How Important is the Treating Physician to a Social Security Disability or SSI case?

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The Social Security Administration considers a treating physician to be a doctor who has an established history of providing treatment to a patient for a specific condition. Because this physician has a history of providing care to a person for whatever their condition is, SSA considers this doctor to be a reliable source of information regarding the individual's A) prognosis, and B) the extent to which--and manner in which--their condition limits their ability to engage in normal daily activities, including work activity.

A treating physician, by definition, is not simply a doctor who has seen a patient once or twice. By the same token, a doctor who is a podiatrist (foot specialist) cannot be considered a treating physician for a disability claimant who is applying for disability on the basis of a mental condition.

How important is the opinion of the treating physician to the decision that is made on a social security disability claim, or SSI disability claim? Fairly important. At a disability hearing where the decision is made by a federally appointed judge, the opinion of a treating physician that is recorded on either a residual functional capacity form, or on some other type of medical source statement (a statement submitted by a doctor which indicates in detail how a person is physically or mentally limited), can absolutely determine if a claimant will qualify for disability benefits, or not.

The opinion of a treating physician is much more highly valued than the opinion of a doctor who has only seen a claimant once or twice. This, of course, makes sense considering that a treating physician, by definition, should know much more about the claimant's condition, treatment, and response to treatment. For this reason, most experienced disability representatives (i.e. a disability attorney or a non-attorney representative) will try to obtain a statement from a claimant's treating physician whenever a case is to be heard by an ALJ (administrative law judge) at a hearing. Disability judges simply give credence and weight to such medical opinions.

Will the opinion of a treating physician carry the same weight when the case is being decided at a lower level, such as the disability application level, or the reconsideration appeal level? Unfortunately, this is often not the case. This is because the lower levels of the disability system are tilted against the claimant. This is easily demonstrated by several facts:

1. The social security administration does not make any attempt to obtain the opinion of a claimant's treating physician, or treating physcians (you can have more than one), when the claim is being decided initially. This is despite the fact that disability lawyers routinely obtain them to present to social security judges at hearings.

2. Social Security will instead use the opinion of a medical consultant who is part of disability examiner's case processing unit. This consultant is a medical doctor who assists the examiner in making a determination on a disability case. In so doing, the medical consultant will review the claimant's medical records, just as the disability examiner has done. However, the fact remains that this doctor has never treated, nor met the claimant. By definition, this doctor is immeasurably unqualified to give an opinion as to the claimant's functional limitations in comparison to the claimant's own doctor.

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SSD and SSI are Federal Programs

The title II Social Security Disability and title 16 SSI Disability programs operate under federal guidelines and, therefore, the program requirements--medical and non-medical--apply to all states:

Alabama, Alaska, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, Florida, Georgia, Hawaii, Idaho, Indiana, Illinois, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Vermont, Virginia, Washington, West Virginia, Wisconsin, Wyoming

Recent approval and denial statistics for various states can be viewed here:

Social Security Disability, SSI Approval and Denial Statistics by state

Special Section: Disability Lawyers and unnecessary claim denials