TITLES II AND XVI: BASIC DISABILITY EVALUATION GUIDES

PURPOSE:

To provide an overview and a further explanation of the definition and terms contained in the disability provisions of title II and title XVI of the Social Security Act and implementing regulations. (A separate Program Policy Statement, SSR 82-56 (PPS-81: The Sequential Evaluation Process) provides an overview of that process in disability adjudication.)

CITATIONS (AUTHORITY):

Sections 223(d), 216(i), and 1614(a) of the Social Security Act, as amended; Regulations No. 4, Subpart P, sections 404.1505, 404.1508, 404.1509, 404.1513, 404.1525, 404.1526, 404.1528, 404.1545, 404.1566, 404.1577, 404.1578, 404.1581, 404.1582, 404.1583, 404.1584, and Appendix 1; Regulations No. 16, Subpart I, sections 416.905, 416.906, 416.908, 416.909, 416.913, 416.923, 416.925, 416.926, 416.928, 416.945, 416.966, 416.981, 416.983, 416.984, and 416.985.

INTRODUCTION:

Several terms included in the various definitions of disability and blindness (under titles II and XVI) and other terms closely related to the concept of disability are subject to more than one possible interpretation. This policy statement explains the various definitions of disability and blindness and describes in detail how pertinent terms are to be interpreted and applied.

POLICY STATEMENT:

Definitions of "Disability"

Under title II, the term "disability" means --

1. In the case of a worker or applicant for childhood disability benefits (CDB), inability to engage in any substantial gainful activity (SGA) by reason of any 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 not less than 12 months; or
2. In the case of a widow, widower, or a surviving divorced spouse (DWB) applicant, the existence of a medically determinable physical or mental impairment(s) expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months, and of a level of severity which under the regulations prescribed by the Secretary, is deemed to be sufficient to preclude an individual from engaging in any gainful activity.

   The individual must have a physical or mental impairment(s) which meets or equals the level of severity described in the Listing of Impairments. Disability for a DWB applicant will be decided on medical considerations alone (i.e., vocational considerations do not apply); or

3. In the case of a worker or applicant for CDB who has attained the age of 55 and is blind (see definition of blindness below), inability by reason of such blindness to engage in SGA requiring skills or abilities comparable to those of any gainful activity in which the individual has previously engaged with some regularity and over a substantial period of time.

Under title XVI, the term "disability" means --

1. In the case of a claimant age 18 or over, inability to engage in any SGA by reason of any 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 not less than 12 months. (See below concerning blindness under title XVI.)

   There are provisions for individuals who are "disabled" according to the definition of "disability" established in a State plan. However, these provisions are not applicable to newly eligible individuals; or

2. In the case of a child under the age of 18, a medically determinable physical or mental impairment(s) which meets the duration requirement described above and is of comparable severity to that which qualifies an individual age 18 or over. Disability is deemed to exist (i.e., to be of comparable severity) if the child is not engaging in SGA, and if the impairment(s) is described in the Listing of Impairments (Part A or Part B); or, if the impairment(s) is not listed but either singly or in combination, with appropriate consideration of the particular effect of disease processes in childhood, is determined to be of comparable severity to that of a listed impairment. The concept of " comparable severity" of children's impairments is applicable (i.e., the child's impairment(s) must meet or equal a listed impairment) when the disability claimant is under the age of 18 and is neither married nor the head of a household.

Definition of Blindness

Under title II and title XVI --

• "Blindness" is defined in sections 216(i) and 1614(a)(2) of the Social Security Act as central visual acuity of 20/200 or less in the better eye with the use of a correcting lens. An eye which is accompanied by a limitation in the field of vision such that the widest diameter of the visual field subtends an angle no greater than 20 degrees shall be considered as having a central visual acuity of 20/200 or less.
• If the applicable listing is met, statutory blindness is established. However, if a visual impairment does not meet the statutory definition of "blindness," consideration must still be given to whether the severity of the impairment is such that the individual may be "disabled" (i.e., the visual impairment prevents the individual from engaging in SGA.)

Under title XVI only-

• Unlike claims under title II based upon "blindness," there is no duration requirement for "blindness" under title XVI. If a title XVI claimant is found to be otherwise eligible and is blind, he or she is eligible regardless of the anticipated duration of the blindness. (The 12-month duration requirement does not apply once statutory "blindness" is established.)
• Statutorily blind individuals are eligible for payments even if they are engaging in SGA, provided the other requirements for eligibility are met; e.g., income and resource specifications.
• There are provisions for individuals who are blind according to the definition of "blindness" established in a State plan. However, these provisions do not apply to newly eligible individuals.

Substantial Gainful Activity

"Substantial gainful activity" means the performance of significant physical or mental activities in work for pay or profit, or in work of a type generally performed for pay or profit. "Significant activities" implies not only that the activities are useful in the accomplishment of a job or the operation of a business, but also that they are the kind normally done for pay or profit. Work may be substantial even if it is performed on a part-time basis, or even if the individual does less, is paid less, or has less responsibility than in previous work. Work activity is gainful if it is the kind or work usually done for pay, whether in-cash or in-kind, or for profit, whether or not a profit is realized. Activities involving self-care, household tasks, nonremunerative training, hobbies, therapy, school attendance, clubs, social programs, etc., are not generally considered to be SGA.

Inability to Engage in Any Substantial Gainful Activity: Title II Worker or Applicant for Childhood Disability Benefits/Title XVI Claimant Age 18 or Older

Title II workers or CDB applicants, or title XVI claimants age 18 or older, are unable to engage in any SGA (see SSR 80-35 (PPS-42: Substantial Gainful Activity Guidelines For Persons Disabled by Blindness)) if by reason of their impairment(s), they are not only unable to do past relevant work, but cannot, considering their age, education, and work experience, engage in any other kind of substantial gainful work which exists in the national economy regardless of whether such work exists in the immediate area in which the individuals live, or whether a specific job vacancy exists, or whether the individuals would be hired if they applied for work.

The statute specifies that "work which exists in the national economy" means work which exists in significant numbers either in the region where the individuals live or in several regions of the country. The purpose of so defining the phrase is not only to make it clear that jobs need not be available in the region in which the individuals live, but also to emphasize that, conversely, a type(s) of job which exists only in very limited numbers or in relatively few geographic locations may not be said to "exist in the national economy." This distinction will assure that individuals are not awarded benefits simply on the basis of lack of jobs in the region in which they live, nor denied benefits on the basis of the presence in the economy of isolated jobs in which the individuals could engage.

Inability to Engage in Any Gainful Activity: Title II Widow, Widower, or Surviving Divorced Spouse/Title XVI Child Under Age 18

In the Listing of Impairments, the regulations describe impairments of a level of severity deemed to preclude an individual from engaging in any gainful activity. An applicant for title II disabled widow's, widower's, or surviving divorced spouse's benefits or title XVI child's benefits must have an impairment(s) that meets or equals an impairment in the Listing.

As in the case of a title II worker or CDB applicant or a title XVI claimant age 18 or older, a title II widow(er), or title XVI child whose work demonstrates ability to engage in SGA is not under a disability. The level of severity of an impairment which a title II widow(er) or a title XVI child must meet or equal to be determined to be under a disability is that which is considered under the regulations to be sufficient to preclude engaging in any gainful activity (i.e., must meet or equal the Listing), as distinguished from SGA. The concept of "gainful activity," however, is used only in setting the requisite level of severity of the impairment in the Listing of Impairments and not otherwise.

Types of Claims Determinable Only on the Basis of Medical Factors

Title II: Disabled Widow, Widower, or Surviving Divorced Spouse

The 1967 amendments provided benefits for widows, widowers, or surviving divorced spouses at age 50 or older whose physical or mental impairment(s) is of a level of severity deemed sufficient to preclude an individual from engaging in any gainful activity. Such a level of severity is described in the Listing. In order to qualify for benefits, a widowed person or surviving divorced spouse must, therefore, have an impairment(s) which meets or equals the level of impairment severity in the Listing, and not be engaging in SGA.

Title XVI: Children Under Age 18

Disability in children under age 18 will be determined solely by consideration of medical factors (i.e., vocational factors do not apply). A finding of disability may be made only when the child's impairment or combination of impairments is as severe as the examples contained in the Listing of Impairments (Part A or Part B). When the specified criteria are met or equalled, disability may be established on the basis of the medical facts in the absence of evidence to the contrary (e.g., the actual performance of SGA).

By Reason of ... Impairment

The physical or mental impairment(s) must be the primary reason for the individual's inability to engage in any SGA (or gainful activity). When, for instance, an individual remains unemployed for a reason(s) not due to a physical or mental impairment(s), such individual may not be considered disabled. Unemployment may be attributable to a number of reasons other than disability: individuals may be unsuccessful in obtaining work they could do; or work they could do may not exist in the local area; or the hiring practices of certain employers, technological changes in the industry, or cyclical economic conditions may preclude their employment; or there may be no job openings; or they would not actually be hired to do work they could otherwise perform.

"Medically Determinable"

The law requires that the physical or mental impairment(s) which results in inability to engage in any SGA (or inability to engage in any gainful activity in the case of a title II DWB applicant or title XVI child) must be a medically determinable impairment(s). This means that the impairment(s) must result from anatomical, physiological, or psychological abnormalities which are demonstrable by medically acceptable clinical and laboratory diagnostic techniques.

An individual's description of his or her impairment(s) (symptoms) is, in itself, insufficient to establish the presence of a physical or mental impairment(s). For the purposes of determining a "medically determinable impairment," the following definitions apply:

Symptoms are the claimant's own description of the physical or mental impairment(s).

Signs are anatomical, physiological, or psychological abnormalities which can be shown through the use of medically acceptable clinical techniques. Psychiatric signs are medically demonstrable phenomena (apart from the claimant's symptoms), indicating specific abnormalities of behavior, affect, thought, memory, orientation, and contact with reality. They must also be shown by observable facts that can be medically described and evaluated.

Laboratory findings are manifestations of anatomical, physiological, or psychological phenomena demonstrable by the use of medically acceptable laboratory diagnostic techniques. They include chemical, electrophysiological, roentgenological, or psychological tests.

Those aspects of the disability determination that relate to the nature, extent and duration of the impairment must be based on medical facts (i.e., symptoms, signs, and laboratory findings).

Residual Functional Capacity

Residual functional capacity (RFC) is the remaining capacity to perform work-related physical and mental activities despite certain functional limitations resulting from medically determinable impairments. The assessment of RFC must be documented to support the adjudicative conclusion of just what the individual can still do in a work setting, and must be fully responsive to the claimant's statements, including those about symptoms (especially pain) which concern the nature and extent of the impairments.

The RFC assessment is based primarily on the medical findings which must be complete enough to permit and support the necessary judgments concerning the individual's physical, mental, and sensory capacities and any environmental restrictions. Descriptions and observations of the claimant's restrictions by medical and nonmedical sources in addition to those made during formal medical examinations must also be considered in the determination of RFC. When multiple impairments are involved, the RFC is derived from an assessment of the remaining functional capacity after consideration of all impairments. (See SSR 82-56 (PPS-81: The Sequential Evaluation Process).)

Duration of Impairment

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 SGA (or any gainful activity) because of a medically determinable physical or mental impairment(s). It extends from the date of onset of "disability" to the time the impairment(s) no longer prevents the individual from engaging in SGA. Since the Social Security Amendments of 1965, the disabling impairment(s) preventing an individual from engaging in any 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). However, there is no "duration" requirement for "blindness" under title XVI. (See SSR 82-52 (PPS-89: Duration of the Impairment) for a further explanation.)

Impairment Which Ended Prior to Decision or Determination

Where the evidence establishes that the claimant was unable to engage in any SGA (or gainful activity) for a continuous period of at least 12 months, but by the time the decision or determination is made, the claimant is able to engage in SGA (or gainful activity), he or she may be entitled to disability benefits for all or some of the time he or she was unable to engage in SGA (or gainful activity).

Impairment Which Can Be Expected to Result in Death

An impairment will be considered likely to result in death if, on the basis of established medical knowledge, it is found to be in a terminal state under the particular circumstances in the case. A disabling condition which actually does result in death will be considered one that was "expected to result in death."

One purpose of this concept is to assure that disability may be established for the individual who has an incapacitating impairment which is expected to cause death before it lasts 12 months. However, if in a title II case, death follows so quickly after the alleged onset date of the impairment that a period of disability cannot be granted (i.e., a waiting period applies and the alleged onset is less than 5 full calendar months before the month of death) and an earlier onset cannot be established, the claim will be denied.

EFFECTIVE DATE:

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).

CROSS-REFERENCES:

Program Operations Manual System sections DI 2051.B., 2091-2099, 2104, and 2382.1.

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