If you're applying for disability benefits but not complying with the medical treatment prescribed by your doctor, Social Security may be able to deny your claim for "treatment non-compliance." This is because Social Security can find that you would be able to work if you took the medicine, had the surgery, or otherwise followed the treatment recommended by your doctor. While there are some exceptions to this rule, it is important to follow your physician's prescribed course of treatment to the extent possible so that you can avoid this matter entirely.
Denial of Disability Benefits for Non-Compliance With Treatment
If you fail to follow prescribed treatment, take prescribed medication, or undergo recommended surgery, this may prevent you from getting Social Security or SSI disability benefits, but only when the following four criteria are met.
- Your impairment prevents you from doing any substantial gainful activity (SGA).
- Your impairment has lasted or will last at least 12 months, or can be expected to end in death.
- Your treating doctor has prescribed treatment that would clearly restore your ability to perform full-time work.
- You have refused to follow your treating doctor's prescribed treatment.
There are several important points to remember here. First, the treatment or medication in question must be prescribed by the doctor who treats you, not by a consulting examiner or a physician for Disability Determination Services (DDS). Also, the treatment instructions must consist of something more specific than general lifestyle advice. If your doctor has advised you to lose weight, stop smoking, and exercise more — and whose hasn't? —this advice does not constitute prescribed treatment. (If, however, your doctor advises you to stop using drugs and alcohol, failure to follow this advice certainly could impact your claim. Read Nolo's article on when drug or alcohol use prevent you from getting disability benefits).
Also note that the treatment or medication your doctor has prescribed must be clearly expected to restore your ability to do full-time work. It literally must be able to make the difference between whether or not you can work. For this reason, a minor deviation from your doctor's prescribed treatment is usually not a sufficient basis for Social Security to deny your claim.
Possible Justifications for Failing to Follow Treatment
If Social Security determines that you meet the four criteria above, the agency can deny your disability claim unless you can show that you were justified in failing to follow treatment. Here are several situations in which your failure to follow treatment will not be held against you.
- The prescribed medical treatment violates your religious beliefs. To use this excuse, Social Security will require you to state your religious affiliation and provide evidence that you are a member of that church. In addition, you must show that the medical treatment in question goes against the teachings of your church, which can usually be done by obtaining a statement from a church authority. (Note: Because it is well established that medical treatment violates the beliefs of Christian Scientists, members of that religion do not need to provide evidence on this point.)
- The treatment prescribed by your treating physician conflicts with the advice of another treating source. If you have more than one treating source, sometimes your doctors will disagree on, for example, whether you should undergo a particular surgery. This is generally considered good cause for refusing treatment.
- You cannot afford the prescribed treatment or medication, and there are no free or low-cost clinics reasonably available to you. Disability claimants are often unable to afford medications or treatments prescribed by their doctors. Social Security will not find this excuse compelling unless you show that you've exhausted all your options, including free and subsidized clinics, charitable care, and public assistance programs. If you don't have health insurance, Social Security will want to see that you've applied for Medicaid in an effort to obtain treatment.
- The prescribed treatment involves the amputation of one of your extremities.
- You have a very extreme fear of surgery. This justification is rarely accepted by Social Security, but you may have a chance if your fear is well documented by a mental health professionals.
- The doctor prescribed an unusually risky surgery. To work as an excuse, the level of surgical risk must be above and beyond the ordinary, unavoidable risk of undergoing surgery. Operations such as open-heart surgeries, organ transplants, and experimental procedures are often extremely risky, and refusing to undergo such a surgery will likely not harm your disability case.
- You have a mental illness, and failure to follow treatment is a symptom of the disease. This argument will be much more persuasive coming from your treating mental health provider. Ask him or her to give an opinion to Social Security on this point if non-compliance with medical treatment is an issue in your case.
While these are some of the most common justifications, this is not an exhaustive list. If you haven't been compliant with the treatment recommended by your doctor but can provide evidence that your refusal is justified, Social Security may still approve your claim.
If Social Security denied your claim for failing to follow prescribed treatment, talk to an attorney about your chances of winning on appeal. You can arrange a free consultation with a disability lawyer here.