Getting Social Security Benefits Before Your Claim is Decided

Serving the Western United States

Presumptive disability (PD) benefits are payments awarded to someone who is currently in the process of applying for SSI benefits, but whose medical condition will likely qualify him or her for disability benefits. In order to receive PD payments, the individual must prove eligibility by meeting a number of nonmedical requirements; such requirements include low income and few assets. PD payments are not awarded to Social Security Disability Insurance (SSDI) claimants (workers who have paid Social Security taxes). Someone who applies for both SSI and SSDI, and qualifies for PD, will be awarded PD benefits on the basis of the SSI claim only.

If you are in the process of applying for disability benefits and are deemed presumptively disabled, the Social Security Administration (SSA) will pay up to six months’ worth of benefits while your disability application gets processed. These interim payments will begin the month in which the SSA deems you presumptively disabled. However, if the SSA has not made a decision on your disability application after six months of PD benefits, these payments will cease until the SSA renders a decision.

SSI claimants whose claims are based on a disability frequently receive cash payments, thus it is not unreasonable to request them. You will be eligible for free healthcare under Medicaid if you are granted PD. However, a PD finding does not guarantee a favorable disability finding on your pending SSI application. If the SSA denies your application for disability benefits before you have received six months’ worth of PD benefits, you will not receive the balance of the PD benefits. However, in most cases, you will not be required to return the PD benefits you received before your disability application was denied.

The Presumptive Disability (PD) Application Process

You apply for PD at your local SSA Field Office at the same time you apply for SSI. If, at that time, you can prove PD eligibility by presenting with a qualifying medical condition, the SSA Field Office can grant you PD at that time. The next section will discuss qualifying impairments. However, in most cases, PD benefits are withheld and applications are forwarded to the state Disability Determination Services (DDS) for a formal decision. Even if your impairment is not listed in the following section, keep in mind that the DDS has the authority to grant PD payments regardless of whether or not your specific impairment is listed. If you do not see your condition listed, be sure to ask the employee handling your claim about PD. Section C will guide you through the process.

Qualifying for Presumptive Disability

If an SSA Field Office employee has reason to believe that you have a disabling impairment that qualifies you for six months of PD benefits, he or she has the power to award you those payments at the time you apply for benefits. While Field Office employees are not physicians, they have the authority to award PD to observably disabled claimants.

There are three bases on which the Field Office may determine a claimant’s eligibility: (1) the representative’s observations, (2) the claimant’s statements, or (3) upon receiving confirmation of the claimant’s condition from another source. The following sections discuss each case.

1. The Representative’s Observations

If a PD claimant is an amputee (specifically, is missing two limbs or has

had a leg amputated at the hip), the Field Office representative can award the claimant PD.

2. The Claimant’s Statements

The word of a claimant or a claimant’s guardian (if the claimant is a minor) may also serve as a reasonable basis on which a Field Office representative can award PD. The impairments an applicant claims to have must be severe enough to be obvious to the Field Office representative, who is not a medical professional. However, it is important to note that the a claimant may ultimately qualify for disability benefits even if the medical severity of his or her condition does not entitle him or her to PD benefits. The disabling conditions include:

-total blindness

-total deafness

-confinement to a bed or immobility

– difficulty walking or using a hand or arm as a result of a stroke that occurred more than three months in the past,

-diabetes with an amputated foot

-Down syndrome characterized by mental retardation, skeletal defects (malformed skull, short limbs, hands and feet that are wider and flatter than average)

-cerebral palsy, muscular dystrophy, or muscle atrophy accompanied by marked ambulatory difficulty without the aid of braces, problems speaking, or motoric coordination of hands or arms

-severe mental retardation in an individual at least seven years old

Simply claiming that you (or your minor charge) is disabled is insufficient. Your statement claiming disability will not win you PD if the SSA Field Office representative cannot observably confirm your disability, or believes your claim may be fraudulent.

3. Outside Confirmation of a Claimant’s Disability

In certain cases, the Field Office representative will need to confirm a claimant’s disability by seeking confirmation from an outside source before granting PD. Outside confirmation is necessary when the claimant’s alleged condition is not apparent to the Field Office employee, or when the claimant’s statement of disability is not commensurate with the employee’s observations. Conditions that qualify a claimant for PD, but that require outside confirmation are as follows:

-HIV infection*

-a terminal diagnosis

-a child six months or younger who had a birth weight below 1,200 grams (2 lbs., 12 oz.)

-a child six months or younger who had a birth weight as follows: Gestational Age (in weeks) Birth Weight

37-40 under 2,000 grams (4 lbs., 6 oz.)

36 1,875 grams or fewer (4 lbs., 2 oz.)

35 1,700 grams or fewer (3 lbs., 12 oz.)

34 1,500 grams or fewer (3 lbs., 5 oz.)

33 1,325 grams or fewer (2 lbs., 15 oz.)

Specialized procedures are required to make a PD determination in the case of a claimant alleging HIV or AIDS.

Presumptive Disability Through the DDS

After the SSA deems you legally eligible for PD benefits, it is up to the Disability Determination Service (DDS), a state agency, to determine your medical eligibility for SSI benefits.

If the SSA Field Office denies you PD benefits, you can seek a favorable PD determination once again when the DDS reviews your application to make its SSI determination. A DDS representative has more leeway in granting PD than a Field Office representative does. The DDS can make three kinds PD determinations based on the likelihood that a claimant will receive PD:

1. High Likelihood

The DDS often decides favorably to the claimant in the following cases:

-mental retardation

-cancer

-diseases of the central nervous system, specifically those resulting in paralysis, ambulatory difficulty, or decreased motoric control of hands and arms

-irreversible kidney disease

-HIV infection

2. Moderate Likelihood

The DDS is less likely to grant PD to claimants with the following conditions because it is hard to forecast their medical intensity or duration:

-diabetes

-epilepsy

-high blood pressure

-heart disease resulting from high blood pressure

-peptic ulcer

-cirrhosis of the liver

-bone fractures

3. Low Likelihood

The DDS is unlikely to grant PD to claimants alleging the following conditions:

-mental impairments, excepting retardation or cases in which there is strong evidence in support of protracted psychosis or chronic brain syndrome (in which case the DDS is more inclined to grant PD)

-respiratory conditions (because medical evaluations of respiratory function are often required to determine the severity of most respiratory impairments)

-back conditions, excepting cases of spinal cord trauma (where the DDS is more likely to grant PD benefits)