The Disability Determination Process

The Social Security Administration requires each state to process its own disability applications, with some exceptions. With that said, the West Virginia Disability Determination Section generally will process claims for residents of West Virginia only. Each state processes claims independently, yet all must follow the same rules and regulations set forth by Congress. As such, the rules will not be different for a person filing a claim in West Virginia than they are for a person filing in California, Florida, or any other state.

Getting Started

Whether filing for Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI), the process always begins by contacting the Social Security Administration in one of these ways:

Disability Determination

When an application for disability benefits is received, a case is opened at the local SSA office and then forwarded to the Disability Determination Section (DDS) to assess whether the medical requirements are met for disability.

When a case is received by the DDS, it is assigned to a Disability Evaluation Specialist (DES). This person reviews the application and may contact the applicant, or claimant, to clarify issues and obtain further information regarding treatment and limitations due to his or her impairments. If necessary, the DES then contacts relevant medical sources to document the impairments. At times, it is necessary to schedule consultative examinations for claimants. This examination provides functional information to help determine what limitations may result from an individual’s impairment(s); they are not for providing further medical treatment.

Important points

  • Under the rules of Social Security, disability for an adult is defined as the inability to perform substantial gainful activity by reason of any medically determinable physical or mental impairment (or combination of impairments) 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. Similarly, a child under the age of 18 will be considered disabled for SSI purposes if he or she has a medically determinable physical or mental impairment (or combination of impairments) that causes marked and severe functional limitations, and the condition has lasted or is expected to last at least one year, or is expected to result in death. (The child also must not be engaging in any work considered to be substantial gainful activity.)
  • The Social Security Administration and DDSs use the Listing of Impairments to guide disability assessment. The Listing of Impairments describes, for each major body system, impairments considered severe enough to prevent an individual from doing any gainful activity (or in the case of children under age 18 applying for SSI, severe enough to cause marked and severe functional limitations). Most of the listed impairments are permanent, or are expected to result in death, or include a specific statement regarding duration. For all other listings, the evidence must show that the impairment has lasted or is expected to last for a continuous period of at least 12 months. The criteria in the Listing of Impairments are applicable to evaluation of claims for disability benefits under the Social Security Disability Insurance (SSDI) program and the Supplemental Security Income (SSI) program.

Medical Assessment

When sufficient medical evidence has been gathered, the Disability Evaluation Specialist (DES) will use the Listing of Impairments as a guide to determine if the individual qualifies for disability benefits. DESs receive assistance in assessing physical and/or mental impairments by having the case reviewed by a medical or psychological consultant (who is a licensed medical doctor or psychologist employed or contracted by our agency).

Some impairments are so severe that they already meet the requirements of the Listings, and further processing and assessment is not needed. However, the absence of a listing-level impairment does not necessarily mean that the individual is not disabled. Rather, it merely requires the DES to move on to the next step of the process and apply other rules in order to resolve the issue of disability. (For example, in an adult claim, the adjudicative team will assess the limitations of the impairments and then the DES will consider other factors, including vocational experience, age, and education, to determine if the person is eligible for disability.)

Informing the Claimant of the Decision

When a medical determination is made on the claim, claimants are advised in writing. If a claimant does not meet the requirements, a detailed explanation summarizes the reasons for that decision.

The Right to Appeal

If the Disability Evaluation Specialist determines that an applicant is not eligible for benefits, an appeal or reconsideration can be requested. This must be done within 60 days of the date on the written notice of the decision. As with the initial application process, this begins by contacting the Social Security Administration in one of these ways:

Please note that an appeal cannot begin by contacting the Disability Determination Section. A summary of the appeals process and procedure can be found here: How Do I Appeal a Social Security Decision?

When the Social Security Administration receives an appeal request, an effort is made to update information and the claim is reviewed by a different Disability Evaluation Specialist and medical/psychological consultant. If the claim is denied at this point, the applicant may file another appeal to have the case heard by an SSA Administrative Law Judge. If he or she is dissatisfied with the hearing decision, the final administrative appeal is for review by the Appeals Council. If the individual exhausts all administrative appeals, but wishes to continue pursuing the case, he or she may file a civil suit in Federal District Court and eventually appeal all the way to the United States Supreme Court.