Wednesday, January 13, 2010

Can You Win a Disability Claim if You Have Little Medical Documentation due to a Lack of Health Care?

Comments from Gary:

"You have one of the most informative blogs ive read, in plain english too i might add. thank you for your time to put this together. What are a person's chances of winning a disability claim if they have very little medical documentation due to a lack of affordable health care?"

Hi Gary, SSD and SSI cases are based on functional limitations that make it much more difficult for a person to engage in work activity at what the social security administration would refer to as a substantial, gainful level (which simply means being able, or not able, to earn a certain dollar amount each month--see the current amount here: SGA, substantial gainful activity). Of course, the people who take part in evaluating your disability benefit claim, the disability examiner and the medical and psychological consultants in the examiner's processing unit, have never seen you. Instead, they have to rely on what your medical records have to say about you.

Unfortunately, most, and I do mean most, doctors do not address functional abilities and functional limitations in their treatment notes. Why not? I think the honest answer is that they don't consider it part of their job. For them, keeping track of patient symptoms, complaints, medications prescribed, tests and procedures performed, and observed signs is sufficient. Sometimes when they dictate office notes, they make reference to functional limitations, but, largely, on a day to day basis for most office visits, no.

That puts disability claim adjudicators (examiners at the first two levels and administrative law judges at hearings) in the position of having infer what the records mean. Not ideal, but this is what they have to do. And, obviously, since this is the case, the more documentation you have access to, the better the potential for making a good assessment of a claimant's residual functional capacity, and determining whether or not the claimant can return to work at the SGA level.

In fact, this is why getting a residual functional capacity form completed can be very helpful to a disability case. The form, which is synonymous with a medical source statement, captures the treating physician's statement and opinion as to what the claimant's functional limitations might be. Such forms may not provide much boost at the initial claim and reconsideration levels (there's a disconnect between how disability examiners and disability judges decide outcomes of cases), but they can provide a decisive edge at a disability hearing, provided that the RFC/Medical source statement does not absolutely fly in the face of what the physician has been recording in his or her own treatment notes.

Now, to your question: Can You Win a Disability Claim if You Have Little Medical Documentation due to a Lack of Health Care? Answer: it becomes much harder. If you don't have much documentation, there's a good chance that the disability examiner working on your case will send you to a social security medical exam, known as a CE, or consultative examination. This is done by an outside source, a private doctor who is paid to examine you. But these exams are just to provide a snapshot, i.e. some amount of documentation that will allow the disability examiner to show that there is recent evidence in the file (not older than 90 days). In other words, it is usually just a way to get the file closed.

Can the results of a consultative exam be used to help win a case? Sometimes, yes. But, usually, if there's little documentation other than the consultative examination report, there won't be enough evidence to get a case approved.

So, what does a person do? The best I can say is try to get seen by someone every three months at the minimum. Without health insurance, this is a tough proposition. In some areas, there are sponsored free clinics. You'd have to check to see if there is something like this where you live.

Claimants in the past have tried other options, such as the use of local hospital emergency rooms as well. Unfortunately, an ER cannot replace an established history with your own treating physician, so if it is at all possible, try to get seen by one periodically. That would mean paying out of pocket and checking into the cost for this, of course. And I realize as I write this that it may be financially impossible. If you have representation, that individual may have suggestions for your immediate area. Good luck on your case.

Return to the Social Security Disability SSI Benefits Blog

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