Disability and the Failure to Follow Prescribed Medical Treatment, or Inability to Access Medical Treatment.

April 1, 2014

How does the Social Security Administration address situations where an individual has a disability, but does not follow prescribed medical treatment, or who does not obtain treatment due to inability to afford care and due to a lack of health insurance?  Social Security Regulation (“SSR”) 82-59 addresses these situations.

SSR 82-59 provides that an individual with a disabling impairment which is amenable to treatment that could be expected to restore the person’s ability to work must follow the prescribed treatment in order to be found to be under a disability, unless there is a justifiable cause for the failure to follow the prescribed treatment.  Thus, in adjudicating claims where there is evidence of a failure to follow prescribed treatment, or of a lack of care due to lack of access, the adjudicator must first make a finding that, without the care, the person would be disabled.  Then, the adjudicator must further find that the recommended treatment, if undertaken, could be reasonably expected to restore the person’s ability to work.  Finally, the adjudicator must determine whether the failure to follow the prescribed treatment was justifiable. If there is no justification for the failure to follow the prescribed treatment, then the adjudicator is to find the individual to not be under a disability.  

If the failure is justified, however, then the person will be found to be under a disability.

SSR 82-59 provides a non-exhaustive list of circumstances which, if properly documented in the evidence, will be found to provide justification for the failure to follow prescribed treatment.  These include:

A valid religious objection to the treatment (e.g., members of the Christian Scientist faith). The individual has such an intense fear of surgery that the operation would be contraindicated. There is disagreement between two licensed practitioners as to whether the treatment should be done. The recommended treatment is a surgical procedure, where the person is disabled due to the failure of a previous surgery of a similar nature. The recommended treatment involves amputation of an extremity (i.e., at or above the level of the ankle or wrist, not simply of a digit or digits). Where a person cannot obtain the recommended treatment due to an inability to afford the care, coupled with a lack of health insurance which would cover such care, the failure to obtain the care may be justified.  However, the person must show that he or she has attempted, without success, to access any community resources which could provide such care at no cost (e.g., community-based health clinics or private free clinics).

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