Social Security Disability and What Your Medical Records Have to Say

"I was denied SSDI and with a attorney filed a appeal and am waiting to go before the ALJ. My letter states that my medical records show I'm impaired and activites are severly restricted; however with treatment they expect them to improve after 12 months if they dont contact them.

People have told me that's a good sign? Is it? Also I am under care every month with a regular MD,and its been a year since this letter. I'm now waiting to see a physchiatrist but they are over-filled and I have to wait 4 months for a appointment. If my case goes before the ALJ before I get a years worth of records from a physc will my case denied?"


Hi Pumpkin,

It sounds as though you have a supporting statement from a treating physician and that's certainly beneficial to your case. I don't know how far you are from being scheduled, but it's always possible that you may need to get another such statement from your treating physician by the time your disability hearing comes to pass. If that is, in fact, the case it would be because the social security administration needs to determine

A) whether or not you are currently disabled, and

B) when your disability began.

Obviously, older medical records can be used to determine your medical onset date. However, to determine whether or not a current state of disability exists, recent medical documentation will typically be needed. That recency requirement can be satisfied by standard medical records, gathered from your medical treatment sources. However, a medical source statement or residual functional capacity form (what the physician's statement can be recorded on) can carry a lot of weight with an ALJ at a hearing, and, logically speaking, is more effective when it falls into the category of "recent documentation".

Since I don't know anything about your case, I don't know if your attorney will find it necessary to get another statement from your treating physician, or if this is even possible (some physicians make it difficult to obtain more than one medical source / RFC statement, and there are a number of doctors who, for various reasons, will refuse to provide any statements in support of their patient's disability claims). Typically, a representative would want to have a statement from a treating physician that could be considered "recent medical record documentation", meaning not older than 90 days.

Being under the regular care of a physician is certainly beneficial to your case as well. This, of course, would have an enhanced benefit if the doctor who sees you regularly is also the doctor who provided a statement on your behalf as it would indicate that the physician's stated opinion is actually derived from regular and recent contact with you.

Will your case be denied if you do not have a year's worth of psychiatric records by the time of your hearing? No. Cases are not denied for such reasons. Ideally, speaking, you and your disability attorney will want to provide as much extensive documentation as possible regarding your various impairments. And that typically means showing a documented history of treatment that extends further back than just a few weeks or months.

However, the social security administration's primary focus is on functional limitations and how those limitations inhibit your ability to peform substantial and gainful work activity, either work you've done in the past, or some other type of work for which you might be suited based on various medical and vocational factors. As long as your medical records illustrate the existence of functional limitations that are severe enough to rule out the ability to engage in substantial and gainful work activity, that will be sufficient. In other words, when it comes to your medical records, verifying your functional limitations supercedes your actual length of treatment.


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