TITLES II AND XVI: DURATION OF THE IMPAIRMENT
To state and explain the policy regarding the duration requirement under the disability provisions of titles II and XVI of the Social Security Act and implementing regulations.
Sections 223(d), 216(i), and 1614(a) of the Social Security Act, as amended; Regulations No. 4, Subpart P, sections 404.1505, 404.1509, 404.1522, 404.1598; and Regulations No. 16, Subpart I, sections 416.905, 416.909, 416.922, and 416.998.
To be found disabled, an individual must be unable to engage in any substantial gainful activity (SGA) by reason of a medically determinable physical or mental impairment(s) which can be expected to result in death, or which has lasted or can be expected to last for a continuous period of at least 12 months. In considering "duration," it is the inability to engage in SGA because of the impairment that must last the required 12-month period. (See Social Security Ruling (SSR) 73-7c.) This policy statement explains in detail the documentation and evaluation requirements for determining if the duration requirement is met.
"Duration of impairment" under title II and title XVI refers to that period of time during which an individual is continuously unable to engage in any SGA, or any gainful activity in the case of a title II widow, widower, or surviving divorced spouse or a title XVI child under age 18, because of a medically determinable physical or mental impairment(s). (There is no duration requirement for title XVI statutorily blind individuals, but the duration requirement does apply to title II statutorily blind individuals.) It extends from the date of onset of "disability" to the time the impairment(s) does not prevent the individual from engaging in SGA (or any gainful activity as appropriate), as demonstrated by medical evidence or the actual performance of SGA. An individual who was previously entitled to a period of disability must again meet the duration requirement before a subsequent period of disability can be established, even though a second waiting period under title II may not be required in certain instances.
The 12-Month Duration Requirement
Since the Social Security Amendments of 1965, the disabling impairment(s) preventing an individual from engaging in SGA (or any gainful activity) must be expected to result in death, or must have lasted (or be expected to last) for at least 12 continuous months from the date of onset (e.g., from January 17, 1981, through January 16, 1982). Exception: The duration and SGA requirements are not applicable in determining blindness under title XVI. (See SSR 82-53 (PPS-74: Basic Disability Evaluation Guides).)
Severe impairments lasting less than 12 months cannot be combined with successive, unrelated impairments to meet the duration requirement. For example, if an individual had two unrelated incapacitating impairments, one lasting for only 9 months and the other developing 6 months after onset of the first and lasting for only 7 months, the duration requirement is not met since neither impairment lasted at least 12 months even though the individual's inability to work lasted for a total of more than 12 months. Where only the second impairment is of requisite severity and duration, onset of disability would be the first day that the second impairment became disabling. Onset cannot be extended back to the date of the first impairment if that impairment itself was disabling for less than 12 months.
In determining whether a beneficiary's disability continues, if a new disabling impairment(s) begins in or before the month in which the last disabling impairment(s) is no longer disabling, disability is found to be continuing. Inasmuch as the individual has already met the "duration" requirement, the new impairment need not be expected to last 12 months or to result in death, but it must be so severe as to preclude SGA (or any gainful activity as appropriate).
Return to Work Within 12 Months of Onset
Entitlement to benefits can be established to begin after the 5-month waiting period in title II claims (or with the first full month of disability in a no-waiting period case, i.e., a previous period of disability ceased within 5 years before the month the current disability began), or as of the month of application or onset, whichever is later, in title XVI claims, when the "disabling" impairment(s) is expected to result in death or has lasted or can be expected to last for at least the required 12-month period. When an individual whose entitlement is established on the basis of expected duration returns to work which demonstrates ability to engage in SGA after an award of benefits but within the 12-month period after onset, benefits should be terminated (subject to the possible entitlement of the individual to a trial work period). The prior award should not be reopened and reversed.
When the return to work demonstrating ability to engage in SGA occurs before approval of the award and prior to the lapse of the 12-month period after onset, the claim must be denied. When an individual returns to SGA during the waiting period and such work continues, the claim for benefits must be denied if the award has not been approved. If the award was previously approved, the claim must be reopened and revised to a denial. If the work attempt proves unsuccessful or detrimental to health, the determination of denial may later be reopened and revised to an allowance. However, the determination or decision can only be reopened within the time limitations under the rules of administrative finality (see Regulations No. 4, sections 404.987 and 404.988; and Regulations No. 16, sections 416.1487 and 416.1488).
Projecting Severity and Residual Functional Capacity
In most cases in which the evidence substantiates a finding of disability, it will be readily apparent from the same evidence whether or not the impairment is expected to result in death or has lasted or is expected to last 12 months from the onset of disability. When the application is being adjudicated (or a hearing decision is being issued) before the impairment has lasted 12 months, the nature of the impairment, the therapeutic history, and the prescribed treatment will serve as the basis for determining whether the impairment is expected to result in death or will continue to prevent the individual from engaging in any SGA (or any gainful activity) for the additional number of months needed to make up the required 12 months duration (e.g., 7 months for the claim being adjudicated in the 5th month, etc.). In the case of a title II worker or childhood disability benefits (CDB) applicant, or a title XVI claimant age 18 or older, a projection of how severe the impairment will be 12 months after onset may also require an estimate of the claimant's residual functional capacity (RFC) as of the 12th month after onset (i.e., the impairment falls short of the level of severity depicted by the Listing, yet there are significant limitations to performing basic work-related functions).
In order to determine the duration of the impairment, the medical reports should reflect all the pertinent symptoms, signs, and laboratory findings, as well as prescribed treatment (drug dosage and frequency of administration, surgery, radiation, etc.), and the response to treatment in terms of changes in symptoms, signs, and laboratory findings. (For a more complete discussion on the contents of medical reports, see SSR 82-14 (PPS-63: Requirements for Consultative Examinations and Tests Purchased in Claims Based on Disability).) When the patient is unwilling to accept the treatment or he or she is unable to carry it out, the specific details should also be reported. (See SSR 82-59 (PPS-78: Failure to Follow Prescribed Treatment).)
When the evidence shows that at 12 months after onset the individual's impairment(s) did not or will no longer meet or equal the Listing (in the case of a title II widow, widower, or surviving divorced spouse, or a title XVI child under age 18), or that the individual is or will be able to return to SGA within 12 months after onset (in the case of a title II worker or CDB applicant, or a title XVI claimant age 18 or older), a finding that the individual is not disabled should be made on the basis that the duration requirement is not or will not be met. Adjudication on the basis of "insufficient duration," therefore, indicates that a claim which would have been allowed must instead be denied because the claimant's impairment was not or will not be disabling for at least 12 months.
The denial determination or decision for insufficient duration should not be understood as independent of the sequential evaluation process. (See SSR 82-56 (PPS-81): The Sequential Evaluation Process).) Rather, it is necessary to follow the principles of sequential evaluation in assessing an alleged impairment according to the duration requirements of the law.
Denial for insufficient duration is applicable in all cases in which:
- The impairment(s) was or is of such severity that the claimant was or is unable to engage in any SGA (or any gainful activity); but
- By the end of 12 months, the impairment is, or will be, no longer of such severity as to prevent SGA.
All cases denied on the basis of insufficient duration must state clearly in the denial rationale that either:
- Within 12 months of onset, there was or is expected to be sufficient restoration of function so that there is or will be no significant limitation of the ability to perform basic work-related functions. (See SSR 82-55 (PPS-84: Medical Impairments That Are Not Severe)); or
- Within 12 months of onset, there was or is expected to be sufficient restoration of function so that in spite of significant remaining limitations the individual should be able to do past relevant work or otherwise engage in SGA, considering pertinent vocational factors.
In the latter case, a thorough documentation, evaluation, and rationalization of the claimant's RFC, work history, and vocational potential will be necessary. (See SSR 82-56 (PPS-81: The Sequential Evaluation Process).)
A denial determination or decision on the basis of insufficient duration may be made either within the 12-month period after onset or at any time following the 12-month period after onset, since the basis for such a determination is not the date of adjudicative action, but the level of impairment severity within a 12-month period.
A claim from a title II worker or CDB applicant, or from a title XVI individual age 18 or older, should be denied on the basis of ability to engage in past or other work (as opposed to the basis of insufficient duration) if the evidence shows that the claimant's impairment(s):
- Is severe or is expected to be severe at 12 months after onset, but is not expected to preclude SGA in relevant past work or other work; and
- During the period under adjudication has never been of such severity as to preclude the claimant's engaging in SGA for a continuous period of 12 months. (See SSR 82-56 (PPS-81: The Sequential Evaluation Process).)
When a claimant has established that an impairment precludes any SGA and is expected to last 12 months from onset, the possibility that ability to engage in SGA may be restored despite the impairment(s) (e.g., through rehabilitation) does not preclude a finding of "disability."
The actual duration of many impairments subject to improvement is directly related to the therapeutic regimen administered by the treating physician. An individual with a disabling impairment which is amenable to treatment that would be expected to restore the ability to work would meet the duration requirement if he or she is undergoing therapy prescribed by treatment sources, but disability, nevertheless, has lasted, or can be expected to last, for at least 12 continuous months.
The policy explained herein was effective on August 20, 1980, the date the regulations covering the basic policy in the subject area were effective (45 FR 55566).
Program Operations Manual System, sections DI 2096, DI 00504.115, and DI 00504.120.