What happens if the Social Security Disability examiner cannot find all the needed medical records?

If the disability examiner cannot find all the needed medical records for a Social Security Disability or SSI Case, what happens?

Answer A): If the examiner cannot find medical records that show treatment for a particular condition, the examiner will probably have to schedule a CE, otherwise known as a consultative examination, and often referrred to as a social security medical exam.

Answer B): If the examiner cannot find current medical records, the examiner will also probably have to schedule a CE. This is because the social security administration requires that the decision on the disability claim is based on at least some current information. Current information is defined as information that is not older than 90 days. Why is current medical information important? Because to establish disability benefits, there must be sufficient proof that the claimant currently has limitations that are significant enough to prevent work activity.

In addition to this, the case must be strong enough for the disability examiner (or the judge if the case is at the hearing level) to believe that the claimant's state of disability will not be "durational". Durational denials on SSDI and SSI claims happen when the claimant is considered to meet the Social security definition of disability but it is also believed that the claimant's condition will resolve or improve to the point of non-disability within 12 months.

Now, can you be denied for SSDI or SSI if social security cannot find all your medical records, or cannot find certain records? There is no rule for this; however, as we've indicated, the ability of the examiner to approve a case depends on what evidence is available to establish limitations that rule out work activity.

The more evidence the examiner has, the easier it will be document the claimant's RFC, or residual functional capacity (what a person can still do, in spite of their disability, or various disabling conditions). Less evidence can translate to a diminished chance of receiving a social security benefit award.

Note: If the only evidence available to a disability examiner is the report of findings from a CE that has been scheduled by a disability examiner, then the outlook is very poor for the disability claim being approved. The medical exams that are scheduled by social security tend to be very brief, simple exams that do not provide much more information to the disability examiner than would be the case for a routine visit to one's doctor.

Adding to this, the independent physician who is paid by SSA (social security administration) to conduct the exam will probably know next to nothing about the claimant's medical history and, therefore, they will have nothing to relate their "ten minute session" with the claimant to. By and large, the only purpose for the consultative examination is so the disability examiner can state that they have current medical evidence in the file before a decision is made and the file is closed. Typically, of course, when there is little more in the file than the report from the CE, the outcome will be that the case is denied.

Claimants who file for disability very much need to have current treatment and also need to maintain regular treatment while their disability application is pendingn or their disability appeal is being reviewed. And, at the time of applying for disability, the claimant should make a strong effort to provide detailed information about their treatment sources. Claimants who apply at a social security office should never simply assume that SSA will be able to locate a Dr. Johnson on carver street.

Claimants can make the process easier and more complete by getting a list of all their various doctors before their disability application interview is done. The list should include all contact information as well as names of doctors. It should also include every single doctor and clinic from as far back as the claimant believes their disability may have begun.

This is important so that the earliest possible onset date can be determined which will potentially mean receiving a higher amount in Social security or SSI back pay.

It could also mean getting one's disability established before their coverage for Social Security Disability expires (all Social Security Disability cases have something known as a DLI, or date last insured, and this is the date up until which a person is covered for the program).

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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