How Failing To Seek or Continue With Treatment Could Hurt Your Disability Case

Disability benefits are available for workers with impairments that preclude substantial gainful activity (SGA) for at least twelve months.  To qualify, an applicant for benefits must prove that they have a severe impairment that impairs their ability to work.  During the evaluation process, Social Security Administration (SSA) will review medical records, treatment notes and any other evidence that may assist with making a determination in regards to the ability or inability to work.  For obvious reasons, a claimant’s lack of treatment may cast doubt on the severity of injuries or limitations affecting work capacity.  Similarly, failing to follow prescribed treatment could negatively affect a claimant’s disability decision.

According to SSA, a failure to follow prescribed treatment determination may be made only where all of the following conditions are met:

  1. The evidence establishes that the individual’s impairment precludes substantial gainful activity (SGA) (or, age-appropriate activities for SSI children).
  2. The impairment has lasted or is expected to last for 12 continuous months from onset of disability or is expected to result in death;
  3. Prescribed treatment is clearly expected to restore capacity to engage in SGA (or gainful activity, as appropriate).
  4. The evidence of record discloses that there has been refusal to follow prescribed treatment.

There are certain circumstances where failing to follow prescribed treatment may be excused.  Acceptable justifications for failing to follow prescribed treatment include, but are not limited to the following:

  1. The specific medical treatment is contrary to the established teaching and tenets of the individual’s religion.
  2. The individual is unable to afford prescribed treatment, which he or she is willing to accept, but for which free community resources are unavailable.
  3. An individual’s fear of surgery is so intense that it is a contraindication for surgery.
  4. The prescribed treatment is cataract surgery for one eye, when there is severe visual impairment of the other eye that cannot be improved through treatment.
  5. Major surgery was previously performed with unsuccessful results and additional major surgery is prescribed for the same impairment.
  6. The treatment because of its magnitude (e.g., open heart surgery), unusual nature (e.g., organ transplant), or for some other reason is very risky.
  7. The treatment involves amputation of an extremity, or a major part of an extremity.
  8. An individual with a severe mental impairment is clearly unable to understand the consequences of failing to follow prescribed treatment.
  9. A treating source advises against the treatment prescribed for the currently disabling condition.