WHAT’S HIDDEN INSIDE YOUR SSA CASE FILE?
WHAT DOES SSA’S CASE FILE SAY ABOUT YOU?
When you file an application for Social Security Disability Insurance benefits, you expect the SSA to review your medical records. You also expect them to review your work history and read the forms that you complete. Additionally, you expect your disability case to be based on facts. However, many people who file for benefits do not realize that the SSA also creates an internal case file about you. This is part of the disability file that you never receive or review.
Your SSA case file follows your disability claim at every stage of the five step review process. It shapes how the SSA views you. Additionally, it influences how your medical evidence is understood. The SSA frames your limitations long before a disability judge ever meets you. If your claim reaches a hearing, then your internal file already tells a story about you. That story may or may not fit your real life.
Understanding what appears in an SSA case file matters if you apply for SSDI or SSI benefits. If your case file focuses on topics other than your medical records, then that can explain why your case is denied. It explains why people with serious conditions can be overlooked by the disability system. It also explains why working with a Social Security Disability lawyer can change the outcome for many individuals.
THE SSA CREATES A STORY ABOUT YOU
From the moment you file your application for disability benefits, the SSA begins building a narrative. This narrative does not simply repeat what your doctors write. Instead, the SSA interprets your medical records, your statements, and your behavior through the lens of SSA rules. You do not get to see this interpretation. But, it affects every decision the SSA makes.
Disability examiners (people who work for Disability Determination Services) summarize your claim in their own words. These summaries reflect how the SSA worker understands your physical and mental limitations. These same summaries also reflect the SSA’s doubts and questions about your case. If your symptoms are hard to measure, then the file may describe your medical conditions are not severe at step two. If your treatment is not ongoing, then your case file may frame that as a weakness.
You never get to see this narrative from the SSA. Additionally, you cannot correct it unless your lawyer requests the file and responds to the statements in it. Over time, those statements can harden into conclusions that are difficult to reverse.
The SSA story about your case travels with your claim. Everyone who reviews your case reads the opinion of the SSA worker. It influences medical reviewers, vocational experts, and the SSA judge who conducts your hearing. Once the story in your case file takes shape, it becomes difficult to change without strong legal advocacy. That is why your disability claim may fail, even before you ever have a chance to explain your disability in person.
CASE FILE NOTES SHAPE HOW THE SSA SEES YOUR CREDIBILITY
The SSA no longer uses the word credibility in decisions. However, credibility remains central to every disability claim. Internal notes, written by SSA workers and doctors, assess whether your statements seem reliable. For example, if you write statements about your symptoms, then the SSA will compare your statements to your medical records. The medical records should support your complaints.
If you describe pain differently across appointments, then the SSA may see that as inconsistency. Likewise, if you minimize your symptoms to your doctor, then your case file may show improvement. Sometimes, the SSA does not see your case in a fair manner. This is especially true if you have substance abuse problems. Additionally, having a history of jail or prison time can also impact your credibility. These judgments do not feel fair, but they shape outcomes. It is the job of those who work at the SSA to judge you.
The SSA is judging you based on many factors. But the SSA may not have all the facts. They may see gaps in your medical treatment. But this does not tell them if you miss treatment due to depression. Unfortunately, the SSA may not always account for lack of medical treatment due to money. Additionally, they may not see that you can’t get to the doctor because you don’t have transportation.
Finally, the SSA’s notes do not account for your stress, confusion, mental illness, or illiteracy. For example, some people struggle to answer the SSA’s forms because they can’t read or spell. Your medical records should include all of your conditions, including symptoms of depression or anxiety. If the SSA gets it wrong, then their impressions follow your claim forward. Your SSD attorney works to address these issues early, before they solidify into a denial of your claim.
THE SSA CAN USE YOUR DAILY ACTIVITIES AGAINST YOU
The forms in your case file are filled out by you. Therefore, the SSA uses them as evidence as to what you can and cannot do. If you fill out the daily activities form focusing on what you can do versus what you can’t, then the SSA will probably find you can work. They do this by using your descriptions of daily life from your SSA forms. On those forms, for example, you might describe cooking, cleaning, driving, shopping, and caring for others. Answer honestly, because you want to cooperate. However, realize how the SSA is going to interpret these activities.
The SSA often compares daily activities to full time work. If you prepare meals, then the SSA may believe you have the ability to work in a kitchen while on your feet. Likewise, if you can drive on a trip, then the SSA may assume you can focus and sit for longs periods of time. Or, if you care for children without help from family members, then they may assume you can work in a day care. The same is true if you take care of an elderly parent. If you can do that for your parent, then you can do it is a job.
What the SSA often misses is context. For example, your records may not reflect pain after activity, the need for rest, or the waxing and waning of symptoms. Pain, fatigue, and brain fog often appear subjective and the SSA favors objective findings. Without explanation, your daily activities can undermine an otherwise strong disability claim. An experienced disability lawyer helps clarify these issues in your case file before they damage your case.
MEDICAL RECORDS DO NOT SPEAK FOR THEMSELVES
Many people believe their medical records will clearly show disability. They believe this even if they have not read them. The SSA’s rules are very strict regarding what counts as a disability. If your medical records don’t have every single element of the listing under step three, then the SSA will find you don’t meet a listing.
Additionally, even if your doctor states you are disabled, the SSA doesn’t automatically accept it. SSA’s regulations state that opinions about disability can only be made by them. Therefore, the SSA reads medical records selectively. If your records conflict with the medical opinion of the SSA doctor, then the SSA will usually accept the opinion of their own doctor.
Many people also believe that medical records are kept in one location and they think the SSA automatically has access to all records. But, they don’t. Medical records need to be requested. And, the SSA cannot request records they don’t know about. Therefore, you have to provide them with all of the information about your doctors. If you have surgery, then you need to submit your operations.
You should also review your progress notes in your medical portal. Most treating doctors have online portals that contain your progress notes and test results. In those records, doctors often write phrases like “she is no acute distress” or “has has a normal appearance.” These phrases are written for the purpose of billing or for other providers. They are not a disability evaluation. But the SSA often focuses on statements like these in your SSA case file. These phrases can weaken your claim if no one explains what they truly mean.
Without guidance from an SSD law firm, your case file may fail to mention the severity of your condition. Even when your doctors support your claim.
THE SSA GIVES WEIGHT TO THE OPINION OF THEIR OWN DOCTOR
When the SSA sends you to their doctor, the resulting report carries significant weight. These exams are done at no cost to you. However, these exams may not last long. For example, some clients report 15 minute appointments. Even if the SSA doctor doesn’t read your records and meets you for a short time, the SSA case file may present their report as highly persuasive. Observations about your behavior or cooperation can influence the SSA’s decision.
When you attend your free doctor exam, the doctor will write about how you sit, stand, walk, or respond to questions. They may watch you walk into the building from the parking lot. They will look to see if you are using a cane or walker. If you are angry or rude to the staff, then that will surely make it into the report. What you are wearing, your hair style, tattoos and makeup all get reported by the doctor. If you appear to be lying or you exaggerate your symptoms, then that is also in the report. For example, some people scream in pain when asked to stand or walk. These dramatic displays of emotion get you a negative report.
Of course, a one time exam often lacks context. The doctor doesn’t know you and has often not read any of your medical records. If you are having a good day, then the doctor may report that you are fine and can work. If you are having a bad day, then your attitude can look like noncompliance. All you can do is be honest and tell the doctor what is wrong. Just keep in mind these exams are important to the SSA. Your lawyer can challenge these conclusions before they control the outcome of your disability claim.
MENTAL HEALTH CLAIMS FACE UNIQUE CASE FILE CHALLENGES
Mental health conditions pose special challenges for your SSA case file. Many examiners lack training in mental illness. The SSA’s internal case file often reduces complex symptoms into simple conclusions about work ability. For example, the SSA will review your progress notes from your therapist. They may state that your calm behavior at the appointment means you are stable. Or, they may find that because you had some brief improvement with medication your symptoms are no longer severe. Learn about the 12 month rule for disability benefits.
Mental illness symptoms can fluctuate. But, the SSA frequently focuses on statements in your mental status exams that you appear normal. The file may assume simple work remains possible, even when real world examples prove otherwise. For example, your file may show that you have been fired repeatedly from multiple jobs, but that won’t stop the SSA from stating you could do a simple job.
Mental illness has many symptoms that impact work. For example, it can affect your ability to concentrate and be reliable. Memory problems and focus issues can make it impossible to finish work tasks. Without explanation, the SSA case file may overlook these limitations. A disability attorney ensures that the case file reflects how your mental health conditions impact your ability to work.
THE SSA INTERPRETS TREATMENT GAPS HARSHLY
One of the other issues that the SSA brings up in your case file is whether or not you are getting medical treatment. Gaps in treatment raise red flags in the SSA case file. Internal notes often frame gaps as lack of compliance. In short, you are saying your medical conditions are so severe you cannot work. But, if you don’t go to the doctor all the SSA says is – she isn’t going to the doctor so how bad could it be? Of course, this doesn’t take into account that you might miss treatment due to cost, access, or illness. The SSA rarely assumes these explanations. Without an explanation, treatment gaps can weaken your disability claim.
Please don’t believe that your failure to get treatment will be excused by the SSA when you claim “there isn’t anything a doctor can do.” It is simply not true. Your doctor may not be able to cure your degenerative disc disease or your diabetes type II. However, they can treat your symptoms. Even if your treating doctor cannot cure your disease, they can treat pain. You can also get treatment at a pain clinic. Doctors and therapists at a pain clinic treat pain and symptoms from chronic diseases. Your ongoing attendance at a pain clinic demonstrates you have a severe medical condition.
WHAT YOU DO NOT SAY CAN HURT YOUR DISABILITY CLAIM
Silence carries meaning in an SSA case file. If your medical records do not mention side effects, then the SSA may write in your case file that none exist. When your need for a device does not appear in progress notes, then your case file may state you really don’t need a cane or walker. For example, if you require a cane to walk, but you show up to the doctor appointment without one, then the SSA will state you don’t need a cane. If you state you don’t need a walker at home, then why would you need one outside of your home? If you are not consistent in what you say to your doctor and to the SSA, then the SSA may write in your case file that your condition has improved.
Many people avoid complaining when they go to the doctor. Others forget to report side effects from medications. Some assume their doctor already knows what they are experiencing. But doctors are not mind readers. You have to tell them what problems you are having for them to offer treatment. You also need to ask your doctor for help with your disability case. Your doctor doesn’t automatically know you have filed an application for disability benefits. Tell them. Then ask for their support. Ask them to write a letter on your behalf. If your doctor never mentions that you are unable to work, then that is on you. The SSA does not fill in these gaps in your favor.
THE SSA CASE FILE FOLLOWS YOUR CLAIM TO A HEARING
When your case reaches a hearing with an SSA judge, your case file already frames your story. The judge reviews your entire file prior to your hearing. They pay special attention to the notes from the SSA that were created at the various stages of appeal. If you were rude to an SSA worker, then the judge will read about it. Likewise, if you didn’t go to the free SSA doctor exam, then that will be in the notes. If you failed to tell the SSA about missing medical records, then by the time you get to your hearing it is too late. The judge needs all of the medical records prior to the hearing. They enter the room with impressions already formed.
This does not mean judges act unfairly. It means first impressions matter. If the file minimizes your symptoms, then you are going to face an uphill battle. Correcting these impressions requires a focused legal strategy from the beginning of your claim. You should hire an attorney with legal experience in disability law. An attorney reviews the SSA file, identifies weak points, and addresses them directly. This process increases your approval odds. Because it helps the judge see your claim clearly.
HOW A DISABILITY ATTORNEY HELPS WIN YOUR BENEFITS
If you need help winning your SSDI and SSI benefits, then you have found the right law firm. You can learn about the attorneys at our law firm on our About Us page. For example, you may want to know that Dianna Cannon has been helping her clients win SSD benefits for over thirty years. Additionally, Brett Bunkall and Andria Summers have also won thousands of SSD cases.
In the past 30 years, we have won over 20,000 SSDI and SSI cases for our clients. Our experts can help you file for SSI benefits using the SSA’s website. However, we will need your help to apply for SSI benefits. Why? Because only you know your personal financial information. SSI benefits require you to have minimal assets and low monthly income. You can learn about the SSI income rules.
Likewise, if you need an appeal, then we can help you do that too. There are also many forms that will need to fill out. Don’t worry. If you have questions about these forms, then we will answer them. You can learn about SSA’s appeal forms. Call us today for help winning your SSDI and SSI benefits.
HIRE OUR LAW FIRM TO WIN YOUR SSD BENEFITS
Our SSD law firm will help you file your application for benefits. We collect your medical records and make sure the SSA has them. Before your hearing, we review your physical and mental conditions. Also, we will prepare you to testify at your hearing. We will explain to the judge why you cannot complete an 8 hour day. Even though every judge is different, all of the questions revolve around whether you can work. For the hearing, we will also review your past relevant work and job skills. We will be ready to argue that your job skills do not transfer to other work.
Prepare yourself to answer questions about your physical and mental health. It is important for you to understand the judge’s questions. You need to be able to explain your physical and mental conditions. Our job is to work with you so that you can explain your symptoms to the judge. You have to prove why you can’t work. We help you do that. That is why we say we are working as a team. If you hire us to represent you, then you will be ready to testify. We will review your answers with you. This will help you feel less anxiety prior to your hearing.
It takes a team effort to get through the disability process. Now is the time to ask for help. Don’t try it alone. We offer a free review of your case. Even if we review your case, there is no pressure to become our client. You can call and ask questions. Contact us today. Let us make sure that your case file supports your claim for benefits. Call us for help to win your SSD benefits.
