A common question asked by clients is whether they need ongoing medical treatment to qualify for Social Security Disability Insurance (SSDI) benefits. Here is the answer – the Social Security Administration (SSA) generally considers an applicant “disabled” to approve an SSDI benefits claim when two prerequisites are met:
- The applicant’s medical condition (symptoms, medication side effects, treatment schedule) makes them unable earn a living in their respective line of work; and
- The applicant’s medical condition will prevent them from working for at least one year or will result in death within one year.
Medical Evidence Requirement vs. Ongoing Medical Treatment
SSA typically requires medical evidence to support an SSDI benefits claim. Though, it is important to note that having sufficient medical evidence is different from necessitating ongoing medical treatment. Generally speaking, the SSA requires documentation that proves the following: (i) your medical condition exists, (ii) its severity, and (iii) how it limits your ability to work. This evidence can come from various sources.
Medical evidence can include the following:
- Diagnostic test results
- Imaging studies
- Laboratory reports
- Hospital records
- Physician notes
- Treatment histories
These records can span months or even years, and they don’t all need to be recent. What matters is that they collectively paint a clear picture of your disabling condition and its impact on your functional capacity.
Challenges with Maintaining Ongoing Medical Treatment
In certain instances, it may be difficult for SSDI applicants to maintain regular, ongoing medical treatment due to legitimate reasons that have nothing to do with the severity or veracity of their condition. For example, financial constraints represent a common issue with maintaining ongoing medical treatment. Even with health insurance coverage, it may be difficult for a disabled individual to keep up with copayments, deductibles, and prescription costs. Unpaid medical bills can wind up being a deterrent to maintaining ongoing care.
Geographic barriers can also play a role, particularly in rural areas where specialists may be hundreds of miles away. Transportation challenges, whether due to physical limitations, lack of reliable vehicles, or inadequate public transit, can make maintaining regular medical appointments extremely challenging.
These factors don’t diminish the reality or severity of their conditions, but they can result in gaps in medical documentation.
Additional Forms of Medical Evidence
In light of the above-described challenges with maintaining ongoing medical treatment, SSA may consider other forms of medical evidence submitted by SSDI applicants, such as:
- Emergency room visits
- Urgent care records
- Hospital admissions
These types of records can provide crucial documentation regarding the severity of a particular condition. Mental health crisis interventions, calls to emergency services, or law enforcement encounters related to mental health episodes can also serve as evidence for an SSDI benefits application.
Pharmacy records can also demonstrate ongoing symptoms and treatment attempts, even when doctor visits are infrequent. Prescription patterns often tell a compelling story about symptom management and medication trials. Additionally, records from non-traditional healthcare providers, such as chiropractors, physical therapists, or mental health counselors, can contribute to your overall portfolio of medical evidence.
Consultative Examination Option
When your submitted medical evidence is deemed to be insufficient, Social Security may, but is not required to, arrange for a consultative examination (CE) with a healthcare provider. This evaluation is designed to fill gaps in the medical record and assess your current functional limitations. The examining physician will likely review your medical history, perform a physical or mental status examination, and provide an opinion about your condition’s severity and impact on your ability to work.
Documentation Strategies Without Ongoing Medical Treatment
If you are unable to maintain regular medical care, then you should consider documenting your condition through other means. For example, keep a detailed symptom diary that tracks pain levels, functional limitations, medication side effects, and how your condition affects daily activities. Include specific examples of tasks you can no longer perform or activities you’ve had to abandon.
Consider gathering statements from family members, friends, neighbors, or former employers who have observed your condition’s impact on your daily life and work capacity. These lay witness statements won’t replace medical evidence, but they can provide powerful supporting documentation of your functional limitations.
Maintain records of any medical care you do receive, including emergency room visits, walk-in clinic appointments, or telehealth consultations. Even brief encounters with healthcare providers can yield valuable documentation if they address your disabling condition.
If possible, seek medical care from community health centers, free clinics, or providers who offer sliding-scale fees based on income. Some areas have programs specifically designed to help disability applicants obtain necessary medical evaluations at reduced costs.
Treatment Gaps
When applying for SSDI benefits, it is important to be transparent about gaps in your ongoing medical treatment and explain the reasons behind them. Attempting to hide treatment gaps or provide misleading information about your medical care can harm your credibility and your claim.
Explain specific barriers you’ve faced in accessing medical care, whether financial, geographic, transportation-related, or due to the nature of your condition itself. This context helps claims examiners understand why your medical records may be limited while reinforcing that the lack of treatment doesn’t reflect the absence or mildness of your condition.
While medical evidence is essential for Social Security disability claims, maintaining ongoing treatment is not a mandatory prerequisite for benefits eligibility. The SSA evaluates the totality of available evidence to determine whether your condition prevents you from working, regardless of whether you’re currently receiving treatment. Understanding this distinction is important when deciding whether to pursue SSDI benefits. The key is working with the evidence you have while being transparent about the barriers you’ve faced in accessing medical care.
With proper preparation and, when necessary, professional assistance, it may be possible, even with limited medical treatment histories, to successfully obtain disability benefits. It is significantly more difficult, but your financial inability to afford ongoing medical care should not prevent you from seeking the disability benefits you’ve earned through your work history.
Have Questions? Speak to an Experienced SSDI Benefit Lawyer
Applying for SSDI benefits can be daunting, particularly if you are already dealing with a new or worsening medical condition. Bross Frankel PA is here to help. Our team of SSDI lawyers will stand by your side throughout the process, helping you avoid some of the most common pitfalls and fighting for your right to disability benefits.
We have helped thousands of people get Social Security disability and other types of disability benefits. Our SSDI lawyers possess decades of combined experience advocating for people with disabilities in New Jersey and Pennsylvania. To learn more or to schedule a free claim review with a Cherry Hill disability attorney, give us a call at 856-795-8880 or fill out our online contact form.