How Failure to Follow Prescribed Treatment Affects Your Social Security Case
Even if you meet all Social Security requirements to receive disability, the policy of the Social Security Administration (SSA) is to deny benefits if you fail, without good cause, to ‘follow prescribed treatment’ that the Social Security Administration/Judge expect would restore your ability to go back to work.
This policy applies at all disability claim levels including:
- At the Hearing level
- When SSA reopens a prior determination or decision involving a claim for benefits based on disability or blindness
- When SSA conducts an age-18 redetermination
- When SSA conducts a continuing disability review (reviews a prior decision to determine whether you are still unable to work).
The Administration will examine your own doctor’s prescribedtreatment for the condition(s) upon which the disability finding is based and decide (1) whether you failed to follow the recommended treatment, and (2) whether the prescribed treatment if followed, would be expected to restore your ability to return to gainful employment. Social Security will consider only your treating doctor’s opinions and will not consider opinions from their own consultants.
In adult claims, you will have to show that you have “good cause” for failing to follow prescribed treatment. In child claims, the parent or guardian has the burden to provide evidence showing that the child has good cause for failing to follow prescribed treatment.
These are some examples of acceptable good cause reasons for not following prescribed treatment:
- Religion: The established teaching and tenets of your religion prohibit him or her from following the prescribed treatment.
- Cost: You are unable to afford prescribed treatment, which you are willing to follow, but for which affordable or free community resources are unavailable.
- Incapacity: You are 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.
- Intense fear of surgery: Your fear of surgery is so intense that it is a contraindication to having the surgery. This is a difficult burden. SSA requires a written statement from your own doctor confirming that your fear of surgery is in fact a contraindication to having the surgery.
- Prior history: You previously had 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:
- Risk of addiction to opioid medication: The prescribed treatment is for opioid medication.
- Other: If you offer another reason for failing to follow prescribed treatment, we will determine whether it is reasonably justified on a case-by-case basis.
If your doctor recommends a treatment that you find unacceptable immediately discuss it with him/her in an effort to get the physician to consider other options; or it may be time to get an alternate treating doctor who has a different opinion!