“I can hardly move, I can’t work!

Why does Social Security need so many medical records to determine if I am disabled?”

Doctor reviewing medical chart

1. Medical Treatment Records

2. Compliance

3. Treatment Over Time

Medical records covering an extended period will show your diagnosis, your treatment plan, and your compliance. The medical findings in an extended course of treatment are extremely useful to Social Security when deciding if your limitations prevent full time work. More like a video than a photograph, records of your treatment over time paint a much fuller picture of the way your condition limits your abilities.

1. You need to have medical records of treatment.

When you apply for disability benefits from Social Security, your medical records will determine whether you will be awarded benefits. If you lack health insurance, and don’t go to the doctor because you cannot afford it, then it will be very hard to establish that the reason you are not working is a medical disability. From time to time we have seen Social Security establish an evidentiary record for disability by sending a claimant to one of their doctors for a consultative exam. A finding of disability based primarily on a consultative exam is very unusual. Usually, a lack of medical records will lead to an unfavorable decision by Social Security.

We have learned from experience that some of our clients have a very hard time obtaining health insurance, while others cannot afford the pills, while still others are distrustful of doctors. Whatever, the reason for not getting into medical care, not having on going medical treatment records for your condition always makes it harder for Social Security to find that you are disabled.

2. You need to get health insurance or free care.

 For this reason we tell our clients to explore the various forms of health insurance that are available to those who are not receiving health insurance through their employer. And if health insurance cannot be obtained, we urge our clients to explore what clinics in their area will be able to provide free care to those in need. Without ongoing medical care of the condition, it is quite difficult for Social Security to determine that there is a medical reason that prevents you from working.

3. A treatment plan shows the physician’s effort to get you healed.

If you do indeed have a serious medical condition, the kind that would prevent you from working, it is expected that you would seek medical care from a physician or a clinic. Everyone wants to get better, and sometimes the medical care improves your situation so that you can go back to work. However if you cannot go back to work despite treatment, the treatment records showing the efforts of trained medical professional to try to improve your situation are the most revealing source of information as to the seriousness and degree of limitation caused by your condition.

The efforts of the physician, and of the paraprofessionals who work with the physician to alleviate your pain, or to cure or improve the condition itself, may not put you in a position to return to work. However, the medical documentation showing the various findings of the medical team will show the extent and seriousness of the medical problem at the beginning of the treatment period and at the end of the period covered by the records. These medical records will be based on your description of how you feel, based on diagnostic tests ordered, and based on an in person physical evaluation of you.  The findings can indicate to Social Security’s decision makers whether you are disabled or whether you are able to participate in full time work.

Once your medical team has developed a treatment plan for your condition, the efforts by you to carry out the plan, and the efforts by the doctor to adjust the plan to you and your condition will be most revealing as to the extent to which the condition might prevent you from full time employment at a competitive job.

4. Compliance with the treatment plan shows your effort to get you healed.

Follow your doctor’s orders! The physician will develop a treatment plan for the condition he or she has diagnosed. However, sometimes the patient fails to comply with the treatment plan, by not taking the prescribed medications, and or by repeated no shows for follow up visits. Non-compliance with the treatment plan is a big problem for a disability claim, since there are a couple of reasonable inferences that Social Security could make on account of the non-compliance shown by the patient. Where there is a clear non- compliance, it could be inferred, absent any explanation, that the condition itself was wrongly diagnosed, or that the degree of severity was over estimated. Also, it is fair to wonder if the treatment plan might have been successful, if the patient had cooperated.

5. Findings by your medical team in medical records showing treatment over an extended period of time, along with patient compliance, are highly reliable and can provide a basis for a finding of disability.

Social Security looks carefully at the findings made by the physician and the medical team while trying to help you over time. The medical records of your treatment, over time, are very revealing of the extent of your condition, and creates a dataset from which the degree of limitation can be determined.

With a treatment plan, and your compliance, the findings of your medical team, while trying to see if medical science can improve your condition or decrease the limitations from it, gain credibility and reliability when seen over an extended treatment period. Think in terms of a series of videos on YouTube taken on a monthly basis for two years, compared to a single photograph posted on Instagram on one day. The Instagram tells you about a single moment, while the You Tube videos allows you to see for yourself how the thing has developed over time, and allows you access to much, much more information. So also, for Social Security, when they have your medical records showing an extended period of medical treatment they have reliable information on which to base a finding of disability.

Are You Looking for a Social Security Disability Attorney in Boston, MA?

If you are looking to apply for social security disability, you need to speak with an experienced social security disability lawyer as soon as possible. Please contact us online or call our Natick Office directly at 508.283.5500 to schedule your free consultation.

John L. Keefe
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Founding Attorney, Massachusetts Social Security Disability Lawyer
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