborating References] [Related Sections: Part 1 - Part 2]
§ N 810. Issues of Terminating Disability Benefits – Medical Improvement
Since receipt of disability benefits rests on an initial determination of disability, termination of benefits on the ground that the person is no longer disabled must rest on affirmative evidence that the individual’s condition has improved. While the individual carries the burden of proof in establishing initial disability, the Agency has the burden of establishing medical improvement.
The Act gives a recipient the right to have benefits continued during an administrative appeal from an Agency determination that the recipient is no longer entitled to benefits because of medical improvement.
The Act also provides that disability benefits should not be terminated while the recipient is participating in an approved vocational rehabilitation program. This exception is conditioned on an Agency determination that the program will increase the likelihood the individual may be permanently removed from disability benefits. The Agency’s view is that this exception does not apply in cases of medical improvement.
When a cessation determination is appealed, the Agency’s view is that the ALJ should consider only medical evidence of the recipient’s condition at the time of that determination. However, in Difford v. Secretary of Health and Human Services, 910 F.2d 1316 (6th Cir. 1990) the Sixth Circuit held that the Act requires the ALJ to consider the recipient’s condition at the time of the hearing.
In DE, NJ, PA, and VI an acquiescence ruling (AR 86-4) implements the Third Circuit’s ruling in Paskel v. Heckler, 768 F.2d 540 (3d Cir. 1985) that an individual in a vocational rehabilitation program is entitled to a “likelihood determination” before termination of benefits despite medical improvement.
In AK, AZ, CA, GU, HI, ID, MT, NV, OR, and WA an acquiescence ruling (AR 86-5) implements the Ninth Circuit’s ruling in Leschniok v. Heckler, 713 F.2d 520 (9th Cir. 1983) than an individual in a vocational rehabilitation program is entitled to a “likelihood determination” before termination of benefits despite medical improvement.
Rev. 6/97
[Supporting and Elaborating References] [Related Sections: Part 1 - Part 2]
§ N 820. Issues of Terminating Disability Benefits – Trial Work
When a person actually returns to work that pays above a level set by the Agency the earnings are ordinarily taken as establishing that the individual is not disabled but able to engage in substantial gainful activity. However, the Act provides a period in which a previously disabled person can test his or her ability to return to work without losing benefits. This is termed a “trial work period” and is the subject of detailed regulations.
Disability beneficiaries are entitled to 9 months of trial work, not necessarily consecutive. Originally only 1 such trial work period was allowed during a period of disability. The Act now provides for a rolling 5 year (60 month) period. A beneficiary exhausts the 9 month trial work period only if he or she exceeds 9 months of trial work during this rolling 60 month period. Monthly earnings above a stipulated level, an amount less than the "substantial gainful activity" threshold, cause the month to be counted. (For 2008 this trial work earnings figure is $670.)
Following a period of trial work there is a “reentitlement period” during which benefits resume in months in which the individual’s earnings fall below the level establishing substantial gainful activity.
In Barnhart v. Walton, 535 U.S. 212 (2002), the Supreme Court upheld the Agency’s interpretation of the trial work provisions of the Act, namely that a “trial work period” is not available to a claimant who returns to work within 12 months of disability onset, before entitlement has been established. Several circuits had taken the contrary view.
Rev. 11/07
[Supporting and Elaborating References] [Related Sections: Part 1 - Part 2]
§ N 830. Issues of Terminating Disability Benefits – Revised View of Original Determination
Issues concerning administrative res judicata and the circumstances under which the Agency can open up a prior determination are raised whenever disability benefits are terminated under circumstances that indicate that the Agency is reopening the original determination rather than concluding that the recipient’s condition or situation has changed.
[Supporting and Elaborating References] [Related Sections: Part 1 - Part 2]
§ N 840. Issues of Terminating Disability Benefits – Reasons Other Than Medical
There are a variety of situations in which disability benefits can be terminated without regard to the individual’s medical condition. For example, a disability benefit recipient who returns to work that does not fall under a trial work period can lose eligibility because of his or her substantial gainful activity. This is true even though there has been no change in medical condition. A recipient who is incarcerated will have benefits suspended on that ground without regard to medical condition.
While the Act gives a recipient the right to have benefits continued during an administrative appeal from an Agency determination that the recipient is no longer entitled to benefits because of medical improvement, the regulations limit that right to such cases.
Rev. 3/96
[Supporting and Elaborating References] [Related Sections: Part 1 - Part 2]