WHEN IS A PERSON COVERED FOR SOCIAL SECURITY DISABILITY CLAIMS?

By: Pitt Dickey – Attorney

Social Security Disability Eligibility – This column will examine how the Social Security Administration determines the time period during which a person is eligible for Disability Insurance Benefits. 

Previous columns have looked at the medical criteria used by the Social Security Administration (SSA) to determine disability resulting from illness and injury. The medical evaluation is only half of the equation in determining if a person is eligible for disability insurance benefits. 

The SSA has a set of criteria that it uses called Listings to determine whether a person is medically eligible for monthly disability insurance benefits (DIB) payments. 

To obtain disability insurance benefit payments from the SSA a person must in general have a health problem that can be expected to last at least one year or to result in death and be unable to perform any type of substantial gainful employment.

In addition to the medical test there is a general requirement that the claimant must have paid into the FICA system for at least ten years. To be eligible for DIB, most claimants must have earned 40 quarters of credits with the Social Security Disability Insurance system by paying a required amount of FICA tax for at least ten years. 

A worker can earn a maximum of four credits per year. There is an exception to the 40-credit rule for very young workers who become disabled before they could have worked long enough to pay in the required 40 quarters of FICA tax.

Disability Insurance Benefits coverage can be likened to car insurance payments. If you purchase an auto liability insurance policy for a year and pay for the premium for that year’s coverage, in the event of an accident during that year the insurance company will pay for your damages. If you have an accident after your coverage has expired, then the auto insurance carrier is not liable for your damages. 

The Social Security Administration Disability Insurance Benefits program is similar to the car insurance company. You pay your premium for your Disability Insurance by paying your FICA taxes. 

After you have paid into the system for ten years then you are covered for disability purposes. Unlike the auto insurance system that ends at the expiration of the one-year policy, the SSA’s disability insurance gives workers a five-year grace period in which it will pay Disability Insurance Benefits after the worker has last paid into the system. 

The SSA refers to this ending date for Disability Insurance Coverage as a person’s Last Date Insured. For example, Ron Raley is a 45-year-old man who has been working full time since he was 22. He decides to quit his job in December 1995 to write a book. He doesn’t earn any income while he is writing his book and doesn’t pay any FICA taxes into the SSA. 

His last date insured for Disability purposes is December 2000. If Ron gets injured in an accident on 30 November 2000 he is fully covered for Disability Insurance Purposes assuming he meets the medical test. If he is injured on 1 February 2001, after his last date insured, he is not covered by Disability Insurance Benefits because his injury occurred after his Last Date Insured no matter how serious his injuries are resulting from the February accident. 

The Last Date Insured is a crucial factor in many disability claims. Most claims are not as clear-cut as the example of Mr. Raley above. In many cases a person will develop a progressively disabling disease such as diabetes. Diabetes has symptoms that can become much worse over time if the disease is not controlled. As an example, consider Linda Jones who worked for the required ten years. 

Linda stopped work in 1992 when she had her first child. Linda developed diabetes during her pregnancy. She never returned to work because she wanted to stay home and raise her child. She will still be covered for Disability Insurance Benefits until 1997 as a result of the five-year grace period. In 1993 She becomes insulin dependent and her blood sugar is very difficult to control. She suffers diabetic retinopathy and painful neuropathy involving her legs and feet. 

It doesn’t occur to her to apply for Disability Insurance Benefits until November 1999 when her doctor suggests it to her. At the time of filing her claim, Linda will have to pick what is called the “onset date” when the illness became too severe for her to be able to work. In her case she alleges an onset date of August 1993. 

She applies for Disability Insurance Benefits and is denied at the initial and reconsideration levels. At her hearing before the Administrative Law Judge she will have to prove that she was disabled in 1993 to receive benefits from her onset date. In the event that she can’t prove that she meets the medical listings in 1993, she is still eligible for DIB if she can prove that she was disabled prior to 1997 which is her last date insured. 

Even if her diabetes has progressed to the point that she clearly meets the medical test in 1999, benefits cannot be awarded to her unless the medical evidence from 1997 or earlier, plus her testimony as to her condition prior to 1997 convince the Judge that she was medically disabled prior to her last date insured. 

The Judge at her hearing will focus on her medical condition prior to 1997 and will not give much weight in his decision as to her condition after 1997. 

In older claims, proving that the claimant has met the medical test prior to their last date insured is crucial in obtaining disability benefits for the claimant.

Notice: Since Social Security Disability is directed under Federal law, the information in this column will apply anywhere in the United States.  However, each Office of Hearings and Appeals and District Office have their own ways of doing things, as does the various Federal District and Circuit Courts.   I have kept this column primarily dealing the mechanics of how the Social Security District Offices and Office of Hearings and Appeals evaluates disability claims. 
– Pitt Dickey

Pitt Dickey has practiced law in Fayetteville since 1978. He has handled SSA disability claims for over twenty years. He practices with the firm of Smith, Dickey, Smith, Hasty & Dempster, P.A. at 555 Executive Place and can be reached at 910-485-8020 or at . Or at the firm website of www.smithdickey.com .

Copyright © 2002 Pitt Dickey – Used with permission