Winning disability with the right medical evidence

The most important aspect of any claim for disability benefits with the social security administration is medical evidence. What does medical evidence entail? In a broad sense, any records that have been compiled by any of your medical treatment sources. This includes every doctor you've been seen by, every clinic you've visited, and every hospital you've been treated at. And it potentially includes every type of record that's been created in the course of providing you treatment, including but not limited to: imaging reports (xrays, cat scans, MRIs), labwork (such as for a CBC), admission and discharge summaries, and office treatment notes.

Social Security Disability and SSI disability cases are adjudicated on the basis of what a claimant's medical records (and this, of course, includes supportive statements submitted by one's doctor, or treating physician) say about their condition. And the information contained in the records do the following:

1. Establish the onset date of a claimant's disability (i.e. when the individual became disabled).

2. Establish a current state of disability, according to the social security administration's disability benefit criteria.

3. Establish an ongoing state of disability per the social security administration definition of disability.

Practically every person who filing and trying to qualify for disability benefits understands the importance of medical records. However, many claimants may be unaware of certain issues regarding medical records and the role they play in the development of a disability case.

1. For cases that are decided at the intial claim (application) and reconsideration levels, where the decision is made by a disability examiner versus an administrative law judge, the primary delay for a decision typically involves the amount of time it take an examiner to receive the necessary medical records. For this reason, an individual who decides to file for disability should strive to provide full and complete information regarding their medical treatment sources on their disability application. A failure to do this can potentially add delays to the processing of their case.

2. Not all records are helpful to a case. And, in this regard, I mean records from sources such as chiropractors. Chiropractic medicine helps alleviate the pain of many thousands of patients. However, chiropractors are not considered medical treatment sources by the social security administration and their records are not used in deciding Social Security Disability and SSI disability cases. Tip: if you have back problems and are receiving treatment only from a chiropractor, you should, for the benefit of your case, consider seeking treatment from an M.D., possibly an orthopedist, and, perhaps, a pain specialist if you have ongoing and debilitating levels of pain.

3. The source of your medical records may point to their relative strength when it comes to helping you win your case. For example, a family doctor who is an M.D. may prescribe anti-depressants for depression or anti-anxiety medications for anxiety. But the records from such a treatment source will simply not carry the same weight as the records from a mental health professional such as a psychiatrist.

4. Many doctors, even those who support a claimant's disability case and who have provided years of treatment for a condition, fail to adequately document a claimant's functional limitations and restrictions which they possess as a result of their medical conditions. Why do they do this? Because, honestly, this type of information is not generally of extreme importance to the physician himself.

However, documentation of a claimant's RFC, or residual functional capacity, is very important for the outcome of a Social Security Disability or SSI disability case. For this reason specifically, it may not be a bad idea to speak with one's physician after the decision has been made to file for disability.

During such a conversation, a claimant/patient may be able to gauge the physician's level of support for the claim (which may indicate whether or not the doctor would be willing to complete a statement in support of the case) and may also be able to indicate to the doctor that it would be to the patient's advantage if the doctor's treatment notes were more detailed in the area of functional limitations.

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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