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
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
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
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
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.