Medical Records, Ongoing Treatment, and how to strengthen your case while waiting for your hearing date.

One of the most common mistakes people make after filing for disability is to stop seeking treatment or not follow up with their doctors. As a person filing for disability, it is often difficult to continue treating your doctors while waiting for disability. However, while you await your hearing date, it is vital to have your doctors document your condition and, in some cases to request doctors perform tests.

Without a complete medical record, it will be harder for a Judge to find in your favor. When working with your doctors, people have some common questions and steps you can take that will benefit your case at the hearing stage.

My doctor said I should apply for disability. Doesn’t this mean I will win?

Unfortunately, no.

The Social Security office has the sole discretion to declare whether someone is disabled. A note from a doctor that says, “This person is disabled” will carry almost no weight with an Administrative Law Judge. You can ask your doctor to document HOW your conditions affect your ability to perform activities of daily living.

For example, a doctor could note that you have difficulties standing for more than a couple of minutes or have lost the strength in your hands. If you are using a cane or a walker, make sure it is prescribed. Ask your doctor to document any balance problems or other problems you have.

Doctors can perform tests on you that document your condition. If you are having problems with your lower back, a positive Straight Leg Raise test helps to demonstrate the severity of your low back problems. For neck pain, a Spurling’s test can be used to show cervical radiculopathy. If you are suffering from fibromyalgia, or other connective tissue disorders, ask your doctor to perform a trigger point test.

If you have carpal tunnel or neuropathy in your hands or feet, request your doctor refer you for an EMG. These tests are what will help the Judge rule in your favor, so always ask your doctor if there are any tests they can perform to document the severity of your condition.

Do I have to tell my doctor everything? Even the embarrassing stuff?

Yes. If you are not honest with your doctor, your doctor cannot know just how severe your condition is. They cannot properly treat you.

Further, they cannot document the severity of your condition. If you are having falls or even just balance problems where you need to hold onto walls or furniture as you move through the house, make sure your doctor knows and documents it.

If you have bathroom accidents such as not making it to the bathroom in time or having to go to the bathroom frequently, make sure your doctor knows.

If you are frequently running to the bathroom, you will have a far harder time staying on task at a job. At the hearing, you will want to tell the judge exactly how your conditions have changed your life, but if you do not have medical documentation where you have told your doctors, it will hurt your case.

Do I have to keep treating? My insurance ran out, and with COVID-19, it is hard to schedule doctors.

Yes. Large gaps in treatment make it harder for a Judge to find in your favor. Even if all you can do is telemedicine checkups online, make sure to keep seeing your doctors. If you are suffering from mental health problems, it is especially vital to document your depression, anxiety, or PTSD.

When it comes to the hearing, years of treatment records showing you are trying to get help, and your condition is still debilitating, allow the Judge to rule in your favor. Without doctors stating the severity of your condition or large gaps in treatment, it is harder for the Judge to understand just how severe your conditions are.

With COVID, it has been very hard for people to schedule treatment when they have a disability. With many treatments being done online, it is even harder for doctors to fully diagnose the severity of your condition.

Someone who has a consistent history of seeking treatment has a far better chance of proving their case than someone with a large gap in medical records. This does not mean you need to go to doctors that cannot help you; ask them to document that you have reached the maximum medical improvement for their area of expertise.

By seeking treatment and working with your doctors through the disability process, you are creating the documentation needed to show the Administrative Law Judge who hears your case that you cannot return to work and therefore should be found disabled.