How Do I Prove I’m Disabled?

It must be in the medical record – The primary source of medical evidence to establish disability is found in your medical records. This is what insurance companies and Social Security will rely on most to accept or deny your claim.

Medical records include the records of all your attending physicians and hospitals. It may include the records of your therapist. It may also include records from alternative care providers such as acupuncturists and chiropractors.

When the plan asks for names of your doctors, be sure to list all that have current medical records on you. However, the records  may not provide the proof you need for a variety of reasons:

  • Records may be vague – If the doctor just writes “pain”, what does that mean? How severe? How frequent?
  • Records may be incomplete – Many doctors are pressed for time so they don’t write their notes as thoroughly as they should. Some will actually omit listing some symptoms, especially if they’re ongoing and repeated at every visit or if there’s no treatment for that particular symptom.
  • Have you tried to read your doctor’s handwriting?

If your doctor’s records are not as complete as they should be it’s up to you to be assertive and ask your doctor to be more complete and explain why. Take lists of your symptoms and other problems that the doctor can transpose or attach to the medical record.

Other sources of medical evidence –

        Third party testimony – A letter from your supervisor outlining the deterioration in your job performance or a statement by your housemate of their observations of restrictions in your daily activities can supplement a medical record and provide persuasive documentation of your declining work abilities.

         Symptom Diary – I encourage most of my clients to maintain a daily log of symptoms experienced, their severity, and their impact on daily activities. Although not fun to do from a psychological point of view, it’s especially helpful when the symptoms are primarily subjective, i.e. not measurable in a lab test, such as pain or fatigue.

         Consultative Exams – These are medical exams ordered and paid for by the insurance company or Social Security. There’s a widespread belief that these exams are done primarily to document a denial. Although you really can’t refuse to take one, there are some things you can do to make sure they are accurate and objective.

o        Ask that your attending physician be permitted to perform the exam (she must be willing to use their forms and accept their fee).

o        Take a friend or family member to observe the exam or get permission to record the exam.

o        Immediately after the exam, write a summary of all that was done and said to the best of your recollection.

Subjective Symptoms - If your symptoms are primarily subjective, your records and other documentation must be even more complete. Subjective symptoms are those that can’t be measured on any machine or with any lab test. There are many conditions, for example, where the primary symptoms are pain or fatigue or both. Insurance companies especially dislike “self-reporting” of symptoms. The symptom diary is especially helpful in these situations.

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