How Does the Social Security Administration Decide if I Quality for Disability Benefits for a Hearing Impairment?
If you have a hearing impairment, Social Security disability benefits may be available. To determine whether you are disabled by a hearing impairment, the Social Security Administration first considers whether your hearing impairment is severe enough to meet or equal a listing at Step 3 of the Sequential Evaluation Process. See Winning Social Security Disability Benefits for a Hearing Impairment by Meeting a Listing.
If your hearing impairment is not severe enough to equal or meet a listing, the Social Security Administration must assess your residual functional capacity (RFC) (the work you can still do, despite your hearing impairment), to determine whether you qualify for benefits at Step 4 and Step 5 of the Sequential Evaluation Process. See Residual Functional Capacity Assessment for a Hearing Impairment.
About Hearing Impairments and Disability
The Structure of the Ear
Our hearing apparatus consists of several structures (see Figure 1 below):
- The external ear is the pinna. This may help deflect sound into the external auditory canal.
- The next structure is the eardrum. This is a thin and delicate membrane. Vibration of the eardrum by sound puts pressure on a series of three small bones in a space behind the eardrum called the “middle-ear.”
- The “middle-ear” bones transmit sound vibration from the eardrum to the cochlea in the inner ear.
- The cochlea is a spiral, fluid-filled bony structure lined with a membrane holding about 15,000 tiny hairs that move when vibrations in the fluid reach them.
- The different hairs react to different frequencies of sound. This information is coded into the auditory nerve and transmitted to both sides of the brain, though principally to the opposite side.
Figure 1: Close-up of structures of the human ear.
Causes of Hearing Loss
Hearing loss can be caused by a variety of different things. Congenital defects anywhere in the hearing apparatus or brain can result in hearing loss. Infections and other diseases account for other cases. Allergies that cause fluid in the middle-ear can also result in hearing loss, if allowed to persist. Other causes of hearing loss are drugs, trauma, immune diseases, cancers, circulatory, genetic and degenerative disorders.
Most hearing loss results from problems with the cochlea or auditory (acoustic) nerve. This is called sensorineural. Hearing loss due to damage to areas of the brain cerebral cortex used in hearing is called central hearing loss. Hearing loss due to damage to the bones of the middle ear is called a conductive hearing loss. Mixed hearing loss means there is a combination of sensorineural and conductive hearing losses.
The most common cause of a combination of deafness and blindness, accounting for about half of the deaf-blind cases in the U.S. is a recessive genetic disorder called Usher syndrome.
There are three types of Usher syndrome:
- In Usher I, the child is born with profound deafness and severe difficulty in balancing. The ability to walk begins late at about 18 months or even older. Progressive blindness appears by age 10. Of course, these difficulties are carried into adulthood. Since the child is born with profound deafness, hearing aids are of little value.
- In Usher II, the child has moderate to severe hearing loss at birth and can be benefit with hearing aids. The retinitis pigmentosa starts in the late teens and does not progress as rapidly as in Usher I. Balance in these individuals is normal.
- In Usher III, the child is born with normal hearing, vision and balance. Hearing loss and blindness are usually significant problems by the time they are teenagers; blindness and deafness are fully in place sometime in adulthood.
Many adults with any type of Usher syndrome will qualify for disability, based on hearing or vision impairment. It is important that the Social Security Administration know the diagnosis in children and teenagers, since progressive severity is to be expected rather than stability or improvement.
Waardenburg syndrome is a genetic disorder resulting in deafness, and one defective gene from either parent is enough to produce the disorder.
There are at least four types of Waardenburg syndrome, with Types 1 and 2 being the most common. In Type 1 Waardenburg syndrome, there is a mutated gene that controls development of part of the face and inner ear. In Type 2 Waardenburg syndrome there is also a mutated gene that is related to development of ear structures and hearing. About 20% of Type 1 and 50% of Type 2 Waardenburg syndromes have hearing deficits to some degree.
An interesting fact about Waardenburg syndrome is that there may be other unusual features. For example, due to possible problems with pigmentation, there can be oddly colored patches of skin or hair (like a white forelock of hair or white patch of skin), and eyes of differing color. A low frontal hairline and eyebrows that grow together are other possible features, or the root of the nose may be widened. Hearing loss may be moderate to profound, and does not correlate with pigmentary or facial peculiarities.
Testing of Hearing
Hearing testing is done by audiometry, and is usually performed by audiologists.
Hearing is tested at several different frequencies. The ones that are important to the Social Security Administration are 500, 1000, 2000, and 3000 Hertz [Hz]. The intensity of sound is measured in decibels (dB), and the decibel level at which a sound of a particular frequency can be heard is the pure tone threshold.
Ability to hear sound of 0–25 dB is normal. Normal conversation takes place in about the 45–60 dB range.
People hear by sounds conducted both through the air and sound conducted through bones in the ear and skull. Audiometry tests both types of hearing. Hearing through air is air conduction and through bone is bone conduction.
Audiometry usually includes a test of how well you can understand words, and is called speech discrimination. Speech discrimination, as determined by speech audiometry, is the percentage of test words correctly identified when spoken from standardized and pre-recorded lists. A normal person will achieve nearly 100% correct identification. This test can be used for adults and older children. However, speech discrimination should not be confused with the speech recognition threshold (SRT), which involves a measure of the lowest decibel intensity at which test words can be heard 50% of the time. SRT is a measure of loudness and does not imply ability to understand speech. Speech discrimination is used to determine how well a patient can understand what he hears. The SRT should reasonably correlate with the pure tone average (PTA) for the 500, 1000, and 2000 Hz frequencies, and can thus serve as a check on the validity of the test. The pure tone average is by standard acceptance the sum of the decibel levels necessary to hear 500, 1000, and 2000 Hz, divided by 3. When the person being tested does not cooperate with the testing procedures, such as in malingering, there will be a substantial discrepancy between the SRT and PTA.
Winning Social Security Disability Benefits for a Hearing Impairment by Meeting a Listing
To determine whether you are disabled at Step 3 of the Sequential Evaluation Process, the Social Security Administration will consider whether your hearing impairment is severe enough to meet or equal the hearing impairment listing. The Social Security Administration has developed a set of rules called Listing of Impairments for most common impairments. The listing for each impairment describes a degree of severity that the Social Security Administration presumes would prevent a person from performing substantial work. If your hearing impairment is severe enough to meet or equal the hearing impairment listing, you will be eligible for disability benefits.
The listing for a hearing impairment is 2.08, which has two parts: A and B. You will be disabled if you meet either part A or part B.
Few people have hearing loss severe enough to qualify under this listing. Profound deafness is required.
Social Security Administration Testing Criteria for the Hearing Impairment Listing
Evaluation for a hearing impairment is based on the best-correctable hearing, which means best-correctable in the better ear. Even if you appear to be meet the hearing loss severity for the listing, but there is a possibility that hearing aids will significantly improve your hearing, then the listing requires that such testing be carried out.
Since the listing criteria are generally based on how you hear with a hearing aid, the Social Security Administration usually needs the results of hearing testing performed with a hearing aid in place.
However, testing can be done without a hearing aid, if in the better ear there is:
- A profound loss of hearing (both air conduction and bone conduction threshold sensitivity are at the levels in Listing 2.08A) and speech discrimination scores are at the level in Listing 2.08B.
- A profound loss of hearing (both air and bone conduction threshold sensitivity are at the levels in Listing 2.08A), and speech discrimination testing could not be completed due to the high decibel level needed.
- A profound loss of hearing (both air and bone conduction threshold sensitivity are at the levels in Listing 2.08A), and the evidence shows the treating source no longer conducts speech discrimination testing due to the high decibel level needed or the individual’s inability to communicate effectively.
Also, to be tested without a hearing aid it is helpful to show history of having attended a special school for the deaf along with development and use of sign language to communicate.
If you have your own hearing aids, testing can be done with those aids. However, claimants frequently come to examinations with hearing aids that do not function, or that are of poor quality by current standards of performance. In these cases, the Social Security Administration performs further evaluation at government cost. You may have to go to three different appointments: (1) the initial ear examination and testing without a hearing aid; (2) an appointment with the audiologist for creation of a hearing aid mold that fits your external ear canal size and shape; and (3) an appointment to measure aided hearing using a state-of-the-art hearing aid in the mold.
Profound deafness in one ear, with or without a hearing aid, is a slight (not severe) impairment if the other ear retains good hearing. With good hearing in one ear, there is never a need to test for improvement with a hearing aid in the hearing-deficit ear.
Meeting Social Security Administration Listing 2.08A for a Hearing Impairment
We can hear sound conducted either through the air or through the bones of our skull. Both types of hearing are tested by audiometry in pure tone adult claims.
To meet the Social Security Administration Listing 2.08A for a hearing impairments the hearing loss (even with a hearing aid) must be shown by an average hearing threshold sensitivity for air conduction of 90 decibels or greater, and for bone conduction to corresponding maximal levels, in the better ear, determined by the simple average of hearing threshold levels at 500, 1000, and 2000 hz.
The audiologist who tests your hearing gradually varies the particular sound intensity (decibel level), until you state that you can hear the tone half of the time. This is the pure tone threshold sensitivity at a given frequency for you to be aware that there is a sound.
The Social Security Administration does not consider all frequencies of sound that are a normal part of hearing. It only considers the range of frequencies that are most important in perceiving speech sounds in regard to functional, everyday communication. Test frequencies used by the Social Security Administration in adult claims are 500, 1000 and 2000 cycles per second (Hertz). Only these frequencies of sound are used for calculation, even if medical evidence contains reports of the ability to hear other frequencies.
In evaluating the audiometric report, the Social Security Administration averages the intensity of sound necessary to hear at each of these frequencies. This average is calculated separately for hearing through air and through bone. The final average must not be lower than 90 decibels necessary for you to hear sounds in the air, and not lower than a “corresponding level” necessary of bone conduction (i.e., about 65 decibels). Bone conduction is measured through the mastoid bone behind the ear. All of this data is plotted out on audiometric charts, for the Social Security Administration’s independent evaluation. The Social Security Administration will not accept conclusions from treating or consultative examination sources as a substitute for the actual evidence derived from testing.
The Social Security Administration will do its evaluation based on how much hearing defect there is in the better ear. In other words, you could be totally deaf in one ear and you would still have to be deaf enough in the other ear, despite use of a hearing aid (when appropriate) to qualify under the listing.
Meeting Social Security Administration Listing 2.08B for a Hearing Impairment
The speech discrimination in the better ear is used to decide if disability benefi ts will be awarded.
To qualify, you must have a speech discrimination score equal to or less than 40%.
If you have poor speech discrimination at the listing-level, then you will most likely also have at least a moderate to marked degree of pure tone deafness.
Residual Functional Capacity Assessment for Hearing Impairments
What Is Residual Functional Capacity (RFC)?
If your hearing impairment is not severe enough to meet or equal a listing at Step 3 of the Sequential Evaluation Process, the Social Security Administration will need to determine your residual functional capacity (RFC) to decide whether you are disabled at Step 4 and Step 5 of the Sequential Evaluation Process.
RFC is a claimant’s ability to perform work-related activities. In other words, it is what you can still do despite your limitations. An RFC for physical impairments is expressed in terms of whether the Social Security Administration believes you can do heavy, medium, light, or sedentary work in spite of your impairments. The lower your RFC, the less the Social Security Administration believes you can do.
Hearing Impairment and Residual Functional Capacity
Although profound deafness in one ear and good hearing in the other is considered to be a “not severe” impairment, most claimants have bilateral sensorineural hearing loss, especially as a result of a lifetime of exposure to loud sounds without adequate hearing protection. If you have good speech discrimination and a better ear pure tone average (PTA) of 40 dB or less, the Social Security Administration will generally find that your hearing impairment is “not severe.”
However, there is no definite medical policy regarding what pure tone average threshold with good discrimination the Social Security Administration would consider “not severe.” Despite the lack of policy, the Social Security Administration would be on medically questionable grounds with a finding that a pure tone average of 50 dB or more in the better ear is “not severe.” Also, speech discrimination of less than 75% should be considered a significant and work-related impairment, although there is no regulatory basis for this position.
Generally, the following values can be used as guidelines for speech discrimination scores:
- 100 – 90% – excellent – normal discrimination
- 89 – 75% – good – slight difficulty sometimes, such as on telephone
- 74 – 60% – fair – moderate difficulty most of the time
- 59 – 40% – poor – difficulty in following conversation
- < 40% – very poor – severe difficulty in conversation most of the time
These discrimination guidelines are not formal Social Security Administration policy because there is no such policy. Also, terms like “mild” or “good” are necessarily arbitrary to some extent, and therefore vary a little in the medical literature. Informed medical and vocational judgment is required for evaluating these claims.
The Residual Functional Capacity may contain some general statement expressing limitation in ability to hear. However, the person establishing the medical (Residual Functional Capacity) part of the determination should communicate clearly to the adjudicator about the vocational determination regarding the functional severity of the hearing deficit. There is a big difference functionally between a person who has a better ear at a 50 dB average hearing threshold with 80% discrimination, and one who has a better ear average hearing loss of 70 dB with a discrimination score of 45%. The former will have minimal functional loss, while the latter cannot do work requiring any significant verbal communication in regard to either speaking or hearing. Social Security Administration vocational analysts generally have little difficulty in citing jobs for hearing-impaired claimants, but one important fact may be overlooked by the Social Security Administration: when a person has near-total deafness, he or she cannot hear verbal warnings and the sounds of dangerous machinery. Therefore, there should be limitations in working around hazardous machinery when hearing impairment could pose a risk to oneself or co-workers.
Another issue is fluctuating hearing loss, as may occur with Meniere’s disease. You might argue that work-related limitations should be based on the worst hearing test results documented in your file. However, there is no Social Security Administration medical policy supporting this position.
Getting Your Doctor’s Opinion About What You Can Still Do
Your Doctor’s Medical Opinion Can Help You Qualify for Social Security Disability Benefits
The Social Security Administration’s job is to determine if you are disabled, a legal conclusion based on your age, education and work experience and medical evidence. Your doctor’s role is to provide the Social Security Administration with information concerning the degree of your medical impairment. Your doctor’s description of your capacity for work is called a medical source statement and the Social Security Administration’s conclusion about your work capacity is called a residual functional capacity assessment. Residual functional capacity is what you can still do despite your limitations. The Social Security Administration asks that medical source statements include a statement about what you can still do despite your impairments.
The Social Security Administration must consider your treating doctor’s opinion and, under appropriate circumstances, give it controlling weight.
The Social Security Administration evaluates the weight to be given your doctor’s opinion by considering:
- The nature and extent of the treatment relationship between you and your doctor.
- How well your doctor knows you.
- The number of times your doctor has seen you.
- Whether your doctor has obtained a detailed picture over time of your impairment.
- Your doctor’s specialization.
- The kinds and extent of examinations and testing performed by or ordered by your doctor.
- The quality of your doctor’s explanation of your impairment.
- The degree to which your doctor’s opinion is supported by relevant evidence, particularly medically acceptable clinical and laboratory diagnostic techniques.
- How consistent your doctor’s opinion is with other evidence.
When to Ask Your Doctor for an Opinion
If your application for Social Security disability benefits has been denied and you have appealed, you should get a medical source statement (your doctor’s opinion about what you can still do) from your doctor to use as evidence at the hearing.
When is the best time to request an opinion from your doctor? Many disability attorneys wait until they have reviewed the file and the hearing is scheduled before requesting an opinion from the treating doctor. This has two advantages.
- First, by waiting until your attorney has fully reviewed the file, he or she will be able to refine the theory of why you cannot work and will be better able to seek support for this theory from the treating doctor.
- Second, the report will be fresh at the time of the hearing.
But this approach also has some disadvantages.
- When there is a long time between the time your attorney first sees you and the time of the hearing, a lot of things can happen. You can improve and go back to work. Your lawyer can still seek evidence that you were disabled for a certain length of time. But then your lawyer will be asking the doctor to describe your ability to work at some time in the past, something that not all doctors are good at.
- You might change doctors, or worse yet, stop seeing doctors altogether because your medical insurance has run out. When your attorney writes to a doctor who has not seen you recently, your attorney runs the risk that the doctor will be reluctant to complete the form. Doctors seem much more willing to provide opinions about current patients than about patients whom they have not seen for a long time.
Here is an alternative. Suggest that your attorney request your doctor to complete a medical opinion form on the day you retain your attorney. This will provide a snapshot description of your residual functional capacity (RFC) early in the case. If you improve and return to work, the description of your RFC provides a basis for showing that you were disabled for a specific period. If you change doctors, your attorney can get an opinion from the new doctor, too. If you stop seeing doctors, at least your attorney has one treating doctor opinion and can present your testimony at the hearing to establish that you have not improved.
If you continue seeing the doctor but it has been a long time since the doctor’s opinion was obtained, just before the hearing your attorney can send the doctor a copy of the form completed earlier, along with a blank form and a cover letter asking the doctor to complete a new form if your condition has changed significantly. If not, your attorney can ask the doctor to send a one-line letter that says there have been no significant changes since the date the earlier form was completed.
There are times, though, that your attorney needs to consider not requesting a report early in the case.
- First, depending on the impairment, if you have not been disabled for twelve months, it is usually better that your attorney wait until the twelve-month duration requirement is met.
- Second, if you just began seeing a new doctor, it is usually best to wait until the doctor is more familiar with your condition before requesting an opinion.
- Third, if there are competing diagnoses or other diagnostic uncertainties, it is usually best that your attorney wait until the medical issues are resolved before requesting an opinion.
- Fourth, a really difficult judgment is involved if your medical history has many ups and downs, e.g., several acute phases, perhaps including hospitalizations, followed by significant improvement. Your attorney needs to request an opinion at a time when the treating doctor will have the best longitudinal perspective on your impairment.
Medical Opinion Forms
Medical opinion forms can be great time savers for both your attorney and your doctor, but they must be used with care. Forms may not be appropriate at all in complex cases; and they need to be supplemented in many cases so that all issues are addressed. The best forms are clear and complete but not too long.
When the time is right, here is a form for your disability attorney to use: