Who Decides If I am Disabled?

Close-up Of Male Doctor Filling The Medical Form

Believe it or not, the Social Security Administration is not the government agency responsible for determining whether you meet its requirements for disability benefits.

While you may submit your application for disability benefits to the Social Security Administration (SSA), the agency actually turns all your information over to Disability Determination Services.

Each state runs its own Disability Determination Services (DDS) agency, so the exact name of it may vary slightly depending on where you live, but for the purposes of this article, we will refer to it as DDS.

“The SSA receives a separate budget from Congress for its employees, office space, computers, supplies, etc. [Its] operating budget is likely lower with this arrangement. There is also an element that the state DDS’s can become more familiar with doctors, hospitals, local medical practices, etc. by being closer instead of one DDS adjudicating all 50 states,” said Evan Zagoria, a disability attorney at Lieberman & Zagoria in Miami, Florida. “Even though DDS handles cases for its own state, they must operate using SSA’s federal guidelines as to disability. The SSA also performs various types of quality review to make sure the cases are done correctly, timely, etc.”

After the SSA sends your file to DDS, a disability claims examiner is assigned to your case. Their job is to gather all of your medical records, as well as any other information they need to make a decision.

“The disability examiner then is supposed to obtain the appropriate records from doctors, hospitals, the claimants, other sources, etc.. Once all the records are received or once the DDS guidelines as to holding onto a case have expired, a medical decision is made,” Zagoria said.

If the disability claims examiner feels that they do not have enough information to make a decision, they may contact you to schedule what’s called a consultative exam.

During a consultative exam, a physician will examine you to try and gather additional information about your condition for DDS. Generally, the disability examiner will send the physician a snapshot of your file and ask her to verify symptoms or perform specific tests.

“Not every claimant has a treating source. Not every claimant sees an endocrinologist for his diabetes but does see a GP occasionally. Not every doctor keeps thorough and readable medical records. Not every doctor orders testing that can more objectively verify how disabled someone might be. Not every doctor cooperates with SSA ‘s requests,” said Zagoria. “Section 404.1519a of Social Security regulation No. 4 provides in general that SSA will order a consultative exam when it cannot get the information it needs from treating sources. In other instances it will request a consultative exam to try to resolve an inconsistency in the record, if there is insufficient evidence in the record, if the needed evidence is not in the treating doctor’s records, if the records from the treating doctor are unavailable, if highly technical or specialized evidence is needed, etc.”

After the disability examiner has gathered your medical information, he will then gather your past work history and educational background to determine whether your condition truly precludes you from working.

Once the disability examiner has gathered all the needed information, he will consult with a DDS medical consultant and write up a medical decision for the medical consultant to review. The write up will discuss whether your condition meets the requirements of a disability listing or whether your residual functional capacity is limited enough to keep you from working. DDS then sends the write up to the SSA, where it will process the case accordingly.

“The disability examiner is a non-physician. The examiner, if unsure as to the proper outcome of a claim or unsure as to more complicated medical impairments, frequently works in a team with the consultant before a decision is made,” said Zagoria. “Some examiners with more experience do not consult with the consultants. A consultant must still sign off on the examiner’s decision.”

We should note that DDS is only responsible for evaluating your disability claim during the initial claim evaluation and, if applicable to your state, requests for reconsideration (the first level of appealing a denial). If you are denied disability benefits and get to the hearing stage, an administrative law judge will be the one to determine whether you meet the SSA’s requirements for disability benefits. You can read more about that process in our “What to Expect During Your Disability Hearing” article.

For the most part, the SSA handles all benefit paperwork and verifies non-medical information, whereas DDS manages medical and vocational analysis. Knowing which agency determines whether you are qualified for disability benefits can make the application process a little less confusing, and gives you an idea on how the agencies use your information to during the determination process.