Case Study 2

Background Information

Debbie was a 42-year-old married woman living in California with her 13-year-old daughter.  Her husband lived there as well, but traveled extensively for his job. A few years ago, her husband was given a work assignment that required that he travel for weeks at a time.  While he was away on a long trip, 2 bad things happened: Debbie’s daughter was attacked at school and Debbie suddenly became sick with a terminal disease which she would later find out was MS.  In addition, Debbie’s mother was in very poor health and Debbie was having to care for her a lot.

Debbie believes that her MS was brought on by extreme stress – the stress of dealing with her daughter’s school and social issues, the stress of her mother’s sickness, the stress of being away from her husband, etc. Debbie reports that a few months into this stressful period, she woke up one morning with a painful “pins and needles” sensation in both her legs.  Within a few days, she was bedridden, completely unable to walk. This was the onset of the MS, although she wasn’t sure of the diagnosis yet.

Debbie’s doctor ran a few lab tests, sent her for diagnostic tests, and referred her to many specialists.  Within 2 months, she was diagnosed with MS.

At the time Debbie fell ill, her husband returned home and ended up requesting a transfer – which brought the family to Atlanta, GA.  Debbie’s condition stabilized to the point where she was able to move around with large metal braces on her legs.  When she finally arrived in Atlanta, Debbie acquired a job as a staff coordinator at a temporary staffing service.

Debbie was in the workforce for approximately one year.  Although she was no longer under severe and direct stress, she had at least three MS “episodes” that were each characterized by the onset of new symptoms.  Each of these episodes lasted around 3 weeks before subsiding, although each left her with lingering symptoms from that episode.  Debbie left her job because of frequent absences based on her condition and increasing vision problems.

Claimant Applies for Disability Benefits and is Denied

Debbie applied for benefits shortly after leaving her job.  In her application she reported symptoms that included having a hard time standing and walking, loss of muscle strength in her left (non-dominant) arm, problems sleeping because of shallow breathing, and periodic episodes of blurred vision.

After applying, the State Agency adjudicator scheduled Debbie for a consultative exam with an internist.  On the day that Debbie went to her appointment, she was actually having a good day – she still needed to use her braces to walk, but her vision was fine and her left arm was not in much pain.

The consultative doctor, who is employed by a clinic that generates most of its income from independent medical reviews (for Social Security), wrote that Debbie’s MS was “mild” and that she could actually perform simple and complex tasks. This is a typical outcome of the initial consultative exam.
The doctor also wrote that her vision test was “normal” and that while he did not doubt that Debbie experienced her claimed symptoms once in a while, he did not see these issues as contradictory with work activity.  He also noted that Debbie could sit for an unlimited time although she should avoid heights, ladders and scaffolds because of her leg braces.

For the time being, the State Agency adjudicator wanted copies of Debbie’s medical records from both her California doctor as well as the primary care physician she had found in Atlanta.  Both of these doctors mailed copies of their largely handwritten notes to the adjudicator.

After receiving the physicians notes and the report from the consultative physician, the State Agency Adjudicator sent the file to a staff physician hired by the State Agency.  This staff physician, who has never actually met Debbie, reviewed the records and then completed a physical functional capacity form in which he determined that Debbie’s symptoms were mild and would not cause any restrictions in her work performance.

Her file was then returned to the Adjudicator, who issued a denial to Debbie stating that the Social Security Agency had decided that Debbie’s condition was not harsh enough to prevent her from returning to her previous job as a “receptionist/secretary.”

Claimant Appeals Denial, is Denied a 2nd Time

After receiving the denial, Debbie asked our law firm to help her with her case.  During our first interview, I spoke with Debbie and her husband all of the symptoms she had had.  We logged onto a web site called the National Multiple Sclerosis Society and reviewed a discussion of other symptoms usually associated with the disease.

As we talked, Debbie described symptoms of depression including crying spells and random thoughts of suicide.  Although she had never received any specific psychological treatment, her primary care doctor had prescribed Paxil – a known psychotropic medicine.

Debbie and her spouse also noted that Debbie seemed to be suffering some cognitive loss, including issues as memory loss, difficulty adding numbers in her head, and mood swings.

After our interview, my paralegal and I completed the request for reconsideration and the reconsideration disability report.  We also included Debbie’s reported allegations of disability arising from depression, cognitive loss, as well as other MS symptoms.

The State Agency adjudicator appointed to the reconsideration file did send Debbie out for a neuropsychological evaluation that was not entirely conclusive but that did note cognitive dysfunction.  The examining psychologist concluded that Debbie should be thoroughly assessed by a treating physician.

As is this case and in most reconsideration appeals, Debbie was denied.  That’s when we filed for a hearing.

Claimant Requests a Hearing

After filing for a hearing, I received the neuropsychologist’s report and then copied it and sent it to Debbie’s doctor.  I also sent him a functional capacity evaluation I had drafted.  Thereafter, the primary care doctor referred Debbie to a neurologist and to a psychologist, both of whom began administering treatment.

When the hearing was finally scheduled, I was able to provide to the Judge treatment records from 3 doctors – the neurologist, psychologist and her primary doctor.  I also had 3 functional capacity evaluations, all of which identified limitations I knew to be significant.

One of Debbie’s doctors was kind enough to state on the form that in his opinion, Debbie’s condition was at a significant level of severity prior to the date she last worked.  Debbie then testified that during the last three months of her employment, she missed more time than she was there.

Based on this information, the Judge allowed us to amend our “onset date” and Debbie was awarded benefits as of our amended onset date.  The hearing took approximately ten minutes – the only real issue was the onset date question.  After taking Debbie’s testimony about her last few weeks of being employed, he turned to the Vocational Expert and asked the following questions:

Judge: “VE, have you reviewed the functional capacity forms completed by the claimant’s treating doctors?

VE: Yes.

Judge: If I accept any one of these evaluations as an accurate representation of this claimant’s condition, could she return to your previous job or any kind of job?

VE: I do not think so, Judge.

Judge: What is your reason?

VE: Well, Judge, let’s take Exhibit 17F, which is the functional capacity form completed by Dr. X.  In it he states that this claimant would have to take unscheduled 15 minute breaks every 60 to 90 minutes.  In my opinion, this is not consistent with competitive employment.

Judge: Thank you.  Mr. Ginsberg, do you have any questions?

Mr. Ginsberg (knowing that this is a good time to keep my mouth shut): No, your Honor.

Assessment

Based on the good medical evidence and forms, we were able to secure a win for my client.  As you see, the hearing was relatively short and painless; the vocational expert’s testimony helped get down to the point quickly.

Keep in mind that this case is only an example – not every case involves such supportive doctors and extensive records. Hopefully, this gives you a general idea of the process. Remember, medical records alone are not sufficient – they have to be translated into a language understood by Social Security and the case has to be prepared in advance for the Judge.  When you make the Judge’s life easier, your results will be much better.