Pain and Disability Clinical, Behavioral, and Public Policy Perspectives (1987) / Chapter Skim
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3. Disability Determination and the Role of Pain
3. Disability Determination and the Role of Pain
Pages 37-65
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From page 37... ...
, established under Title lI of the Social Security Act, and Supplemental Security Income (SSI) , established under Title XVI of that Act.
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Program Definitions In administering both of its disability compensation programs, the SSA is bound by statutory definitions of disability. As set forth in the Social Security Act, disability is [An]
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Further "physical or mental impairment" is defined in the statute as: an impairment which results from anatomical, physiological, or psychological abnormalities which are demonstrable by medically acceptable clinical and laboratory diagnostic techniques.
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40 - ~ ~ oD lo 433 ~ ~ o ca (Q cd ~ - · c)
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. The 10 musculoskeletal impairments in the listing include active rheumatoid arthritis, arthritis of a major weight-bearing joint, arthritis of one major joint in each of the upper extremities, disorders of the spine, osteomyelitis, soft tissue injuries, and various amputations, anatomical deformities, and fractures.
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From page 42... ...
manifested by pain and limitation of back motion and paravertebral muscle spasm, with X-ray evidence of either: 1. Compression fracture of a vertebral body with loss of at least 50 percent of the estimated height of the vertebral body prior to the compression fracture, with no intervening direct traumatic episode; OR 2.
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From page 43... ...
The evaluation team is presented with a file on each claimant containing the forms filled out by the individual with the help of the SSA district office and the information forwarded to the DDS by physicians and others who have treated the individual. These forms differ from state to state, but generally include what is believed to be the pertinent information about the medical conditions that prevent the individual from working, as well as other information about past work history and current level of income.
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RFC for Past Work? 1 No Claimant Denied Beneflts Claimant Awarded Beneflts ~ on Medical Basis Alone 5.
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A claimant is said to "meet" the Listing of Impairments when the medical evidence in his or her file substantiates all of the signs, symptoms, and findings called for in the listing. A claimant who is judged to meet the listing is found disabled on the basis of medical evidence alone and is awarded benefits.
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From page 46... ...
Such claimants are assessed on the basis of their level of functioning, including such things as relationships with family members and others, and the ability to carry out necessary daily tasks, such as shopping for and preparing meals and caring for personal hygiene. Based on the assessment of residual functional capacity, the disability evaluator determines whether the claimant can perform work as before (Step 41.
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From page 47... ...
This team goes through the same five-step sequential evaluation process used by the initial evaluation team. The applicant may provide additional evidence or claim a worsening of the condition.
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48 1 1 o ~s ~D os o ~s ~D Q oo O O ~ .
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Program Benefits Although a person may apply for SSA compensation at any time after becoming disabled, cash benefits under SSDI cannot begin until 5 months from the date of onset of the disability, as established by the disability determination services. The monthly payment awarded to SSDI beneficiaries is dependent on the amount of money they earned during SSA-covered employment.
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From page 51... ...
The SSA estimates that fewer than 10,000 of the more than 6 million beneficiaries annually engage in trial work. Whether this is because they are too impaired to work, fear losing benefits, or have no incentive to return to work given the structure of the program is not clear (see Chapters 4 and 5~.
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of P.~. 98-460, the Social Security Disability Benefits Reform Act of 1984 (see Social Security Administration, 1984a)
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Other pain forms elicit more information from the claimant, in terms of the pain's effect on daily activities, relationships with others, and the ability to work and carry out work-related activities. Pain and the Sequential Evaluation Process SSA has detailed operating guidelines for its adjudicators that include review of the law and regulations relative to the evaluation of pain.
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From page 54... ...
At the second step, the decision as to whether or not an impairment is severe enough to significantly limit basic work activities must be based on a weighing of all the evidence, including reports of pain. When the pain described is out of proportion to the medical findings, the claim of pain must be further investigated to look for any limitations imposed by the pain in addition to those indicated by the medical evidence.
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From page 55... ...
19631. In that case the court enunciated the following standard: If pain is real to the patient and as such results in that person being physically unable to engage in any gainful occupations suited to his training and experience, and this results from 'any medically determinable physical or mental impairment,' the disability entitles the person to the statutory benefits even though the cause of such pain cannot be demonstrated by "objective clinical and laboratory findings." Not Tong after this case, the determination was made in Ber v.
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From page 56... ...
Califano) ; that a claimant's subjective complaints of pain cannot be rejected because of the absence of substantiating objective evidence unless there is contradictory evidence contained within the record; and that the opinion of the treating physician as to a claimant's disability is binding on the adjudicator.
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From page 57... ...
The consent decree to which the Secretary and the plaintiffs agreed set forth the following standard on the evaluation of pain as a disability: · Although the claimant has the burden of proving that the disability results from a medically determinable physical or mental impairment, there need not be direct medical evidence of the cause and effect between the impairment and the subjective effects of pain. · The absence of objective medical evidence is only one factor to be considered in making the disability determination.
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From page 58... ...
, the Workers' Compensation system, private disability insurance carriers, and programs in Western Europe in order to provide some points of comparison with the SSA disability system. Table 3-3 presents a synopsis of the four major disability compensation programs in this country.
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In addition to monthly cash benefits, disabled veterans are eligible to receive medical treatment at VA facilities, prosthetic dences, an allowance for modifications to homes and automobiles if required by the disability, and vocational rehabilitation sernces. Vocational rehabilitation is not mandatory in order to receive or continue receiving benefits.
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60 ct by o Pa ._ ._ ._ .
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Formulas for calculating death benefits and weekly compensation rates differ significantly from one state to the next. Although the SSA requires that a person be unable to engage in any kind of substantial gainful employment, most Workers' Compensation systems require only that the employee be unable either to perform his or her former employment or to obtain other employment suitable to his or her qualifications and training.
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Private Disability Insurance Income replacement is the benefit generally available under private disability insurance programs (see SouTe, 19841. A disability insurance policy is an agreement between parties that a particular amount will be paid periodically if the claimant becomes disabled.
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European systems also pronde temporary disability benefits, preferring to maintain individuals on temporary disability rather than labeling them as "permanently disabled," in order to encourage rehabilitation efforts. Another major difference is that in European countries the health, unemployment, disability, and retirement insurance systems are usually coordinated and also may be linked to medical and vocational rehabilitation, including job retraining.
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From page 65... ...
Cross-national comparisons in social policies regarding disability payments and vocational rehabilitation. Background paper prepared for the IOM Committee for a Study of Pain, Disability, and Chronic Illness Behavior, 1986.
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