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Helping Fibromyalgia Patients Obtain Social Security Benefits
by Joshua W. Potter, Esq.

Mr. Potter is an attorney in the firm of Potter, Cohen, & Samulon, 3852 East Colorado Boulevard, in Pasadena, CA 91107.

ABSTRACT:  A physician's evidence and testimony may be the deciding factor in the success of a patient's application for Social Security disability benefits; however, the fact that the reports are signed by a physician will not by itself sway the Social Security Administration.   Especially if the disability is related to one of the "new" or sometimes unrecognized disease entities, such as fibromyalgia, a brief unsupported conclusion that the patient is unable to work will likely contribute to denial of benefits.  The physician's report must be detailed, complete, prove knowledge of the patient and the disease, and document disabilities (including physical capacities, time duration for various activities, pain, and behavioral factors).    Coordination with an attorney may help make the physician's report most effective. (J Musculoskel Med 1992;9(9):65-74)

    The Social Security system does not easily or quickly rule favorably on a claim of disability.    For patients with fibromyalgia and similar disease entities, whose very existence is often questioned, proof of disability is especially difficult.    Nevertheless, by following an orderly and logical process, claimants may become eligible to receive benefits ranging between $350 and $1,000 a month until age 65, in addition to Medicare, which begins making payments 24 months following disease onset.

    When you are convinced that a patient is unable to work at any job, your medical evidence may be the deciding factor in determining whether the disability claim is successful.    As the treating physician, your efforts should be coordinated with the claimant and an attorney to establish that, within the Social Security Administration requirements, a period of disability did exist.

    In this article, I review the claims process, with emphasis on the role of the physician.    I discuss the kinds of information you may be asked to provide, the need for clear and objective statements rather than terse opinions, and the fact that the investment of a small amount of your time may be instrumental in your patient's being judged eligible for benefits.

WHAT IS DISABILITY?

    The Social Security Administration test of disability is "An inability to perform any substantial gainful activity because of a medically determinable physical or mental impairment which can be expected to last for a continuous period of not less than 12 months." (1)   In Social Security terms, "substantial gainful activity" means work that "(a) involves doing significant and productive physical or mental duties; and (b) is done (or intended) for pay or profit." (1)    A person is ineligible to receive Social Security disability benefits if he or she:

Is working (except in a "sheltered" setting), even though chronically ill
At present has the statutory ability and capacity to work
Recovered within 12 months of the onset of a disabling illness
Has no medically determinable impairment (except for one of the somatoform disorders, which are considered under a separate set of rules) (2).

THE PROCESS BEGINS

    The sequence of actions usually necessary for a person -even one who clearly appears disabled - to obtain disability payments is shown in the Table:
Table - Steps in the process of applying for Social Security
Administration disability benefits

Action   Comments
Initial application    Filed by patient
Request for reconsideration  Filed by patient within 60 days of initial rejection
Chart copied  Information about patient supplied by physician at the request of Social Security Administration
Physical examination   Performed by Social Security Administration physician
Request for hearing  Filed by patient within 60 days of rejection of request for reconsideration
Chart update, report   Supplied by physician
Trial   A new determination; attorney and physician participate
Appeal  Filed by the attorney with the Appeals Court within 60 days
Suit Filed by the attorney with the United States District Court within 60 days    (Attorney must have license to practice in District Court.)
If the 60-day time limit is not met, the process is ended and a new application must be filed.

    Physicians should advise every patient of the option to file for Social Security disability benefits when that patient has not been able to work because of illness for 12 consecutive months.    Indeed, an application may be filed as soon as it appears that the duration of disability will exceed 12 consecutive months.   Often such a prognosis may be made within 6 months of disease onset, and at that time the filing process for Social Security disability benefits should commence.

    A person who has worked and paid Social Security taxes applies for Social Security Disability Insurance ("Title II"), and a person of limited income and resources receives disability benefits through Supplemental Security Income ("Title XVI").

    Claims for Social Security disability benefits are made at the local Social Security District Office, either in person or by telephone (800-772-1213).   Initial filing - which asks about the nature of the disease, name of the physician, and vocational background - is made by the claimant; physicians and attorneys are not involved at this time.   It is the filing of a claim that alerts the government to a person's inability to work.

    Once the initial claim is filed, the Social Security Administration gathers by separate inquiry three types of information: