In most cases, no, you can’t qualify for disability without medical treatment. Getting necessary medical treatment, and documenting your illness with doctors and providers who understand your condition is critical to winning a disability case, and critical for your own well-being.For a lot of people unable to work, it becomes harder to get treatment. They might have lost their work-based insurance, be unable to afford COBRA, or not have access to affordable care. But, can a diagnosis be enough to prove a disability claim? What do I tell clients when they ask me “Can I qualify for disability without medical treatment?”
Unfortunately, the answer is no. Let’s look at how Social Security reviews the need for treatment.
Social Security’s Rules for Following Treatment:
The Social Security Administration (SSA) has specific rules about the need to follow prescribed treatment. Under SSA’s rules, if you are prescribed treatment and you fail to follow that treatment as prescribed by one of your own providers, you are often unable to obtain benefits… even if you would be found disabled.
Social Security specifically looks at whether the treatment, if followed, would be expected to restore an individual’s ability to engage in competitive work. If so, they will ordinarily deny the claim. (Social Security Ruling 18—3p).There are, at least, good cause exceptions for a failure to follow prescribed treatment. Some of those good cause exceptions:
- Religion: The established teaching of your religion prohibit you from following the recommended treatment;
- Cost: You are unable to afford prescribed treatment, which you are otherwise willing to pursue but affordable or free community resources are unavailable. There must be proof of the unavailability;
- Incapacity: You are incapable of understanding the consequences of failing to follow treatment;
- Medical Disagreement: There is a reasonable disagreement between your medical sources and you are following the advice of one of your providers;
- Intense fear of surgery: This requires a letter from a medical source affirming that the fear is so great that it is a contraindication to having the surgery, it cannot be your own assertion or concern;
- Prior history: You previously had major surgery for the same impairment and it was unsuccessful; There are a few other exceptions, but most of the time, Social Security is skeptical of a failure to follow treatment.
Can I at least prove that I’m limited without treatment?
No. In most cases, you won’t be able to prove that you are limited without treatment, even if you can show you have a good reason for not following prescribed treatment.
In order to be found disabled you need medical evidence to support that 1. You have a “medically determinable” impairment, and 2. That it is severe enough to cause observable functional limitations. This means that simply being diagnosed with, or having complaints of a serious impairment are not enough.
In order for a medical problem to meet this standard, it has to be shown by clinically acceptable tests and examinations and diagnosed by a medical source. In order to document functional limitations, a medical source usually has to offer an opinion providing a description of your medically necessary limitations on a function-by-function basis.
You cannot obtain that documentation if you are not treating with a doctor or appropriate provider.
What can I do to prove my claim if I don’t have enough treatment?
If you don’t have enough treatment to prove your claim for disability benefits, there are some steps you should take before applying.
If you are unable to work, but are not currently treating, my typical recommendation is to first, try to work as long as you can, and second, to establish treatment.
From a common-sense standpoint, while it can be difficult to get treatment for your conditions, especially if you don’t have access to insurance, as a public policy matter: you are claiming that you are too limited from your medical problems to work, and as a result, you are seeking a government benefit to help you survive. The government wants to know that you are doing everything in your power to be as functional as possible before awarding that benefit.I often think of the example of an individual with severe diabetes.
Imagine someone with diabetes who is impaired, but refuses to take insulin, oral meds, or follow their doctors’ diet recommendations. As a result, they cannot work, but, if they followed those instructions and took the medication, they’d improve, and be able to work. On the other hand, many people with diabetes struggle to control their disease even when getting all necessary treatment. In that case, the person doing everything right has a good chance of winning their claim and a good chance of having a doctor willing to go to bat for them, since they’re trying their hardest. The person refusing treatment, is likely to be denied.
In short, you really can’t expect to obtain benefits from a diagnosis or a complaint alone. You need significant treatment with specialists. That’s common sense – if you are sick enough that you can’t work, that is a medical crisis, and treatment is warranted. Sometimes, even with treatment, supportive doctors and piles of documentation you may be denied or turned away. That’s when a skilled attorney can get involved to help sort through your history and shape those records into a narrative that not only shows what, but how your impairments prevent you from working. The first step – getting the treatment you need is the most important.
Related: How Far Back Will SSDI Pay?
Rich Frankel is the managing partner of Bross & Frankel. He is a member of the New Jersey and Pennsylvania bars. He has focused exclusively on disability and social security benefits since 2005.
Mr. Frankel joined what is now Bross & Frankel after having watched his father struggle with disability, fighting a lengthy illness. Mr. Frankel founded the firm’s veteran’s law practice and substantially grew the social security disability practice, focusing Bross & Frankel’s ability to fight for all of the disability benefits available to his clients.
Mr. Frankel additionally fights for clients in court, obtaining frequent victories in Social Security appeals and against insurance companies in Federal court.