Senior America's Information Magazine

 

MEDICAL OPINIONS AND SOCIAL SECURITY DISABILITY CLAIMS

By: Pitt Dickey - Attorney

Preface: Since Social Security Disability is directed under Federal law, the information in this column will apply anywhere in the United States.  However each Office of Hearings and Appeals and District Office have their own ways of doing things as does the various Federal District and Circuit Courts.   I have kept this column primarily dealing the the mechanics of how the Social Security District Offices and Office of Hearings and Appeals evaluates disability claims. 
- Pitt Dickey


If your doctor says that you canít work, why doesnít the Social Security Administration automatically approve your disability claim? 

This is a fairly common question among people who have been told by their physician to stop working. The answer is that the SSA makes a legal decision and the doctor is making a medical decision. A physicianís opinion is entitled to weight by the Social Security Administration (SSA) but his opinion is not binding on the SSA in evaluating disability insurance benefits claims. 

The SSA has a legal test which it must apply to determine if a person is disabled. The doctorís opinion does not necessarily meet the standards that the SSA must apply to decide disability claims. This column will examine the weight that the SSA gives to medical opinion evidence.

The test applied by the SSA can be summarized as follows: The person must have either a physical or mental condition that can be expected to last at least 12 months or to result in death which prevents that person from not only performing his prior job but any other type of work that exists in the economy based upon the personís health, education, and work experience. 

The SSA regulations require that the personís health problems must result from "anatomical, physiological, or psychological abnormalities which are demonstrable by medically acceptable clinical and laboratory techniques."

The SSA will obtain medical opinions from physicians, psychologists or other acceptable medical sources. These sources must make judgments about the nature and severity of the persons health problems. The sources may also reflect the medical providerís notations about the personís symptoms, diagnosis and prognosis, and the providerís opinion about what the person can still do despite his health problems.

As part of the initial application process for disability the person will submit a form with the names and addresses of all of his medical care providers to the SSA. The SSA is supposed to contact all of the medical providers listed by the applicant. However it is not unknown for the SSA not to obtain all of the medical records for one reason or another. 

The applicant must be certain to carefully review the letters of denial to determine if all of the relevant medical records have been obtained by the SSA. The SSA does a good job in obtaining medical records but it is not perfect. The applicant needs to be vigilant about providing medical information to the SSA.

The SSAís standards for reviewing the claimantís medical and other records records is set out below:

1. If all of the evidence received is consistent and there is sufficient evidence to decide if the claimant is disabled, then the SSA will make its decision based on that evidence.

2. If any of the evidence is inconsistent with other evidence in the case file, or is internally inconsistent, the SSA will weigh all of the evidence and determine if it can make a disability decision based on the evidence it has.

3. If the evidence is consistent but the SSA determines that it does not have sufficient evidence to determine if the person is disabled, the SSA will attempt to obtain additional evidence. The SSA can request additional existing records, recontact the personís treating medical providers, ask the person to undergo a consultive evaluation with a medical provider paid by the SSA or request additional information from the claimant or other personís with knowledge of the claimantís condition.

The SSA has guidelines for how much weight it gives to medical opinions. The SSA gives more weight to the opinion medical professionals who have actually been treating the person over a period of time. The SSA recognizes that a personís treating physician will have better insight into the personís health than by medical test results alone or one time examinations of the person. 

The SSA will sometimes have a person examined by a medical provider on a one time consultative evaluation which will not generally be given more weight than the opinion of the personís long time doctor.

The SSA will give controlling weight to the opinion of the personís treating physicianís opinion on the nature and severity of the personís impairments if it is well supported by medically acceptable clinical and laboratory diagnostic techniques. 

The opinion must not inconsistent with other substantial evidence in the case file. If the SSA does not give controlling weight to the opinion of the treating source, the SSA will consider the following factors:

1. The length of the treatment by the source and the frequency of examination by the source: The longer that a doctor has treated the person and more often he has seen him increases the weight of the opinion of the doctor with the SSA.

2. The nature and extent of the treatment relationship: The more knowledge a medical provider has about the personís condition gives more weight to the sourceís opinion. The SSA reviews the type of treatment the source had provided, the types and extent of the exams, and testing that the source has provided the patient.

3. Supportability: The more the source provides evidence such as laboratory findings and medical signs, the more weight assigned by the SSA to his opinion. The better explanation that the medical source provides for his opinion the more the SSA is likely to consider this opinion.

4. Consistency: The more consistent the sourceís opinion is with the case record overall the more weight the SSA will grant it. In other words, if all of the medical records point in one direction and one medical provider has an opinion that is different from the rest of the record, the less weight will be assigned to that opinion. One medical sourceís opinion that a person is disabled that contradicts the other documentation in the file will not result in the SSA finding disability.

5. Specialization: The SSA gives more weight to a medical specialist expressing an opinion within the area of his specialization than it will give to the opinion of a source who is not a specialist.

6. Other factors: The SSA can consider other factors that the claimant or other persons bring to its attention which tend to support or contradict the opinion. The SSA gives as example if a medical source has knowledge of its disability programs and requirements then the SSA will give that source greater weight in evaluating the claim. It would appear that if a person has a disability claim then he would be well advised to find a doctor who is familiar with the SSAís disability standards.

The SSA does reserve certain opinions to itself which are not going to be decided by a medical source no matter how knowledgeable that source is with the patient. For example the SSA will always make the final decision as to whether the person is disabled. 

The SSA makes the decision as to whether the patient meets the legal requirements for disability insurance benefits. A statement from a medical source that a person is "disabled" or "not able to work" does not mean that the SSA will find that the person meets the legal requirements for disability benefits.

Pitt Dickey has practiced law in Fayetteville since 1978. He has handled SSA disability claims for over twenty years. He practices with the firm of Smith, Dickey, Smith, Hasty & Dempster, P.A. at 555 Executive Place and can be reached at 910-485-8020 or at pitt@smithdickey.com . Or at the firm web site of www.smithdickey.com .

Copyright © 2002 Pitt Dickey - Used with permission

 

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