There are many ways to sabotage an otherwise strong Social Security Disability claim. Failing to follow prescribed medical treatment is a common reason some claims are denied. In this blog post we’ll explain how the Social Security Administration (SSA) views claimants who fail to follow prescribed treatment plans by their treating provider.
Why is Medical Treatment Important in a Social Security Disability claim?
The SSA reviews your medical treatment when making a disability determination.
Medical treatment is a broad term that could encompass test results, medical examinations, doctors’ notes, and any type of diagnostic treatments ordered during the course of your care. It is common for a Social Security Disability claimant to submit records and evidence from multiple hospital stays and doctor’s offices as they seek benefits.
Medical treatment records help the SSA better understand the severity and duration of your medical impairments. This is critical in helping them determine whether you are disabled since your impairment must be categorized as long-lasting (must prevent you from working for 12 consecutive months or more) and severely limiting (must prevent you from doing work of any kind) to award you Social Security Disability benefits.
In addition to studying your interactions with medical professionals and your treatment records to confirm your diagnosis, its severity, and its duration, the SSA will want to know what treatments are available to you. This is where claimants who fail to comply with medical treatment plans may run into trouble.
Failure to Follow Prescribed Treatment and Social Security Disability Claims
The SSA applies rules around failure to follow prescribed treatment. These rules are subject to meeting the following conditions:
Condition 1: The individual is otherwise entitled to disability or statutory blindness benefits under titles II or XVI of the Act
Condition 2: There is evidence that an individual’s own medical source(s) prescribed treatment for the medically determinable impairment(s) upon which the disability finding is based
Condition 3: There is evidence that the individual did not follow the prescribed treatment.
SSA moves on to the next step after determining the above conditions. Next, they assess whether the prescribed treatment may help claimants return to work if followed. In addition, they assess whether the individual has ‘good cause’ for not following the prescribed treatment.
What is ‘Good Cause’?
The SSA outlines in detail examples of ‘good cause’ arguments. They are:
- Religion: The established teaching and tenets of the individual’s religion prohibit him or her from following the prescribed treatment. The individual must identify the religion, provide evidence of the individual’s membership in or affiliation to his or her religion, and provide evidence that the religion’s teachings do not permit the individual to follow the prescribed treatment.
- Cost: The individual is unable to afford prescribed treatment, which he or she is willing to follow, but for which affordable or free community resources are unavailable. Some individuals can obtain free or subsidized health insurance plans or healthcare from a clinic or other provider. In these instances, the individual must demonstrate why he or she does not have health insurance that pays for the prescribed treatment or why he or she failed to obtain treatment at the free or subsidized healthcare provider.
- Incapacity: The individual is unable to understand the consequences of failing to follow prescribed treatment.
- Medical disagreement: When the individual’s own medical sources disagree about whether the individual should follow a prescribed treatment, the individual has good cause to not follow the prescribed treatment. Similarly, when an individual chooses to follow one kind of treatment prescribed by one medical source to the simultaneous exclusion of an alternate treatment prescribed by another medical source, the individual has good cause not to follow the alternate treatment.
- Intense fear of surgery: The individual’s fear of surgery is so intense that it is a contraindication to having the surgery. We require a written statement from an individual’s own medical source affirming that the individual’s intense fear of surgery is in fact a contraindication to having the surgery.
- Prior history: The individual has a history of major surgery for the same impairment with unsuccessful results and the same or similar additional major surgery is now prescribed.
- High risk of loss of life or limb: The treatment involves a high risk for loss of life or limb. Treatments in this category include:
- Surgeries with a risk of death, such as open-heart surgery or organ transplant.
- Cataract surgery in one eye with a documented, unusually high-risk of serious surgical complications when the individual also has a severe visual impairment of the other eye that cannot be improved through treatment.
- Amputation of an extremity or a major part of an extremity.
- Risk of addiction to opioid medication: The prescribed treatment is for opioid medication.
- Other: If the individual offers another reason for failing to follow prescribed treatment, we will determine whether it is reasonably justified on a case-by- case basis.
The SSA further stipulates that they “will not consider as good cause an individual’s allegation that he or she was unaware that his or her own medical source prescribed the treatment, unless the individual shows incapacity as described above. Similarly, mere assertions or allegations about the effectiveness of the treatment are insufficient to meet the individual’s burden to show good cause for not following the prescribed treatment.”
In laymen terms, this means you can’t use ignorance of the treatment as an excuse. And, claimants cannot overturn a failure to comply ruling by asserting or alleging that a treatment won’t be effective.
Social Security Disability Denials
Failing to comply with medical treatment means the claimants who would sadly otherwise receive benefits are denied those benefits due to lack of participation. This is a poor result but is something you can appeal in future. If you are working with a disability lawyer, they will help you gather and submit relevant medical information supporting your claim. And they will give you solid advice about the importance of complying with medical treatment plans. In the event you are unable to comply for a ‘good cause’ reason listed above, it’s a good idea to let your disability lawyer know so they can prepare you for next steps and outcomes.