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Social Security's Responsibility to Fully Develop the Medical Record in Your Disability Case

Posted on in Social Security Disability

disability benefits, Chicago Social Security attorney, disability claim, disability case, medical recordsSocial Security officials often resort to using boilerplate language or checklists when denying claims for disability benefits. Federal courts must continually remind Social Security this is not an acceptable practice. Every disability applicant has the right to fair consideration of the unique facts and circumstances applicable to his or her case, especially any medical evidence documenting his or her physical or mental impairments. Yet ironically, Social Security itself often tries to dismiss such medical evidence on the grounds that doctors use boilerplate language or checklists in filling out some of their assessments.

Court Criticizes Social Security for Resorting to “Rank Speculation” in Denying Disability Claim

Consider this recent disability case from here in Illinois. The plaintiff spent 25 years as a yard manager for the Chicago Transportation Authority. But in 2004, he was forced to stop working due to a combination of medical conditions, including bad knees, high blood pressure, and lower back pain.

At a 2015 disability hearing before a Social Security administrative law judge (ALJ), the plaintiff presented his medical records, composed largely of treatment notes from his primary doctor. The ALJ chose to give the doctor's medical opinions “extremely limited weight,” however, declaring they were inconsistent with the rest of the plaintiff's records. In particular, the ALJ decried the doctor's purported use of a “checklist-style form” that “appears to have been completed as an accommodation to the claimant and includes only conclusions regarding her functional limitations without any rationale for those conclusions.”

For this and other reasons, the ALJ denied the plaintiff's application for disability benefits. But on appeal, a federal magistrate judge ordered Social Security to conduct a new hearing. The magistrate said the ALJ failed to give “good reasons” for dismissing the treating physician's medical opinions. Indeed, the magistrate said it was the ALJ, not the plaintiff's doctor, who drew “conclusions from evidence without any basis in fact.” It was “rank speculation” on the ALJ's part that the doctor—who had a “longstanding treatment history with the plaintiff—only provided answers as an "accommodation” to him.

Beyond that, the magistrate said the ALJ failed to properly develop the rest of the evidentiary record prior to rejecting the plaintiff's disability claim. For example, the ALJ declined to consider the testimony of another medical expert who testified at the hearing, on the grounds this person did not have access to the plaintiff's medical records beforehand. As the magistrate explained, it is the ALJ's job to ensure “that a complete record was developed by providing the medical expert with those materials or with time to review them.” And in fact, the ALJ will need to take greater care to further develop the record at the new hearing ordered by the court.

Do Not Let Social Security Treat You Unfairly

Your disability case is important. Social Security officials may not think so, but they have a legal obligation to ensure there is a fully developed record before granting or denying your application for benefits. If you need help from an experienced Chicago Social Security attorney in presenting your case to the government, call Pearson Disability, LLC, at 312-999-0999 today.


Lewis v. Berryhill , U.S. District Court for the Northern District of Illinois, Nov. 9, 2017.

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