Official Fires Back At Dr. Harris

Administrator Answers Disability Questions

Ocean County Observer

March 30, 1983

I am responding top your January 13, 1983 letter to former Secretary Schweiker concerning the newspaper article about the Social Security disability process.

The Social Security Administration (SSA) gives high priority to administering the disability insurance program fairly and in a manner Congress intended. While I cannot address all the specific issues raised in Dr. Harris’ article without knowing the details of the case to which he refers, I would like to provide you with a general description of the disability process. I hope this information will be helpful to you in understanding the program.

The law provides and congress has specified, that disability determinations made by State agencies in compliance with regulations containing performance standards and other administrative requirements and procedures relating to the disability determination function.

One of these performance standards is the accuracy of the disability determinations. This accuracy is assured by a monitoring of the disability determinations on a sample selection and review basis at both the state and federal level. In this review consideration is not only given as to whether disability decisions are right or wrong for payment or denial, but also whether the claims have all the needed evidence and whether all factors contributing to a sound decision were considered. Since the State agencies make determinations of disability on behalf of the Secretary of Health and Human Services on the basis of standards and guides issued by SSA, SSA is accountable to reach the decision.

A basic fact in the disability determination process is that we must deal with objective medical evidence and not opinion evidence. Each individual case is decided on its own merits and rests with the objective evidence and individual’s capacity to do work. In making the medical decision all the evidence requested from and submitted by the individual’s treating physicians, hospitals and other medical examining sources is considered. When necessary additional medical findings are requested to resolve the issue of medical severity. This is done by re-contacting the above sources and/or, when appropriate, obtaining a medical examination by a specialist at no expense to the applicant.

Under the law, disability determination by a State agency must be made buy an adjudication team consisting of a medical consultant and a disability adjudicator qualified to interpret and evaluate medical and other evidence relating to a claimant’s physical or mental impairments.

The claimant’s physician on the other hand, diagnoses and treats illness and injuries and is considered an extremely valuable source of evidence used in the determination process. In fact 65 to 70 percent of all initial disability claims nationwide are decided solely on reports provided to the State agency team by the claimant’s own medical sources. Thus rather than impugn or question their integrity we rely heavily on these sources and their cooperation and assistance is greatly appreciated.

The Social Security Act defines disability generally as the inability to engage in substantial gainful activity by reason of a medically determinable physical or mental impairment which has lasted or can be expected to last for at least 12 months or result in death, The Act specifies that the impairment be so severe as to prevent the person from working only his usual occupation but in any other substantial gainful work, when considering his age, education and work experience.

As an underlying consideration in the evaluation of disability claims, the Act specifies that the impairment must be demonstrable by medically acceptable clinical and laboratory diagnostic techniques. Regulations implementing the Act require that the medical evidence (signs, symptoms and laboratory findings) be sufficient to enable a reviewing physician to arrive at an independent evaluation as to the nature and limiting effects of the claimant’s impairment, his or her ability to engage in physical mental work-related activities, and the probable duration of the impairment.

There are certain rules and criteria that must be followed to ensure national uniformity in making any determination of disability. The same applies to the notification of the applicant of any adverse decision on his or her claim. We have been assured that the New Jersey Disability Determination Services (DDS) follows these rules without exception.

Normally when a case is received by the DDS it is assigned to an adjudicator, and from that point on the adjudicator handles the entire case with the assistance of a DDS medical consultant, until a decision of disability can be made.

The DDS medical consultant makes the determination of impairment severity and functional capacity while the adjudicator applies the program considerations involving age, education and work experience to arrive at the conclusion of disability, or non-disability as defined as defined by the law and regulations. Thus all the evidence, both medical and non-medical is considered by the adjudicator-physician team. Only when both members of the team are satisfied that the evidence is complete is a decision of disability reached and a formal determination prepared and signed by both members of the team.

If the decision is adverse to the claimant a personalized explanation is provided. Form notices are used to give the basic reason for denying entitlement to disability benefits (i.e. the condition is not disabling within the meaning of the law). Form notices also contain certain stock language which explains the claimants' rights to appeal the decision and how to do it.

However, attached to each disability denial form notice is a personalized attachment with an explanation of the decision and how it was reached? The personalized explanation is based on the facts of the particular case. These personalized explanations are sometimes completed on word processing systems and stock language is sometimes used. However, each explanation mentions the specific impairment(s) involved, the medical sources and information about specific finding sin the individual case.

In the evaluation process the adjudicator and the medical consultant do not consider whether an applicant or beneficiary can lift and carry certain weights , sit stand and walk for certain lengths of time etc. unless certain other findings are made first. These factors are considered only when it has already been decided that the individual is not engaging in substantial gainful activity (SGA) and has an impairment(s) which though severe does not meet or equal the medical criteria in the Social Security regulations. If the claimant is not performing SGA but does not meet the regulatory medical criteria the medical consultant translates the individual’s symptoms, signs and laboratory findings into work related terms in an assessment of residual functional capacity (RFC)

The adjudicator subsequently compares this RFC with the physical and mental demands of the individual’s past relevant work. If the limiting effects of the impairment(s) prevent the performance of this work, the final step in the process is to decide whether the individual can engage in other work, considering his or her RFC, age, education and work experience.

The regulation takes into account classification of jobs by categories which have been developed by the U.S. Department of Labor. Light work, for example, is defined as work involving lifting no more than twenty pounds at a time with frequent lifting or carrying or carrying of objects weighing up to 10 pounds. Even though the weight lifted may be very little, a job in this category when it requires a good deal of walking or standing, or when it involves sitting most of the time with some pushing or pulling of arm or leg controls (sic). Other defined exertional categories of work are sedentary (less demanding than light) and medium (progressively more demanding than light). Many impaired persons while perhaps being unable to return to – or adjust to – more strenuous work, have the functional capacity to perform light or sedentary work in spite of their impairments. The letters to which Dr. Harris refers explain what this means for special capacities

With regard to Dr. Harris’ requests for information about the physician who made the disability determination on the case he wrote about, it appears that the New Jersey DDS and local Social Security office acted properly in withholding this information. To reveal the name of the physician and non-medical adjudicator who made the disability determination in any case would in fact reveal information from the claimant’s records.

Because of the need to protect the confidentiality of a person’s records, disclosures of any information is generally prohibited without the written authorization of the subject individual. If Dr. Harris’ patient were to request this information from his or her record or authorize its disclosure to Dr. Harris or another party we would be glad to comply. However without such a request or authorization we believe that release of the information would be an unwarranted invasion of the individual’s privacy.

I appreciate your sharing the newspaper article with us

. However I do not feel that the author presented a fair and complete understanding of the disability determination process. I trust that this reply will clear up any misconceptions.

John A Sven was the U.S. Commissioner of Social Security at the time.