Qualifying for disability benefits with the social security administration

Qualifying for disability benefits with the social security administration is based primarily on the information derived from a claimant's medical records. What do the medical records need to say? Ideally, for an adult individual to be approved, the medical records would simply make it extremely clear to the disability claim decision-maker (if the claim is at the disability application or reconsideration appeal level, the decision maker will be a disability examiner; if the claim is at the hearing level, the decision maker will be a federal administrative law judge) that the claimant could no longer engage in substantial and gainful work activity.

By the way, substantial and gainful activity is defined as being able to earn at least a certain dollar amount each month (to see the current SGA amount: SGA and social security disability). And the demonstrated inability to work at this level is necessary for qualifying for disability benefits with social security.

Unfortunately, the great majority of medical records do not do this. They do not provide the type of information that will allow a decision maker on a social security disability or SSI claim to conclude A) that a claimant cannot engage in substantial gainful work activity while performing work they have done in the past or B) that a claimant cannot engage in substantial gainful work activity while performing some type of other work that their job skills might make them qualified for.

What type of information is social security looking for in a claimant's medical records, and why is it not easily found? In general terms, Social security adjudicators are really looking for concrete evidence of a claimant's inability to engage in normal daily activities. In more specific terms, disability examiners and disability judges are looking for evidence that a claimant cannot engage in the types of activities that would be required in one of their past jobs or in some type of associated work. So, for this reason, decision makers will look for signs in the medical treatment records that indicate that the individual has trouble with: lifting, reaching, bending, sitting, standing, grasping, etc, etc. If the claimant has alleged one or mental impairments on their claim, the decision maker may look for evidence indicating that the claimant has difficulty with memory, or concentration and attention, or difficulty getting along with coworkers and supervisors.

The entire picture drawn by a claimant's physical and/or mental treatment records will allow a disability examiner or a disability judge to compare a claimant's remaining capabilities (referred to as residual functional capacity) to the requirements of their former jobs, as well as the requirements of other jobs that they might be thought capable of doing, given their age, education, and job skills.

But, again with the unfortunate part: most physicians do not typically include notes and observations in their medical treatment notes as to what a claimant can or cannot do, in light of their condition. For example, while a doctor's treatment notes will ususally include a diagnosis, a prognosis, or a prescription, very seldom will a treating physician indicate that a patient with carpal tunnel syndrome has difficulty picking up small objects, or that a patient with anxiety disorder has difficulty adapting to changing environments, or that a patient with degenerative disc disease has difficulty standing more than a certain amount of minutes. Sadly, the doctors who provide front line treatment for patients do not take the time to record this information in their notes, which then become the medical records that are evaluated by the social security administration.

What happens when a disability examiner or a disability judge cannot find the specific evidence in the medical records that they are looking for, the type of evidence that paints a clear picture of what a claimant can still do or no longer do? They are forced to extrapolate; that is, they are forced to draw conclusions to the best extent possible. Often, this is very difficult. And very often this is why a disability examiner will contact individuals who are filing for disability to ask them about their routine daily activities.

Of course, this is exactly why qualified and competent disability attorneys and non-attorney claimant representatives will attempt to retrieve from a claimant's treating physicians the type of information that is absent from the medical records. They do this by asking the physician to complete a detailed and objective statement on the claimant's behalf, one that asks the doctor to actually rate their patient's ability to perform certain physical or mental tasks. These types of statements are known as medical source statements and residual functional capacity statements.

Are such statements effective? Yes, without a doubt. Statements from treating physicians can often form the basis for a social security disability or SSI disability approval, particularly when presented in co-ordination will updated medical records at a hearing where both the claimant and their representative appear at a hearing together to present the facts of the case to a disability judge. Can these statements be provided at earlier steps of the process such as the disability application or reconsideration appeal. Yes, they can. However, disability examiners, who work in state-level processing agencies (known as DDS, or disability determination services, these are the agencies that make medical decisions for SSA), tend to give little credence to such statements. Which, of course, is not surprising as more than seventy percent of initial claims are denied by disability examiners throughout the country, while adminsitrative law judges tend to approve the majority of claimants who appear before them.