A common question that comes up from people who are considering applying for disability is whether they need to see a “disability doctor.” The truth is, there is really no such thing as a “disability doctor” when you are dealing with a Social Security claim. Whether a person is disabled is entirely up to the Social Security Administration (SSA) as it is a legal term that is derived from both medical and vocational (i.e. age, education, work experience) factors. A person cannot be disabled without having a formal medical diagnosis(es) made by a medical source.
SSA defines medical sources as “an individual who is licensed as a healthcare worker by a State and working within the scope of practice permitted under State or Federal law, or an individual who is certified by a State as a speech-language pathologist or a school psychologist and acting within the scope of practice permitted under State or Federal law.” (20 C.F.R. §404.1502(d)/404.902(i)). Generally speaking, most licensed medical professionals are considered a medical source by SSA, and your own providers are most likely within that category if they are eligible to bill insurance, Medicaid, and/or Medicare for services. SSA determines what your conditions are and how severe they are largely by reviewing your medical treatment records. This being said, the medical records from your own provider(s) should be sufficient to show that you do have a medical diagnosis/impairment. Typically, when you see a medical provider, they are documenting not only the reason for your visit but their own objective findings from their physical or mental examinations. Your treatment records should also contain other important sources of objective evidence that prove a condition exists such as imaging and labs. Therefore, your medical providers do not need any special training in SSA’s rules to be able to provide evidence of your medical conditions or even to provide an opinion about how your conditions affect your ability to function.
SSA does employ physicians to review claim files and decide whether a condition qualifies as a medically determinable impairment, whether it is severe, whether it meets or equals any of SSA’s medical listings, and to what degree, if any, that the condition(s) may limit you. These physicians are referred to as non-examining medical consultants. You will never see them or even speak to them as they only review the information in your file and arrive at their given opinions. These non-examining medical consultants that work for SSA (and/or the State Agencies that are contracted to do the initial medical determinations for SSA) are familiar with SSA’s rules and considered to “highly qualified and experts in Social Security Disability evaluations.” It is important to note again however, that they are only providing opinions based on a limited review of your medical records, and they are no substitute for your actual medical provider. Unfortunately, the opinions from these non-examining medical consultants will often be adopted by SSA and drive the decision made on your claim necessitating appeals and delays in getting your benefits.
Often times SSA will order examinations to be obtained at their expense before a decision is rendered in your claim. These examinations are referred to as “consultative examinations.” SSA’s rules state that these examinations will be ordered “if your medical sources cannot or will not give us sufficient medical evidence about your impairment.” (20 C.F.R. §404.1517/404.917). We often see these examinations being ordered even when your providers do offer plenty of information, so the reason for the examinations being scheduled seem to vary upon other factors as well. Examinations by general/internal medicine doctors and psychologists are quite common. However, from time-to-time SSA does order examinations to be completed by specialists such as ophthalmologists, orthopedists and neurologists to name a few, provided these doctors are willing to contract with SSA to perform such examinations. The pool of specialists willing to contract with SSA to perform these examinations is usually pretty small nation-wide, so it is certainly not possible for SSA to obtain these in every case. The type of examination is dependent on your particular factors and what information SSA is trying to develop. Most often the medical examinations are very short and limited in scope, and these providers are not establishing a treatment relationship with you. Psychological examinations usually take a bit longer due to the nature of the examination, and again, no treatment relationship is being established. The consultative examiner’s role is to report the findings of their examination and/or to establish a diagnosis, and to offer an opinion about whether you have any limitations in your ability to perform the various physical, non-exertional, or mental demands required in basic work activities. Sometimes SSA may provide them with some of your medical records to review before the appointment, although it is rarely more than a few select pages. Although they are paid by SSA to perform the examinations, they are expected to be neutral with respect to the examination and any opinion they may offer SSA. These providers typically have no special training or familiarity with SSA’s rules, nor do they have any control on the outcome of the decision SSA makes. Therefore, even consultative examiners are not “disability doctors.” Even if a consultative examiner tells you that they believe you are (or you are not) disabled, SSA’s team of non-examining medical consultants and claim examiners are ultimately the ones that determine the outcome of your case.
At the end of the day, what you need to understand is that you do not need a “disability doctor” to file a claim for disability. Having your own medical sources suggesting or agreeing that you apply for disability may be a helpful indicator as to how severe your conditions are, however, you do not need a recommendation from your own provider to apply. Whether you are “disabled” is a complicated legal standard dictated by SSA. Since they wrote the rules on this legal standard, the law also says they have the right to make the decision about whether you are disabled independent of what your own providers or even contracted providers may say. Additionally, disability is not something that is met based on a diagnosis alone (except for certain rare and terminal illnesses named on the compassionate allowance list). Your condition(s) must be so severe it prevents you from working (or is expected to keep you from working) for at least 12 months or longer. For most people, depending on your age, it must also prevent you from doing any type of work on a substantial basis. Again, all complicated legal terms here that would take another blog to unpack, but the point is that if you are suffering from conditions that make you unable to work, you should talk to a professional that can better assess the situation and help you determine whether applying for disability is right for you.
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