If you're worried that your medical records don't support your disability claim as much as you would like, you are not necessarily out of luck. While you'll still need a doctor to weigh in on your case, a medical expert may be able to explain your medical condition at your Social Security hearing and support your claim for disability even if other doctors have not.
The medical evidence typically needed to establish a medically disabling condition includes diagnostic test results, doctor's treatment notes, and statements from your doctors describing your functional limitations. Medical records are of the utmost importance in Social Security because most cases are decided on the basis of medical evidence alone.
Some doctors refuse to fill out forms for disability or write supportive letters for disability applicants, even if there's information in that doctor's records that support an award of disability. This doesn't only happen when a doctor is too busy or is reluctant to help add another person to the disability roles; sometimes the doctors' group or HMO has a policy of not providing that kind of information.
Other times, an applicant doesn't have medical insurance, or has not had medical insurance at some point in the past. Also, clients who have had to move frequently have not had the opportunity to establish a regular treating relationship with a doctor.
Finally, the nature of some clients' medical condition prevents them from receiving treatment (for example, a client whose mental or emotional impairment makes them distrustful of physicians or puts them in denial about having an impairment).
When medical evidence is lacking or outdated, Social Security may send an applicant to a consultative exam, but it's not common for someone who is sent to a consultative exam to be approved for benefits. Doctors to whom Social Security sends applicants for consultative exams are paid by Social Security and don't typically include information in their reports that will help applicants get disability.
Another time a doctor may look at an applicant's file is when an initial disability decision is made on an application at state Disability Determination Services offices (the agencies that make the disability decisions on the initial applications for Social Security). A doctor (called a medical consultant by DDS) is required to review a claim along with the claims examiner before a claim is denied. But medical consultants who work at DDS office see disability claims all day long, and many are conservative and likely to recommend that a claim be denied.
Your last chance to have a doctor paid by Social Security review your file is at a disability hearing. Sometimes a Social Security judge will ask a medical expert (either a physician or mental health professional) to call in to an appeal hearing to weigh in on your medical condition. Out of the three types of doctors that Social Security pays, medical experts who are called at hearings are the most likely to find an applicant's condition disabling. In fact, data published by the Government Accountability Office (GAO) in 2017 showed that when medical experts testify at an applicant's disability hearing, the applicant is 160% more likely to be approved for benefits.
Social Security judges typically call medical experts when there is a complicated medical issue or a rare condition that needs explaining, or when the judge needs help determining whether the applicant's condition might "equal an impairment listing" rather than meet its exact requirements. A medical expert may also be called if the judge needs help deciding your disability onset date; that is, when your disability began for the purpose of being entitled to benefits.
If Social Security doesn't give you notice that a medical expert will testify at your hearing, you (or your lawyer) can also request that a medical expert paid by Social Security attend the hearing, but Social Security does not have to grant your request.
A medical expert will testify about the nature of your medical conditions and may give an opinion on whether your impairment(s) meet or equal Social Security's impairment listings. If asked, the expert may also point out limitations that might make it difficult or impossible for you to do certain work activities. Your lawyer will be allowed to question the medical expert at the hearing.
If you recieve notice that a medical expert will testify at your hearing, consider hiring a lawyer so that your lawyer can ask the medical experts questions to elicit answers to help your case.
If your claim is denied and you hire a disability lawyer for your disability hearing, he or she may be willing to hire a medical specialist to review the medical records that are available and give a medical opinion as likely course of your medical condition during the times you were not in treatment. Or, at the hearing your lawyer can ask you questions about your condition to "fill in the gaps" in your record.
While Social Security does allow you to bring in your own medical expert to testify at your hearing, hiring your own expert is expensive. (And your doctor wouldn't likely agree to come to a hearing without being paid.) If you have an attorney, he or she may pay for the medical expert’s fee and then let you to reimburse him or her if you win. But if you don’t win, you would probably have to pay the attorney back out of your own pocket. For these reasons, it's rare to bring your own medical expert to a hearing.
Sometimes an applicant's medical history has information that seemingly contradicts itself, or contains a doctor's statement that hurts the claim. Also, sometimes an applicant has never been formally diagnosed with a medical condition (usually because of no health insurance). In these cases, a medical expert could really help win the claim. Here are some examples where the testimony of an ME helped a claimant win his or her claim.
Despite the risk of having to pay for the expert even if you don't win, depending on your case, it may be worth having an expert testify on your behalf at your hearing. But your best bet would probably be to ask Social Security to have a medical expert present at the hearing.