When Can Social Security Decide Not to Follow My Treating Doctor's Opinion?

Social Security disability judges and claims examiners often ignore doctors' opinions in violation of Social Security policy.

If you're applying for Social Security disability benefits, your chances of success improve greatly if your case is supported by your treating doctor (the physician who sees you regularly). That's because the Social Security Administration (SSA), recognizing that treating physicians often possess unique insight into their patients' conditions, has promulgated rules that generally require claims examiner and judges to give substantial weight to the opinions of treating doctors.

However, Social Security will not automatically defer to the judgment of your doctor. Administrative law judges (ALJs) and other adjudicators must consider a number of factors when considering how much weight to give your treating physician's opinion, including the nature and length of your treatment relationship and the medical evidence supporting your doctor's conclusions.  In practice, judges routinely ignore the opinions of treating physicians, relying instead on doctors consulting for Social Security who have either performed one brief exam or never examined the disability applicant.

To minimize the chances that the SSA will disregard your doctor's opinion, it's important to understand how the SSA evaluates the medical opinions of treating doctors, and what kinds of medical opinions the agency tends to find persuasive.

The Treating Physician Rule

Under the SSA's "treating physician rule," your treating doctor's opinions are entitled to "controlling weight" (meaning the doctor's opinion rules) if the following two criteria are met:

  • The opinions are well-supported by medically recognized clinical and laboratory diagnostic techniques.
  • The opinions are "not inconsistent" with the rest of the evidence in your file.

Weight Given to Treating Physician's Opinions

If your doctor's opinions aren't entitled to controlling weight, Social Security will consider the following factors in determining the level of weight to assign:
  • Length and frequency of treatment:  According to Social Security, a doctor who has performed frequent and consistent exams over an extended period of time is more likely to have a "detailed, longitudinal picture" of your limitations.
  • Nature and extent of doctor-patient relationship:  Social Security will consider the type and amount of treatment provided in assessing the physician's opinions. For example, the statements of a gastroenterologist regarding her patient's limitations due to fibromyalgia will usually be less persuasive than the opinions of the patient's treating rheumatologist or pain specialist.
  • Amount of medical support provided for opinions:  Your doctors should cite the medical evidence that supports their opinions. The opinions of physicians who merely tick the boxes of a form without any explanation are routinely ignored.
  • Consistency with other evidence in your file:  Doctors who exaggerate their patients' symptoms are not being helpful. If your physician's opinion is contradicted by other medical evidence in your file, it may be given little weight.
  • General practitioner or specialist:  A specialist who offers an opinion  within his area of expertise  is generally found more persuasive than a general practitioner.

SSA regulations require ALJs to assign weight to all medical opinions, and to specifically address the factors above when explaining the level of weight assigned (for example, substantial weight, little weight, no weight). Failure to provide  good reasons  for disregarding a treating physician's opinion is one of the most common reasons that the Appeals Council reverses or remands (sends back) a denial of benefits by an ALJ.

Your Doctor's Opinion on Whether You Are Disabled

Oftentimes a physician who wishes to support his patient's disability case will offer to write a letter regarding the patient's condition. Unfortunately, because most doctors don't understand the disability process or what issues they need to address, these letters tend not to be very helpful (in particular, if the doctor simply states that the patient is, in his or her opinion, disabled). The question of whether the claimant is "disabled" is for Social Security to decide, not physicians. "Disability" is a legal rather than a medical term, and physicians' opinions on this matter are not given any special consideration.

On the other hand, when denying benefits, ALJs occasionally state in their decisions that "No physician has ever found this claimant to be disabled." Despite this inconsistency, it's safe to say that your doctor's opinion as to whether you're "disabled" is not nearly as important as his or her opinions on the nature and extent of your work-related limitations. Your disability attorney should be able to provide your doctor with a Residual Functional Capacity (RFC) form that will address all the issues relevant to your case if your doctor fills it out completely.

Getting Weighty Residual Functional Capacity Forms

For Social Security to give your doctor's opinion a great deal of weight, make sure your doctor fills out the RFC forms in detail. In an RFC form for a claimant with physical limitations, the doctor should specify the individual's exertional (strength-related) limitations, including the ability to lift, carry, sit, stand, and walk. Non-exertional restrictions should be addressed as well, especially those related to reaching, handling, bending, stooping, climbing, and crawling. Any environmental restrictions, such as exposure to dust, odors, or extreme temperatures, should also be noted.

In a mental RFC form, the treating physician or psychologist should address the patient's ability to understand, remember, and execute simple and complex instructions; maintain attention and concentration; interact with co-workers and the general public; and stay on-task for an entire eight-hour workday without excessive breaks.

In both mental and physical RFC forms, the doctor should address attendance and punctuality, and in particular, the question of whether the patient would miss more than two days of work per month for medical reasons.

Perhaps most importantly, the physician completing the RFC form must provide a medical basis for any of the above limitations the doctor includes. Doctor who merely check the boxes on a form without citing any treatment notes, medical imaging, blood tests, or other evidence to support their opinions is not being nearly as helpful as they could be. You can get a physical RFC form here and a mental RFC form here.

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