Social Security Disability Insurance: Developing the medical record

by Feb 28, 2017Frequently Asked Questions

Home » Blog » Articles » Social Security Disability Insurance: Developing the medical record

On behalf of Jason Baril at the Disability Advantage Group

An SSDI application must be supported by objective medical evidence of disability.

In an application for Social Security Disability Insurance, supporting medical evidence of the claimant’s impairments, resulting symptoms and limitations is crucially important. While the Social Security Administration has the legal duty to develop the medical record, in practice it often falls upon the applicant to see that the objective medical evidence in his or her SSDI file at the agency is comprehensive enough for SSA employees or agents to make a finding of disability.

Retaining an experienced SSDI attorney is particularly helpful for assistance with developing the medical record. A lawyer who regularly practices before the SSA will know what holes need to be filled in the medical evidence.

The definition of disability is unique as it concerns SSDI eligibility: the claimant must have a severe medical impairment – physical or mental – or combination of impairments expected to last at least one year or result in death that prevents him or her from engaging in substantially gainful activity (being able to hold a job and work regularly enough to earn more than an insignificant amount of money.)

When a claimant works with his or her legal counsel on an SSDI application, the lawyer will extensively interview the client about his or her physical and mental medical conditions. The attorney will document the names of treating doctors and other medical practitioners, specialists the claimant has seen, emergency and urgent care visits, therapy received (physical, occupational or mental health) and any other medical services received.

The medical records from treating sources are particularly important to the SSA, which gives the opinions of treating doctors great weight. Legal counsel may request information from a treating physician that is important to the SSDI claim such as:

  • Diagnoses
  • Laboratory and other medical tests supporting diagnoses
  • Observations, examinations and evaluations
  • Symptoms caused by the diagnoses
  • Physical limitations caused by impairments like those impacting sitting, standing, walking, lifting, bending, fine motor skills and so on
  • Mental limitations caused by impairments like fatigue, poor concentration, limited memory, confusion and so on
  • Prognoses such as expected length of impairments or whether any are fatal

Legal counsel may use a variety of techniques to gather such information from a treating physician, including questionnaires; calls or correspondence with the doctor to communicate exactly what information would be most helpful to the patient; or a request for a letter from the physician outlining the needed information.

In addition, through detailed discussions with the client, an attorney can discern whether certain symptoms or impairments should be further developed by having the treating doctor or an appropriate specialist examine the claimant. For example, a claimant may have severe physical impairments that cause significant pain for which he or she has received medical treatment, but concurrently the client may appear to have developed depression or anxiety that should also be assessed, since the SSA must consider the impact of all impairments in combination.

The lawyer will be familiar with and able to use agency technology allowing the submission of medical evidence electronically, taking some of the burden of developing the record off the claimant so that he or she can deal with health and financial issues that become difficult in a time of disability that prevents working.

The experienced SSDI attorneys of the Disability Advantage Group, based in Knoxville, Tennessee, represent clients locally and across the nation in their claims for SSDI.