The Social Security Administration has a straightforward eligibility standard for disability benefits: You must have an illness/injury/disease preventing you from financially supporting yourself. Plain and simple.
But every standard has exceptions. What if the disability, though legitimate, is tied up with something the person can or could have at one point controlled–such as alcohol or drug abuse?
In this case, the SSA tries to separate the substance abuse and disability symptoms to determine the disability’s cause. If the SSA finds that a claimant is abusing drugs or alcohol and that stopping would alter the disability to no longer meet eligibility requirements, then the case is dismissed. However, if the substance-abusing individual would continue to have an eligible disability without the substance, then the use of drugs and/or alcohol is immaterial. Even if substance abuse caused or sparked the disability of a now-sober claimant, his or her previous substance abuse is immaterial to the case.
How substance abuse is determined
Occasional use of alcohol or drugs will not prevent a person from receiving disability benefits from the SSA. With the exception of nicotine use disorders, the SSA defines substance abuse the same way the medical community does–with the criteria of the Diagnostic and Statistical Manual of Mental Disorders V. This criteria defines “substance use disorder” as an unhealthy pattern of dependence on drugs or alcohol leading to significant impairment or distress, occurring within one year. Its symptoms, varying in severity, include failing to fulfill responsibilities of work, school, family, etc; Substance-related legal problems include: engaging in physically hazardous activities, withdrawing, and more. The criteria for a substance use disorder, however, is not used in the case of:
- Fetal alcohol syndrome,
- Fetal cocaine exposure, or
- Addiction to, or use of, prescription medications taken as prescribed, including methadone and narcotic pain medication
Medical records confirm whether a substance use disorder is present, making it all the more important to go over medical notes with your lawyer to prevent any surprises. Once substance abuse is determined, the SSA considers whether the alcohol or drug abuse is relevant–or irrelevant–to the case.
How materiality (relevancy) is determined
The following chart, provided by the SSA, takes you through the step-by-step process used to determine whether a claimant’s substance abuse is material to the case–that is, whether the substance abuse is the cause of or exacerbates the disability. (Note: DAA stands for “drug or alcohol addiction,” which is the technical term for substance abuse which the SSA uses.)
|1. Does the claimant have DAA?||a. No–No DAA materiality determination necessary.|
b. Yes–Go to step 2.
|2. Is the claimant disabled considering all impairments, including DAA?||a. No–Do not determine DAA materiality. (Denial.)|
b. Yes–Go to step 3.
|3. Is DAA the only impairment?||a. Yes–DAA material. (Denial.)|
b. No–Go to step 4.
|4. Is the other impairment(s) disabling by itself while the claimant is dependent upon or abusing drugs or alcohol?||a. No–DAA material. (Denial.)|
b. Yes–Go to step 5.
|5. Does the DAA cause or affect the claimant’s medically determinable impairment(s)?||a. No–DAA not material. (Allowance.)|
b. Yes, but the other impairment(s) is irreversible or could not improve to the point of nondisability–DAA not material. (Allowance.)
c. Yes, and DAA could be material–Go to step 6.
|6. Would the other impairment(s) improve to the point of nondisability in the absence of DAA?||a. Yes–DAA material. (Denial.)|
b. No–DAA not material (Allowance.)
During the final step of this process, the SSA estimates the severity of how the claimant’s other impairment(s) would be without the substance abuse. This estimate relies on the evidence provided by the claimant’s case record, medical judgments about the effect of sobriety on functionality, periods of abstinence from substance, and other sources such as nurse practitioners, family members, and close associates of the claimant. Impairments that may improve in the absence of substance include alcoholic hepatitis, fatty liver, and alcoholic cardiomyopathy.
The SSA’s regulations try to prevent the enabling of unhealthy behaviors by not allowing those whose disability stems from substance abuse to rely on governmental benefits. Having substance abuse problems does not necessarily disqualify you from Social Security disability benefits, but it can complicate the approval process. If the substance abuse is the cause of your disability, then the SSA will deny your claim.
Photo courtesy of Michael Chen via Creative Commons