Social Security Disability is a program sponsored by the Federal Government through the Social Security Administration. It provides for disability payments in the same amount as the retirement benefits would be if that person becomes “disabled” prior to age 65. Additional benefits may be payable for dependents. Widows or widowers in certain age brackets may receive benefits based on the earnings of a deceased spouse if they become “disabled” within 7 years of that spouse’s death. Neither benefits are dependent on income of the claimant or other family members.
A separate program known as “Supplemental Security Income” or “SSI” is available to those who have not worked at least 5 out of the last 10 years and are “disabled” provided that they are also below the “poverty line” both as individuals and as a family.
Social Security defines disability as an inability to work as a result of a “medically determinable” and “severe” impairment or combination of impairments for a minimum period of at least 12 months, or having a fatal condition that will result in death within 12 months.
Persons under the age of 50 must be completely unable to do any job that exists in the national economy of the United States (age 45 if illiterate or unable to communicate in English).
Persons over the age of 50 must be unable to do any of the jobs they have had in the past 15 years and be unable to perform other work “considering their age, education and prior work experience” (age 45 if illiterate or unable to communicate in English).
If mental impairments are present, this may affect the finding of disability (usually in favor of the claimant) regardless of age, education and prior work experience.
If a person is found to be “disabled” under the above criteria, they become eligible for Medicare after a waiting period of 29 months from the date of disablement. Medicaid may be available immediately through State programs for persons eligible for SSI.
No benefits are payable for the first 5 months after disablement for Disability beneficiaries. Benefits are available for Disability beneficiaries for up to 12 months before the application was filed if disability commenced previously. SSI benefits are available as of the date of the filing of the application without a 5-month waiting period but are not available for the period of time before the application was filed, regardless of the date of disablement.
Benefits are available to disabled children under the SSI program if other financial conditions are met.
Persons seeking to qualify under the widow/widower’s benefit programs must be completely unable to work if between the ages of 50 and 60. Benefits are not available prior to age 50. Benefits are automatically paid to widows/widowers over the age of 60.
Children seeking to qualify for children’s SSI benefits must meet certain medical criteria specified in the Social Security Regulations.
Persons who are currently employed and earning over $800 per month after 1/1/03 are not eligible for benefits, with certain exceptions.
Applications are commenced by contacting a local District Social Security Administration office, either in person, by phone, or via the Internet. A decision is made after obtaining all available medical information which is called the “Initial Determination.” Two-thirds of the Initial Determinations are denied.
An appeal, called a “Reconsideration,” can be filed at that point. Eighty-five percent of the Reconsiderations are denied.
A Hearing may then be requested. The hearings are informal and are conducted by a lawyer who is independent of the Social Security Administration. Most of the people who persist to this stage win their claims.
Further appeals are possible after a Hearing but have a poorer chance of success.
Social Security disability benefits interact with state Workers Compensation benefits (not to be confused with unemployment benefits) in various ways depending on the state.
PRIVATE DISABILITY INSURANCE
EMPLOYER BENEFIT PLANS
Various employees may be covered by employer benefit plans which provide for benefit payments in the event the employee becomes unable to work due to impairments. These plans vary greatly and the individual insurance contracts must be referred to determine eligibility and exclusions.
All insurance plans allow for appeals of denials of coverage. Once the appeals are exhausted, a suit must be instituted in Federal court. In that event the court is limited to the evidence provided to the insurance company and can only reverse the denial decision if it is arbitrary and capricious (very difficult to prove in MCS, FMS and CFS cases).
PERSONAL DISABILITY PLANS
Various disability plans are available for purchase by individuals and vary greatly in their terms and conditions. They usually pay a fixed monthly amount for disability or may pay for an expense such as a car payment or mortgage for the life of that obligation.
Individually-purchased plans will also provide for internal appeal procedures. After that, however, the individual may sue the plan in state court and request a jury trial with the jury deciding the claim de novo(from the beginning). These are much better for the claimant than an employer-sponsored plan.
STATE DISABILITY PLANS
Certain state employees, and sometimes teachers and school district employees, may be covered in their states by state plans. These vary from state to state and, accordingly, no general information can be offered here about any given plan.
Some of the above plans may interact with Social Security disability benefits and state workers compensation benefits. Private plans sometimes will not reduce benefits for receipt of benefits from those other sources, depending the specific contract provisions.
Some states may have welfare plans as well for the disabled, which will vary considerably from state to state. Being income-dependent, as is the case with SSI, receipt of other benefits from any source will affect eligibility.