In any social security disability claim, the treating physician’s notes or medical records are most important. The SSA would be looking for objective medical findings that will justify the claim. More importance is attached to office notes compared to narrative reports, mainly because office notes are made in real time and hence more reliable.
Since the government’s definition of disability is very strict, emphasis is on the applicant’s eligibility to function and not merely on diagnosis and treatment. All clinical signs, symptoms, findings, functional limitations and medical opinions must be documented clearly to support the disability claim. The issue in physician documentation often stems from the fact that very often doctors are eager to find out that their treatment plan is providing relief to their patients, and as a result they document each small improvement. However, the medical chart should also show continuing limitations if it is to justify a social security claim. Physicians must document the fact that a claimant cannot work full-time, if that is the case. If a patient can work as a result of the good treatment but is not willing to return to work, it is the onus of the physician to explain the same to the patient and encourage him/her to get back to work.
Social security disability benefits are often denied if the patient refuses to release the medical records to the SSA and display a lack of co-operation. When the treating doctor’s medical notes are incomplete, or when the claimant has no treating doctor the SSA may ask for a consultative examination by a doctor they appoint for the purpose at government expense. In case the applicant refuses to cooperate, or request that the SSA make a decision on the basis of the medical documents already available, the claim may be denied. Disability claims may also be denied when a claimant does not follow the treating doctor’s prescribed therapy in spite of having the ability to do so.
However, legitimate medical and non-medical excuses that SSA accepts in case a claimant fails to follow the prescribed therapy include:
- Presence of severe mental illness that prevents the claimant from following the therapy.
- The claimant has an intense fear of surgery.
- The claimant has a severe impairment that prevents him/her from following the prescribed therapy without assistance.
- The claimant doesn’t have money to pay for the treatment.
- The claimant has religious beliefs that prohibit him/her from receiving the medical therapy.