The medical professional’s role in a Social Security disability benefits claim

By Brian J. Gillette, Esq.

When it comes to establishing whether or not a person is eligible to receive Social Security disability benefits, the opinions of a treating medical professional can be crucial. The Social Security Administration (SSA) will generally give more weight to opinions from your treating sources, since they are likely to be the medical professionals most able to provide a detailed, longitudinal picture of your medical impairments and may bring a unique perspective to the medical evidence that cannot be obtained from the objective medical findings alone or from reports of individual examinations, such as consultative examinations or brief hospitalizations.

For clarification, SSA considers an “acceptable medical source” to be a licensed medical physician, osteopath, psychologist, optometrist, podiatrist, or speech-language pathologist. While the opinions of other treatment providers must be considered, greater weight is generally given to the opinions of an acceptable medical source.

Let me be clear from the start, however, that a letter from your physician stating that you are “totally and permanently disabled” usually is inadequate to prove a disability claim.

It is the responsibility of the SSA to determine whether you meet the statutory definition of disability, and it will consider your age, education, past work experience, and the limitations that result from your physical and/or mental conditions in determining whether or not you are disabled. Your doctor is likely not familiar with all the vocational requirements of your past work nor all of SSA’s rules and regulations; however his or her opinions about how your symptoms limit your ability to perform work activities on a sustained basis can be key in deciding your claim.   

 Let me also make it plain to physicians who are reluctant to work with patients making disability claims that the SSA is not asking you to determine whether or not your patient is disabled. Also, copies of your medical records alone will generally not provide enough information about how your patient’s symptoms limit their ability to do work activities on a full-time basis. After all, the records are created for treatment purposes and not for documenting your patient’s claim for disability. A functional capacity evaluation is also not necessary; the SSA recognizes that a treating source can provide a unique perspective that cannot be obtained through objective medical findings alone, and is interested in your opinion as a treating healthcare provider.

It is also important for you to note that a physical or mental condition that may not be considered disabling on its own may still help a patient prove a claim when combined with other factors. For example, let’s say a person over the age of 50 is no longer capable of doing a physically demanding job and is now limited to only doing a desk job, but that individual has no transferable skills to a sit-down job. A doctor may say they believe that person is physically capable of doing a desk job, but the SSA would find that without transferable skills, being limited to a sit-down job would mean the person is disabled under the regulations. Being “disabled” does not mean total incapacity.

This brings us to documenting the opinions of a treating source. The SSA, and individuals claiming disability benefits, routinely ask treating sources to complete questionnaires and provide opinions about their patients’ physical or mental limitations. It may seem like there is a lot of detailed information requested on these forms, but the questions are designed to allow the SSA to have the information it needs to decide a claim according to its regulations.

The SSA will consider the following factors in deciding the weight to give to any medical opinion:

  • Examining relationship: Generally, more weight will be given to the opinion of a source who has examined you than to the opinion of a source who has not examined you.
  • Treatment relationship: Generally, more weight will be given to opinions from your treating sources.
  • Length of the treatment relationship and the frequency of examination: Generally, the longer a treating source has treated you and the more times you have been seen by a treating source, the more weight will be given to their opinion.
  • Nature and extent of the treatment relationship: Generally, the more knowledge a treating source has about your impairment(s) the more weight will be given to the source’s medical opinion.
  • Supportability: The more a medical source presents relevant evidence to support an opinion, particularly medical signs and laboratory findings, the more weight will be given to that opinion. The better an explanation a source provides for an opinion, the more weight will be given to that opinion.
  • Consistency: Generally, the more consistent an opinion is with the record as a whole, the more weight will be given to that opinion.
  • Specialization: More weight will generally be given to the opinion of a specialist about medical issues related to his or her area of specialty than to the opinion of a source who is not a specialist.

As you can see, if you are considering filing a disability claim with the SSA, the opinions of your treating healthcare providers can be valuable in the disability benefits determination process. In addition to monthly payments, being approved for disability benefits may also allow you to qualify for Medicaid and/or Medicare to help pay for your medical treatments.

If you do file a claim for benefits, there is still a high likelihood that your claim will be denied. If you are denied benefits, the SSA will send you a letter explaining their decision. If you do not agree with their decision, you can appeal by mailing a written request within 60 days.

If you need assistance with your appeal, or any other part of the claim filing process, you may want to contact an attorney with experience in disability benefit claims. As your appointed representative, an attorney will act on your behalf in getting information from your Social Security file, helping you obtain medical records and opinions, and representing you at an administrative hearing before the SSA.

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