Medical Records for a Disability Hearing can include your doctor's statement

Medical Records for a Disability Hearing can include your doctor's statement

This post concerns the importance of medical evidence at a Social Security Disability hearing.

Medical evidence at a hearing or any other level of the disability system forms the cornerstone of decisions on Social Security Disability and SSI claims that are decided.

Some decisions on cases will rely entirely on the evidence contained in medical records, which can include admission and discharge summaries from hospitals, physician's notes, reports of imaging studies (MRIs, CT scans, xrays) and labwork, but which can also include detailed objective statements from physicians as to a patient's prognosis and functional limitations that result from their various medical conditions, both physical and mental.

It can be invaluable to your disability claim for your physician to provide a statement that gives an opinion as to what you can still do in spite of your disabling condition or conditions. The statement should include a description of your ability to perform work related activity, such as, walking, standing, sitting, carrying, hearing, seeing, speaking, lifting, carrying or handling objects, and traveling.

If you have a mental disability, your mental health provider should include, as well as evidence of any testing you may have had, a statement as to your ability to understand instructions, remember and carry out those instructions, and your ability to appropriately respond to coworkers, supervisors, and work pressures in a work setting.

See: What medical conditions can you apply for disability for?

Can it be hard to get a statement from a doctor?

It can be. Working in claimant representation, I have had physicians tell me on the phone that they simply do not fill out forms or write letters to help their patients who are filing for disability. Why does this happen? My own estimation is that too many doctors simply do not want to be bothered with taking time from their busy schedules.

That said, most doctors will provide a medical source statement. If you have a disability representative or disability lawyer, that individual will attempt to obtain statements on your behalf, usually for use at a hearing.

For more on this topic: A "proper" statement from your doctor can have a dramatic effect on your disability case.

There are two ways to get disability approved

The decisions that are made solely on the medical evidence are known as listing allowances. Probably less than half of all approvals on cases involve situations where a person has a condition in the Social Security listings manual and their medical evidence will them to meet or equal the requirements of the listing; for example, the listing for for coronary artery disease or affective disorders (including depression).

Half, or more than half of all cases are decided on the basis of medical evidence and information concerning a person's work history. These decisions are medical vocational in nature. However, even when vocational factors such as a person's age, education, and job skills are taken into consideration, as well as the types of jobs they have done in the past, the bulk of consideration on a case involves medical records

A disability lawyer or a non attorney advocate (many non-attorneys are former social security employees) will focus, prior to a hearing, on assembling as much medical information as possible on a claimant's behalf. This often includes contacting a claimant's doctors to see if they will provide statements which support a claimant's allegations of disability.

Keep getting treatment to help your case

However, even when an attorney or non-attorney representative is involved, a claimant will still need to be seen somewhere for medical treatment. This is because in order to be awarded benefits, medical evidence must be obtained that establishes A) how far back a disabling condition exists (to establish back pay amount and, in the case of SSD, to determine when medicare coverage begins) and B) whether or not the individual is currently disabled.

The chances of winning disability benefits via an appeal will always be subject to providing the Social Security Administration with sufficient medical record documentation. In other words, medical record updates and detailed statements from one's treating physicians.

Unfortunately, the ability to provide this type of documentation is predicated on the ability to receive continuing medical treatment and many claimants arrive at a point (while they are filing for disability) where they no longer have medical insurance.

About the Author: Tim Moore is a former Social Security Disability Examiner in North Carolina, has been interviewed by the NY Times and the LA Times on the disability system, and is an Accredited Disability Representative (ADR) in North Carolina. For assistance on a disability application or Appeal in NC, click here.

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