If you're applying for Social Security disability benefits but you haven't seen a doctor, Social Security is likely to be skeptical of your claim. Even though you might have legitimate reasons for your lack of medical treatment—whether it's cost, childcare responsibilities, work commitments, or something else—Social Security won't approve your claim unless you have medical records that document how severe your condition is.
Under Social Security rules, the agency can't approve or deny your claim without any medical evidence. That means after you apply for disability, the agency will often schedule an appointment for you with a consulting doctor who will examine you and submit a report to the agency.
Unfortunately, consultative examinations have a well-deserved reputation for being quick and not very thorough. By themselves, they hardly ever form the basis for an approval of benefits. That's why it's important to get as much treatment as you can on your own, and not rely on the consulting doctor's report.
For some people, regular doctor appointments are a luxury they can't afford. While the Affordable Care Act made generous subsidies available for the purchase of health insurance, millions of Americans are still without insurance. And paying out of pocket just isn't financially feasible for most people.
This presents a problem for those who become disabled and file for Social Security disability insurance (SSDI) or Supplemental Security Income (SSI), because disability examiners base their decisions on information contained in an applicant's medical records. Without some sort of recent medical evidence (specifically, a doctor's visit within the past three months), a disability examiner has no proof that the patient is currently not able to work (or even has an impairment, for that matter). And if you're not receiving treatment for your condition, Social Security might think you can work if you take the proper medication or get other medical treatment.
So if you've applied for disability and haven't received medical treatment for your disabling condition, Social Security will send you to a consultative exam with a doctor. Depending on the nature of your condition, the examining doctor might ask you to perform a series of movements to assess your ability to perform work-related movements, such as sitting, standing, and walking.
In most cases, these doctors will not be biased in your favor, and in fact the opposite is more likely to be true. Social Security doctors may be more likely to believe you can do more than you actually can. That's why it's important for you to get all the medical treatment you possibly can on your own, even if it's expensive and even if it's not likely to help your condition. Investing a moderate amount in medical care up front to show how severe your condition is can pay off if you're later approved for disability benefits.
Social Security can't deny you disability benefits just because you haven't been to a doctor. There are several acceptable reasons for not seeking medical treatment, including:
If you fall into one of these categories, Social Security is not supposed to use your lack of treatment against you in evaluating your claim. In practice, your lack of treatment will be a mark against you anyway, but if your condition is clearly disabling, it might not matter too much.
For your Social Security claim, the more recent your treatment, the better. But even if you were treated years ago for your condition (or a medically related one) and haven't been seen since, Social Security will consider those records as part of your claim.
Be sure to list where and when you received treatment on your application, even if was many years ago. These older medical records can help show, for example, that your condition is longstanding and chronic, or that medical professionals have previously told you that nothing more can be done to help your condition—which might explain your lack of recent treatment.
If there's a lack of medical evidence in your file, a disability examiner will schedule a consultative exam (CE) with a private physician. As noted above, these exams are brief and are seldom used as a basis of approval of any claim. Disability examiners send applicants to consultative exams because without some sort of medical opinion from a doctor or other approved medical treatment source, disability examiners can't deny a claim.
The physicians who perform consultative exams are not employees of Social Security, although they do get paid to perform examinations for disability claims.
Are consultative exams biased against disability applicants? Some people think so. At a minimum, keep in mind that physicians who perform CEs have contracted with Social Security to provide an opinion on a claimant's ability to work. This is different than the doctor/patient relationship that forms between a treating physician and his or her patient.
Doctors who treat patients will try to safeguard their patients' health and act as their advocate, while physicians who perform consultative exams are merely providing a service to Social Security so that disability examiners can close their cases.
Even after you go to a CE, you're not likely to win benefits without at least some other medical evidence. So you should try to get some sort of medical attention before filing for disability, even if it means you need to visit a free clinic or an emergency room, so that you have something in your medical record.
The ideal, of course, is to establish a relationship with a primary care physician who can supply Social Security with a diagnosis, a prognosis, a date of onset of disability, and a detailed list of your physical and/or mental limitations. Having your limitations set out in a residual functional capacity (RFC) form from your treating physician can greatly improve your chances of approval.
If you haven't been able to see a doctor, or have only seen a doctor once or twice, a disability lawyer can develop medical evidence through testimony or by hiring a medical specialist to review your case or examine you. (For more information, see our article on developing evidence of disability when you haven't seen a doctor.)
Disability attorneys only charge a fee if you win your case, so cost should not be a major concern when deciding whether to hire an attorney.
Updated January 19, 2022