The Disability Appeal Summary Letter

The Disability Appeal Summary LetterOnce scheduled for a hearing before a Social Security Administration Administrative Law Judge, your disability attorney should be double and triple checking all of your medical documentation to ensure that it supports your impairments, accurately reflects the period in question, and in the case of an open claim, is up-to-date. Few things anger an ALJ more than having to grant a continuance and keep the record open because “updated medicals” were never requested by counsel. In addition, your disability lawyer should be reviewing all possible questions with you, as well as the theory of your case, and, what many of them neglect to do, forward a summary letter to the hearing office in advance of your appearance, along with your medical evidence. Here is a sample of what we mean. It is unrelated to an actual case and in no way reflects the personal information of an individual. It is provided as an example only, and like all of our posts, is not intended to constitute legal advice:

Honorable ****** *. *****
Administrative Law Judge
Office of Hearings and Appeals
Social Security Administration
123 Main Street
Any Town, State 12345

Re: John Doe, S.S.# 123-45-6789

Dear Judge *****:

The above-noted individual has a claim pending at the hearing level, and is scheduled to appear before you on March **, ****. The relevant medical evidence in his file suggests a fully favorable decision can be made on the record. To assist you, a brief summary of the same is provided hereinafter.

Mr. Doe is a 37-year-old high school graduate with previous experience as a tavern owner and construction worker. With the exception of a short unsuccessful work attempt period of less than three months, he has been unable to engage in substantial gainful activity since September **, ****, as a result of several debilitating physical and cognitive impairments. These include severe migraine headaches, persistent neck pain, depression, attention deficit disorder (“ADD”), and Tourette’s Syndrome.

From June **, **** until the spring of ****, Mr. Doe was under the care of Dr. **** *****, a specialist in neurology and psychiatry in *****, PA. A review of this treating source’s office notes provide valuable insight into the history of Mr. Doe’s conditions and symptoms, as well as his compliance with all regimens prescribed.

Mr. Doe’s original intake with said treating source, dated July **, ****, reveals he suffered from daily throbbing headaches in both temples, constant pain at the back of his neck, and Tourette’s Syndrome. Dr. ***** tried various medications, to no avail. On April **, ****, he was also diagnosed as suffering from ADD. Moreover, he was treated for depression. Mr. Doe’s headaches continued throughout ****, as documented in the office notes. His medications included Haldol, Anapril, Librium, and Prozac. Office notes dated May **, **** reveal “compulsive checking rituals.”

In ****, Dr. ***** tried other medications including Chlordiazepoxide, Benadryl, Cardene, and Inderol, with little success. Mr. Doe’s symptoms continued. Said physician’s office notes, dated January **, ****, reveal headaches, as well as other medication attempts, including Depakote. Buspar and Zoloft were tried in the spring and summer of ****.

In early ****, Dexedrine was also prescribed. Later in the year, Ritalin and Adderall were added. Despite the same, Mr. Doe’s headaches continued to affect him. “Pounding headaches” were documented on May **, ****. On November **, ****, Dr. ***** noted Mr. Doe experienced deterioration in his condition. On January **, ****, said physician noted Mr. Doe was “doing poorly.” Luvox and Remiron were tried. Throughout ****, ****, and ****, Mr. Doe felt almost no relief.

On October **, ****, a rheumatologist, Dr. **** *******, of ******, PA, evaluated Mr. Doe. Said physician found he suffered from chronic pain syndrome in his head and neck, Tourette’s Syndrome, lower back pain with limited range of motion in his cervical and lumbar spine, and a positive rheumatoid factor of 51.

A Customer History Report from ********* Pharmacy, for the period January **, **** through December **, **** provides valuable insight into Mr. Doe’s care and treatment. Throughout the entire period, Mr. Doe complied with taking the medications prescribed to him. These included Haloperidol, Neurontin, Dexedrine, Prozac, Lorazepam, Ultram, Paxil, Propranolol, Midrin, Vioxx, and others.

Given the combination of Mr. Doe’s impairments, as substantiated by his treating physicians’ reports, it is clear his functional abilities have eroded to less than sedentary capacity. As a result, a finding of disability is warranted.

Respectfully submitted,

Your Attorney, Esq.