GOOD MEDICAL RECORDS LET ME DOWN....AGAIN!

I just returned from a Social Security disability hearing.  The medical records were excellent.  They were neatly typewritten from the doctor's transcription, so they were easily to read.  They were complete, thorough, very detailed.  They were actually the kind of medical records most disability advocates only dream about.  Rarely do we get such good and complete records from doctors.

The hearing judge had obviously looked over the file before the hearing began.  He asked the claimant a few questions, then allowed me to question the claimant without interruption for about 20 minutes.  I used that time to make the evidence of record personal to the individual I was representing.  The claimant's testimony was convincing and consistent with what the medical records said.

The problem came, as it usually does, with the vocational expert.  When the judge asked the VE if there was any work that the claimant could perform, the VE found examples of 3 or 4 jobs at the sedentary level.  OK, there goes the case!  Except for one thing.  One final piece of evidence saved the day.

I had obtained an additional Medical Source Statement from the claimant's treating physician, a specialist.  When the hearing began, the judge asked if I had any objection or additions to the evidence in file.  I made it a point to tell him that I had submitted recent evidence, including updated medical records and a Medical Source Statement that should be considered.

So now the judge asks the vocational expert a final question.  "When you consider the limitations on the Medical Source Statement from Dr. ----------------, do you find that the claimant can still perform any of these jobs?"

The whole case, I felt, was now riding on that one piece of paper.  In spite of 200 pages of excellent medical records, the case would probably have been lost, except for that one little piece of paper.  The claimant had turned pale with disbelief.  I held my breath and waited.  The vocational expert said, "Give me just a moment to review this document."

Finally, the vocational expert's answer came.  "No, Your Honor, with the restrictions specified in this document by Dr. ------------------, there would not be any work that the claimant could perform."

200 pages of excellent medical records failed to win the day.  Excellent testimony from the claimant failed to hold the case together, in my judgment.  They hearing had been won a couple of weeks ago when I finally convinced the doctor to complete and sign that piece of paper called a "Medical Source Statement of Ability to Do Work-Related Activity."

Why do Medical Source Statements (MSSs) often work when medical records do not?  Here are my theories:
  • MSSs address medical conditions in vocational language - what are the limitations in function?
  • MSSs state the severity level of functional restrictions.  Are they moderate, marked, or severe?
  • This document forces the doctor to give a medical opinion - not just a diagnosis or treatment plan.
  • It is specific and goes to the very core of what Social Security wants to know.
  • This MSS is a document familiar to Social Security Judges; they see it every day.
  • Finally, the MSS is a brief and concise document that can read in about 30 seconds.
I don't want to give anyone the idea that winning a Social Security disability case is as simple as obtaining one form from the doctor.  I do want to get across the idea that it's important to have a winning strategy in a disability case - especially at the hearing level - and it's also important to have a back up plan. My personal strategy is build, build and build the case, then build some more.  If there is one more thing you can do to improve the odds of winning, do it before the hearing.  In a separate post, I am going to write about "going the extra mile" to win a Social Security disability case.

Written by a senior partner in the Forsythe Firm, Social Security Advocates in Huntsville, AL.  Connect with Mr. Forsythe at www.forsythefirm.com

National Organization of Social
Security Claimants Representatives
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Comments

  1. Charles W. Forsythe, MSApril 19, 2019 at 12:56 PM

    It is increasingly important to enlist the help of your doctor in order to get approved for SSDI. What we need is a form from your doctor, in which he or she establishes your Residual Functional Capacity (RFC). At Step 3 of the mandatory decision making process, Social Security must establish your RFC. If your doctor does not do this, then Social Security will come up with their own RFC, which usually will not prevent all work and, therefore, will deny the claim. It is much better if your doctor, who knows your medical history, helps to establish this RFC.

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