Proving a Social Security Disability Case Often Means Getting a Statement from Your Doctor

After a Social Security Disability or SSI disability claim is taken at a social security field office, it is transferred to disability determination services where it is assigned to a disability examiner.

As the first step in the processing of the disability claim, the examiner will send out requests for the claimant's medical records. The wait for records may take weeks or sometimes even months, but at some point, the records will be received and the case can be evaluated.

The information contained in the records will be used to ascertain in what manner and to what degree the claimant is physically or mentally limited. And reaching these conclusions will be reflected in the physical residual functional capacity rating or mental residual functional capacity rating that is given to the claimant.

For adults, these ratings will be compared to the type of work the claimant did in the past and will allow the disability examiner to determine if the claimant can go back to a prior job or do some type of other work; for children, a rating can be used to determine if the child's condition prevents them from staying on pace in age-appropriate activities such as academic school work.

Ultimately, of course, what the medical records have to say about the individual's condition will determine whether or not the case is approved. How much information does the disability examiner need from the medical records to reach a decision, or to approve the case?

Why doctor statements are necessary

To approve a disability case, the examiner will need to be able to find sufficient information in the claimant's records to show that their current physical and/or mental limitations will not allow them to engage in work activity at a substantial and gainful activity level.

This can be difficult very often due to the fact that most doctors do not record information in their treatment notes as to what a person's limitations might be (such as difficulty with short-term memory, or difficulty with lifting more than a certain amount of weight, or difficulty grasping objects, etc).

And it is for this reason that a disability lawyer, after a case has reached the social security hearing level, will attempt to obtain a medical source statement from a claimant's doctor that conclusively specifies in what ways the claimant is limited.

Such statements tend to be very effective with disability judges at hearings, assuming that the statement is supported by the bulk of the medical evidence and that it also indicates limitations that rule out substantial and gainful work activity.

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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