Failing to Follow Your Doctor’s Prescribed Therapy When Making an SSDI Claim in Massachusetts and Around the Country

In order to obtain benefits from the Social Security Disability Insurance (SSDI) program, a claimant must establish that they have been diagnosed with a medical condition or injury (or, what is otherwise referenced in the regulations as a severe medically determinable impairments) that prevents them from undertaking any manner of gainful employment for which they are reasonably suited.  The Social Security Administration (SSA), utilizing the assistance of state agency offices referred to as Disability Determination Services, reviews SSDI claims, and generally only approves about 30 percent of claims. A rejected claim is not the end of the road, though, since claimants may request reconsideration of their application or a hearing before an administrative law judge (ALJ).

Understanding the most common reasons for claim denials can help claimants prepare their initial applications. The SSA rejects many SSDI claims based on findings that the claimants are not following the treatment plan prescribed by their doctor or doctors.

Proof of a Medical Diagnosis Is Required for an SSDI Claim

Sections 216(i) and 223(d) of the Social Security Act define “disability,” for the purposes of the SSDI program, as:

1. A “medically determinable physical or mental impairment” that renders a person unable “to engage in any substantial gainful activity,” and that is likely either to last for 12 months or more or to result in the person’s death; or
2. Blindness, defined as visual acuity of 20/200 or less.

Section 1614(a) of the Social Security Act uses the same definition for the Supplemental Security Income (SSI) program.

Failure to Follow Prescribed Treatment

An application for SSDI benefits must include a substantial amount of evidence of a “physical or medical impairment,” which would need to be medically diagnosed by a physician.   Treating sources are considered to include that of osteopathic doctors (with the credentials D.O after their name), medical doctors (with an M.D. after their name) or licensed psychologists and podiatrists.  The treatment records would need to show evidence of the fact that the medically severe condition is likely to remain severe and disabling for a year or longer.

SSA regulations for both SSDI and SSI specifically state that a claimant must demonstrate that they are following the treatment prescribed by their doctor or doctors “if this treatment can restore [the claimant’s] ability to work.” Treatments can include medication, surgery, physical therapy in the case of an injury, and counseling in the case of a mental health-related disability.

A finding by the SSA that a claimant is not following their prescribed treatment will result in the denial of their claim. If a beneficiary, who is already receiving SSDI or SSI benefits, is found to no longer be participating in their prescribed treatment, the SSA can cut off future benefit payments.

Justifications for Failure to Follow Treatment

A claimant may be able to demonstrate a justification for failing to follow their prescribed treatment. SSA regulations state that the agency may consider factors specific to each claimant, such as any “physical, mental, educational, and linguistic limitations.” An inability to attend doctor’s appointments because of a lack of transportation could constitute a justifiable reason in some cases, as might the failure to follow a doctor’s instructions because of a language barrier.

The regulations identify five specific situations that might constitute justification, but they note that this is not an exclusive list:

1. The claimant has religious objections to the specific treatment;
2. Surgery on one eye could result in further impairment of the other eye;
3. The same surgery was already performed without success;
4. The treatment is unusual and overly risky for the individual, using the examples of open-heart surgery or organ transplant; or
5. The treatment requires total or partial amputation of a limb.

Possible Next Steps After Denial for Failure to Follow Prescribed Treatment

After the denial of an initial SSDI application, claimants in most states may request reconsideration of their claim by a different SSA investigator. New Hampshire and several other states have been deemed pilot project states that no longer undertake the reconsideration appeal process: in these states, a claimant proceeds directly to a hearing before an administrative law judge (ALJ), without the need to first proceed with the reconsideration process, and therefore must formally request a hearing before an ALJ.

Either stage of review (whether it be the reconsideration process or the request for hearing process) allows the claimant to submit additional information that has become available since the initial denial. Ideally, this would include evidence of additional zealous treatment that would show the claimant is following the recommendations of their treatment providers.   In some cases, however, a claimant may be wise to initiate a new application for benefits (rather than appeal).  Considerations as to how best to proceed is best determined by an experienced Social Security disability attorney.

You can get the guidance you need on your SSDI claim and where you stand with your existing claim or potential new claim by scheduling a free and confidential consultation with the Law Offices of Russell J. Goldsmith. Contact us today at 1-800-773-8622.

More Blog Posts:

How to Apply for SSDI Benefits in Maine and Beyond, Social Security Disability Lawyer Blog, July 1, 2015

What is SSDI? An Overview for Residents of Massachusetts and Other States, Social Security Disability Lawyer Blog, June 24, 2015

Qualifying for Social Security Disability Insurance, Social Security Disability Lawyer Blog, June 17, 2015

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