PRESUMPTIVE DISABILITY: How It Works & Insurance Covers


Most disability policies include a provision for presumptive disability. Only total disability qualifies a person for benefits under a disability insurance contract; partial disability does not. However, the definition of total disability can be ambiguous at times.

What is Presumptive Disability

Presumptive disabilities are medical conditions that qualify for disability benefits and can be easily identified; thus the term “presumed disability.” You can apply for PD while applying for SSI. Because SSI applications take so long to review, PD allows people to get help right away.

Social security Presumptive Disability

People who apply for Social Security Disability benefits are frequently in serious financial distress. If you are unable to work, you may be faced with mounting bills and overwhelming financial obligations. To make matters worse, your Social Security Disability claim may be denied for months or even years. You may be concerned about how you will feed your family and pay your rent in the meantime. Fortunately, there is a provision that may allow you to receive Social Security Disability benefits; while your disability claim is being processed.


When you apply for Social Security Disability and Supplemental Security Income benefits; the person who handles your claim will forward your case to your state’s Disability Determination Services department. At this point, the Social Security Administration can determine whether you are eligible for presumptive disability benefits. If you qualify and are approved, you will be paid while your Social Security Disability claim is being processed. You may not be eligible for cash benefits under Social Security’s Presumptive Disability program in some cases; but you may be eligible for Medicaid to help cover medical expenses while you wait for a Social Security Disability determination.

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It is critical to understand that if your Social Security Disability claim has been denied; you are in the process of appealing, you will not be eligible for Presumptive Disability under the SSI program. You must be at the beginning of your Social Security Disability claim process. If you are eligible for presumptive disability; you will only be able to receive these benefits for a maximum of six months. Your benefits will be terminated after several months, or when the Social Security Administration; makes a decision on your Social Security Disability claim.

Presumptive Disability Form

Use this form to find out quickly if you qualify for Medicaid presumptive eligibility. Presumptive eligibility allows you and your family to receive health care; while you apply for regular Medicaid or other health coverage. You must complete the [State information: State single streamlined application] to find out if you qualify for regular Medicaid or other health coverage. While you wait to find out if you qualify for regular Medicaid or other health coverage; you can get health care through presumptive Medicaid eligibility.

Sample of Presumptive Disability Form

Presumptive Disability Benefits

In some cases, the Social Security Administration is willing to pay benefits while gathering evidence for a decision on your Social Security Disability claim. To be eligible for Presumptive Disability, you must have sufficient evidence that your Social Security Disability claim is likely to be approved, as well as meet the Supplemental Security Income program’s income limit requirements.

The Presumptive Disability program is only available to those who qualify for Supplemental Security Income, which means their household income and assets must be below the Social Security Administration’s limits, and they must have a condition that is likely to result in the approval of their Social Security Disability claim. The following are some examples of disabling conditions that may qualify you for presumptive disability:

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  • AIDS or asymptomatic human immunodeficiency virus (HIV) infection
  • Amputation of a leg at the hip
  • Amyotrophic lateral sclerosis (ALS), also known as Lou Gehrig’s disease.
  • Cerebral palsy, muscular dystrophy, or muscle atrophy that causes significant difficulty speaking, using hands or arms, or walking
  • Bed rest — or immobility without crutches, a walker, or a wheelchair — due to a long-standing condition rather than an accident or recent surgery
  • Down syndrome
  • End-stage renal disease, also known as chronic kidney failure
  • A cognitive disability or neurodevelopmental disorder, such as autism, is accompanied by the inability to perform basic self-care activities such as eating or dressing.
  • A spinal cord injury that renders a person unable to move without the assistance of a walker or other similar device.
  • A stroke that occurred at least three months ago and results in ongoing difficulty walking or using hands or arms
  • With a life expectancy of less than six months, you have terminal illness.
  • Complete blindness
  • Complete deafness
  • Low birth weight in a child under the age of one year
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The field offices can only consider the conditions listed above, but the DDS has the authority to grant presumptive disability for other impairments. When Social Security makes a decision on your SSI claim, or after six months, the advance payments stop (whichever comes first).

Babies with Low Birth Weight

Babies born with a significantly low birth weight are eligible for presumptive disability (whether or not the baby was premature). To be eligible for presumptive disability due to low birth weight, your baby must be six months old or younger and have a birth weight of less than:

  • 4 pounds, 6 ounces (2,000 grams) if born at 37 weeks or later.
  • If born at 36 weeks, 4 pounds, 2 ounces (1,875 grams)
  • 3 pounds, 12 ounces (1,700 grams) if born at 35 weeks
  • If born at 34 weeks, 3 pounds, 5 ounces (1,500 grams)
  • 2 pounds, 15 ounces (1,325 grams) if born at 33 weeks, or
  • If born at any gestational age, 2 pounds, 10 ounces (1,200 grams) would be the limit for a healthy adult.

If your baby meets the above weight requirements, you will be eligible for SSI payments for up to six months while your case is being resolved. Your child will also be eligible for free medical care through Medicaid. Before granting you presumptive disability, your SSA representative will need to confirm your child’s birth weight by contacting the hospital or doctor.

How Much Will You Get Under Presumptive Disability?

The amount of your total household income and assets will influence the number of your Presumptive Disability payments. Only SSI applicants are eligible for Presumptive Disability, and SSI is a needs-based program. Even if the Social Security Administration is certain that your case for Social Security Disability benefits will be approved, you will not receive any Presumptive Disability payments if you do not meet the income requirements.

In most cases, your Presumptive Disability payment would be equal to the amount of SSI benefits you would receive. The maximum SSI benefit amount for an individual is $674 per month and $1,011 for an eligible couple.

What if your claim is denied?

Many people are concerned that if their claim for Social Security Disability benefits is later denied, they will have to repay presumptive disability payments to the Social Security Administration. This is not always the case. If your disability claim does not work out due to medical reasons, you will not have to repay the presumptive disability benefits you have received. If, however, your claim for SSI is denied due to clerical errors or discrepancies in household income, then you may be responsible for paying back the Presumptive Disability payments you received while waiting for a decision on your Social Security Disability claim.

Do You Meet the Criteria for Presumptive Disability?

Presumptive Disability payments are not available to many people who apply for Social Security Disability benefits. If, on the other hand, your income and assets are very minimal, and you have a severe medical condition that is likely to qualify you for Social Security Disability and SSI, you should contact the Social Security Administration to inquire about Presumptive Disability payments.

Who Decides Whether You Are Eligible for Presumptive Disability?

In many cases, your local SSA field office can make a presumptive disability determination. For some conditions, the field office must obtain confirmation from a trustworthy source of information, such as a doctor, social worker, or school personnel.

If the SSA declines to grant you disability benefits, you may still qualify when your file moves to Disability Determination Services (DDS), the agency that determines whether you qualify for regular disability benefits. The DDS has more leeway in granting presumptive disability and can grant benefits to applicants with illnesses and conditions not listed above.

Take note

  1. Presumptive disability payments are only available while the SSA is processing your initial SSI application. You will not be able to receive them while your case is on appeal.
  2. You may have to repay some or all of the money if the SSA rejects your claim for reasons other than your medical condition or determines that your presumptive benefit amount was incorrect.
  3. Presumptively disabled applicants who face an immediate financial need, such as a medical emergency or imminent homelessness, may be eligible for a one-time “emergency advance payment” from Social Security. It can happen as early as the month they apply for SSI. This money must be repaid, either in a lump sum or as deductions from future benefits.

Frequently Asked Questions

What is an example of a presumptive disability?

Total deafness, total blindness, amputation of the leg at the hip, confinement to bed or a wheelchair, a stroke resulting in the inability to walk or use one hand, cerebral palsy, muscular dystrophy, certain cancers, and other disabling conditions are examples of disabling conditions that may qualify you for Presumptive Disability.

What is considered a presumptive disability under a disability income policy?

Presumptive disability is defined differently in different contracts. The basic idea behind presumptive disability is to protect against sudden and severe disabilities. They generally protect you from losing your hearing, sight, speech, or use of any two limbs.

What is presumptive status?

Presumptive benefits status permits veterans seeking disability benefits to forego certain paperwork and medical testing required to demonstrate that their injuries and illnesses are directly related to their service in the military.

Can the VA deny a presumptive disability?

The VA will deny any claim that does not have a demonstrable in-service link. There is, however, one exception: the VA’s presumed conditions list. If you have a condition on this list, you do not need to prove an in-service link, and it does not need to be documented in your service medical records.

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