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How Social Security Evaluates an Adult Claim for Disability Benefits

This is perhaps the most fundamental question a client will ask me. The conversation usually starts something like this: "My doctor says I'm disabled! How could Social Security deny my claim?"


Well, to begin at the beginning: first of all, just because a doctor says a person is "disabled" doesn't mean that Social Security will award benefits. That's because Social Security has a very unique and precise definition of what "disability" means which is very different from how a doctor might use that term or how its used in everyday language. To quote Social Security:


"To meet our definition of disability, you must not be able to engage in any substantial gainful activity (SGA) because of a medically-determinable physical or mental impairment(s):

  • That is expected to result in death, or

  • That has lasted or is expected to last for a continuous period of at least 12 months."

That's pretty technical language and I will unpack what it all means in due course. For now, just understand that Social Security has a very specific definition for the word "disability" that you won't find in any dictionary.


Substantial Gainful Activity (SGA)


The definition begins by talking about something called "substantial gainful activity" or "SGA" for short. (Like all branches of the government, Social Security loves it's abbreviations). "SGA" is essentially what the rest of the world calls "work." Again, in the words of Social Security:

"We use the term "substantial gainful activity" to describe a level of work activity and earnings.


Work is "substantial” if it involves doing significant physical or mental activities or a combination of both. For work activity to be substantial, it does not need to be performed on a full-time basis. Work activity performed on a part-time basis may also be SGA.

“Gainful” work activity is:

  • Work performed for pay or profit; or

  • Work of a nature generally performed for pay or profit; or

  • Work intended for profit, whether or not a profit is realized."

So, "SGA" is something you do to earn money - what most people would call a job. Notice a couple of things though: it doesn't say you actually have to earn any money - just that you are doing something to try to make money. Sometimes, I have clients say, "But my business didn't make any money - I had to file bankruptcy! I never made any money!" That doesn't matter: if you were doing something for the purpose of making money, then its SGA even if at the end of the day it didn't make you any money at all.


So, to be eligible for disability benefits, a person has to be unable to work - unable to perform "SGA" - because of a "medically-determinable physical or mental impairment(s)." I'll unpack that language later, but for now understand that what that means is a person has to be unable to work because of some type of medical condition. This comes up in conversations with clients like this:


Client: "I have cancer! My doctor says I am disabled! Why did Social Security deny my claim!"


Lawyer: "Are you working?"


Client: "Of course I am working! How else could I pay my bills?"


Lawyer: "Then you are not 'disabled' as far as Social Security is concerned because you are still able to work even though you have a terrible medical condition."


Bottom line: its not enough to have a serious medical condition - the medical condition has to interfere with a person's ability to actually do work before a person can be considered disabled for purposes of Social Security disability benefits. This is the first step in something called the "Five Step Sequential Evaluation" for establishing disability. I will explain in more detail in later blogs what the "Five Step Sequential Evaluation" is but know for now that the first step in being found disabled is being unable to work because of a medical condition.

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