‘Playing Doctor’: What to Do When the Administrative Law Judge in Your Illinois Social Security Disability Case Substitutes Her Own Opinion in Place of Proper Medical Evidence

In the parenting world, when a young child “plays doctor,” it may represent an opportunity to teach the child about human bodies, boundaries, and privacy. In the world of Social Security Disability benefits claims, when an administrative law judge  (ALJ) “plays doctor,” it’s a problem, as it means the ALJ is substituting his/her own opinions in place of reliable evidence obtained from a qualified medical professional. When that happens, it may represent an opportunity to get your denial of benefits reversed. An ALJ who decides to “play doctor” (as the courts have called it on several occasions) is just one of many potential pitfalls your disability case may face and represents just one of many reasons why it pays to have a skilled Chicago Social Security Disability lawyer on your side.

So what, precisely, does an ALJ “playing doctor” in a Social Security Disability case look like? It can occur in many different ways. A recent claim filed by a southern Illinois woman makes for a good example of one form.

The applicant, C.K., had worked as a janitor but suffered from chronic back and neck pain that eventually got bad enough that she couldn’t work. The woman first applied for Social Security Disability benefits in September 2015.

As part of that filing, a doctor reviewed the janitor’s records and issued an opinion report in which he stated that the woman had some limitations, but was still capable of working. That report was dated January 2016. What made this 2016 document so important was that it was the only medical opinion that looked at C.K.’s medical problems and opined about how much they restricted the woman’s ability to work.

A year later, C.K.’s health took a turn for the worse. C.K.’s pain became so bad that it was “barely controlled with gabapentin and ibuprofen,” and the woman could not stand for very long. Later in the year, C.K. had additional X-rays and MRIs done. The MRIs showed some stenosis in the woman’s lumbar spine. A report from C.K.’s physical therapy provider said that the woman “could not ‘grip’ or ‘carry’ heavy things.”

The ALJ in the woman’s case determined that she was not disabled, but the 7th Circuit court reversed that ruling.

Your ALJ Cannot Make Her Own ‘Independent Medical Findings’

This ruling in favor of this applicant is a reminder that administrative law judges in Social Security Disability cases must not substitute their own opinions for qualified medical ones when it comes to interpreting new medical evidence. As the 7th Circuit court has explained on multiple occasions spanning several decades, “ALJs must not succumb to the temptation to play doctor and make their own independent medical findings.” That includes not interpreting “new and potentially decisive medical evidence without medical scrutiny.”

That was what happened in C.K.’s case and that was why she was entitled to a reversal of the denial of benefits. The only evidence from a qualified medical professional that addressed how C.K.’s medical problems limited (or prevented) her working was dated January 2016. However, the evidence also indicated that C.K.’s medical condition deteriorated substantially in 2017. C.K. had MRIs and X-rays done in 2017. The ALJ, according to the court, should have obtained an updated medical opinion that interpreted the results of those tests. By determining that C.K. was not entitled to benefits without getting that updated medical opinion, the ALJ had impermissibly played doctor and substituted the ALJ’s personal opinion for that of a qualified medical professional.

This ALJ’s failure to obtain an updated medical opinion meant that there was not substantial medical proof to support the denial, as required by the law, and that C.K. should receive a new hearing.

When you file a Social Security Disability claim for musculoskeletal pain or other issues, you need several things. One of the most important is a legal advocate who is both knowledgeable and experienced. The AV-rated firm of Katz, Friedman, Eisenstein, Johnson, Bareck & Bertuca proudly offers clients exactly that. Our team of Chicago Social Security Disability lawyers has been fighting for injured workers for more than 50 years and knows what it takes to get you the successful outcome you deserve. To set up a free case evaluation, contact us at 312-724-5846 or through our website.