The Value of Medical History Documents in a Disability Claim

Having a clear and complete diagnosis and medical history are crucial aspects of any successful disability claim.  Disability insurance companies are masters at seizing on any potential discrepancies in these records as a basis to dispute, delay or deny a claim.  One of the best ways to help yourself, your doctors, and your disability claim is to prepare a medical history document that tracks your health information over time.  While this document is not intended to replace your medical records or an interview by a physician, it can be a crucial reference tool that provides much needed information in a condensed and organized manner when deciding on best courses of treatment – or when discussing your claim with a claims examiner or field investigator.  The best advice would be to calmly and thoroughly prepare a medical history document for every member of your family before a critical need arises.  As almost everyone has done, you’ve completed a general health history form at your doctor’s office before seeing the doctor.

The focus of this blog is on disability claims, so I’m going to focus on the what’s and how’s of a medical history document for people who have become disabled and either have filed or will file for disability benefits with their insurance company.  The primary difference from a general history is that the process concentrates on accumulating the information related to the disabling conditions.  And yes, there’s seldom a singular disabling condition.  It’s normal and common to have several conditions that, taken together, result in a disability.  For example, you may be suffering from a disease which may be the initial diagnosis, but the effects of the treatments for that disease can add another layer of disabling conditions.  In addition, many people develop compensating conditions resulting from their initial conditions, which may also add another layer of disabling conditions.  The purpose of compiling a medical history record for the purposes of a disability is to organize all of the “moving parts” of your medical conditions and treatments.

A strong medical history record will reduce the stress and amount of work needed to complete disability claim paperwork and forms.  The timeframe of this medical history starts when the conditions have been either suspected or diagnosed.  There are several key pieces of information that should be included in a medical history document.


This is the single most important area of the medical history.  Start by listing every condition for which you are currently being treated or have been treated.  Again, this is meant to focus on the medical conditions that have resulted in a disability.  It’s nice to know medical terminology, but describing your conditions in your own words is completely acceptable.  List each and every one of the symptoms that have been suffered.  If you’re already under a doctor’s care, try to match up the symptoms with the diagnosed conditions – but do NOT make assumptions.

Again, the completeness of this section is critical, even at the risk of duplication.  For example, if there is pain in the left leg, describe the pain in greater detail.  Is it a constant ache, a shooting pain, or a sensation of needles or fire?  What about on a scale of 1 to 10?  What about different times of the day and night?  This level of detail and quantity of information may be challenging to gather but can make a difference in both your treatment and the eventual decision in a disability claim.

Appointments and Treatments

A detailed list of appointments is a good starting point for a medical history.  This is also critical in demonstrating dates of disability and appropriate care and treatment.

Treatments often vary over time.  Keep a detailed record of what treatments occurred when.  Again, this is focused on those conditions related to the disability.  If you wore a TENS unit, record how many hours over what days it was used.  If you had chiropractic care, include each appointment along with the type of adjustments as well as any other treatments.


This section is often even more technical than the conditions.  Depending on your conditions, tests may encompass a wide spectrum.  For example, there are many different types of blood tests and labs.  Radiological tests such as x-rays, CT scans, and MRI’s may be relevant.  Neuropsychological testing can be very extensive and important to your diagnosis and treatment.  The information summarized should include the type and dates of tests as well as any positive (or negative) results or additional observations as interpreted by a medical professional.


Any and all medications being taken, both prescription and over-the-counter, should also be listed.  Be sure to include any supplements, non-traditional, or alternative medications.  If you’ve been prescribed medications but did not take them, list those as well.  Be specific when listing medications – list the names of the drugs taken, how often they’re taken, the dosage amounts, and the reason for each specific medication.  Have a section that specifically lists any known (or suspected) allergies.


All health “milestones” should be included in a medical history.  Milestones include all major surgeries and significant tests and treatments for other medical problems that preceded the disabling conditions.  As examples, complications in childbirth, knee replacement surgery, or chemotherapy treatment for prostate cancer.  Milestones can also encompass less life-altering procedures, such as tests for melanoma or treatment for anxiety-based headaches.  Accurate dates for these milestones is important, so it may be a good idea to double check with your medical providers when compiling this section.  After a health history document has been created, it’s simple to update the document after any new milestone to ensure the information stays up to date.

A medical history document can serve several purposes for someone filing a claim for disability benefits.  First, it can be an effective tool in helping your doctors evaluate and diagnose your condition correctly.  In some cases, the physician treating you for your condition may be a specialist who isn’t your regular doctor.  Having to obtain medical records from several different sources can be very time-consuming for the doctor’s office, and the information they receive may be incomplete or out of context.  Providing your own medical history creates more confidence that the physician has all of the relevant information when deciding on courses of treatment and that any forms that must be completed for a disability claim will be thorough, complete, and accurate.

A medical history document can also be beneficial to you as a claimant when completing your own claim forms as well as when being interviewed by a claim examiner or undergoing an IME.  This document can act as a script to keep you calm and composed and make sure that you provide the best information for the questions they’re asking.  Their training and experience sometimes lead them to confuse claimants into making contradictory statements, creating reasons to deny or delay benefit payments.  Having a document to use as a reference when discussing sensitive and complex details can help prevent this from happening.

Insurance companies have tremendous resources to fight disability claims, so it’s important for claimants to take advantage of every possible resource.  A medical history document is a resource for claimants that can be assembled before it’s needed in the heat of the moment and can prevent many errors and headaches during the disability claim process.  Waiting until you or a loved one experiences a tragedy or is diagnosed with a debilitating condition is never an easy time to gather this information, as your state of mind and ability to think clearly on these issues is compromised by the stress and confusion of the day.

If you’ve come across this article and are already in the process of filing your claim for disability benefits, it is not too late.  Our firm has a team of experts that is ready and willing to help you sift through all of the confusing medical information and documents to derive what can make a difference in your disability claim and help you organize that critical evidence into a clear and concise document that proves your claim and cannot be ignored by the insurance company.  If you would like help in creating a medical history document or have any other questions about your disability claim, please call our offices toll-free at (855) 828-4100 or sign up for a free consultation on our website.

4 thoughts on “The Value of Medical History Documents in a Disability Claim

  1. Pingback: 10 Ways to Protect Your Disability Claim in 2013 | Royal Claims Advocates

  2. Pingback: 3 Reasons Your Invisible Disability Benefit Claim Was Denied | Royal Claims Advocates

  3. Pingback: 6 Tips To Keep Your Disability Claim Moving | Royal Claims Advocates

  4. Pingback: Insurance Investigators: An Inside Look At Their Techniques | Royal Claims Advocates

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