Does Social Security Require Ongoing Treatment to Approve Your Disability Claim?
The answer to this question is both simple and complicated. The simple answer is “no.” There is no requirement in the Social Security Administration’s (SSA’s) eligibility criteria that says you must be undergoing ongoing treatment to qualify for disability (SSD) benefits.
The SSA considers you disabled if you are unable to engage in substantial gainful activity (SGA) due to a medical condition or combination of conditions, and that condition has lasted or is expected to last for at least 12 months or end in death. There are additional technical requirements, but they relate to issues like work history and legal status in the U.S., not your medical condition.
The more complicated answer is that not having a record of ongoing medical care can make it much more difficult to get your SSD application approved.
Why Ongoing Medical Treatment Matters
Some disabling medical conditions are readily verified and measured by objective testing. However, many conditions are less amenable to clear diagnostic testing. In those situations, records from your treating physician typically play a critical role in establishing the diagnosis and the severity of your condition. Some types of evidence that may be important in the disability determination process include:
- Diagnostic testing
- Evaluative testing over time to show improvement or decline in your condition
- Your doctors’ progress notes
- Hospitalization records
While there’s usually no specific requirement that medical records span a certain time period or test results are fresh, you will need medical records sufficient to establish your day-to-day medical condition. That typically includes medical records over time. Depending on the condition, it may also require recent testing. If you don’t have recent tests to submit, the SSA may schedule them for you before proceeding with your application. Similarly, they may schedule you for a consultative examination with a physician they pay. But, they may also make a determination on the evidence provided and deny your claim.
In some cases, the SSA may even deny your claim because they believe you might be able to work if you were undergoing appropriate treatment.
Difficulty Proving Your Claim without Consistent Medical Records
While the SSA can and often will schedule testing or evaluation for you, the burden of proving that you meet the Social Security’s definition of disabled is on you. That means you will want to make every effort to provide as much relevant medical information as possible.
Even if you haven’t been seeing the same doctor regularly or following a specific, ongoing treatment plan, you will likely have some records available.
These may include:
- Your original diagnosis and related older medical records
- Records of treatment in emergency rooms or urgent care facilities
- Records from inpatient hospital stays
The first step is typically to assess the existing available records. If you have gaps in your medical history, an experienced disability benefits advocate can tell you what types of documentation typically carry the most weight. Your advocate may even suggest that you resume treatment or undergo additional testing before filing your SSD application.
You may also be able to create records of your own over time, though this is something you would typically want to have started before you were at the point of applying for SSD.
Some examples of useful logs might include:
- A record of asthma attacks and their duration and severity
- A record of seizures or fainting due to a medical condition
- A record of panic attacks and their duration and severity
- A log of blood pressure and heart rate, if you have cardiac issues
- A journal tracking how your condition impairs your activities on a day-to-day basis
You will also complete a questionnaire where you will be asked to answer questions about how your disability impacts your ability to attend to normal activities such as grooming, cleaning and grocery shopping. You can also ask someone close to you who observes your daily challenges to complete a similar questionnaire.
Note, though, that there is no real substitute for good medical records. If you are just beginning the process of investigating SSD benefits and have not been receiving medical care for your condition, consider scheduling an appointment with your doctor or establishing a relationship with a new physician.
Failure to Follow Prescribed Treatment
Your SSD claim may be denied if the SSA finds that:
- You would otherwise be entitled to SSD benefits, but
- Your treating physician has prescribed a course of treatment for the condition your application is based on, and
- You have failed to follow that prescribed treatment plan
That doesn’t automatically mean your application will be denied, though. The SSA will also assess the likelihood that the treatment would allow you to return to substantial gainful activity if followed. And, they will consider whether you had good cause for failing to follow the treatment plan.
There is no standard order for these two assessments. If either is determined in the applicant’s favor, it terminates the process and the application will not be denied based on failure to follow prescribed treatment.
What is Considered Good Cause for Not Pursuing Treatment?
It is generally up to the applicant to prove that they had good cause for not following the recommended treatment plan. However, the SSA recognizes several different types of good cause, including:
- Conflicting advice from other medical professionals
- Inability to afford the prescribed treatment
- Lack of mental capacity to understand the importance of and/or follow the prescribed treatment
- Prior history of similar surgery that was unsuccessful
- Concern about addiction to opioids
- Religious convictions
- High risk of death or amputation associated with recommended surgery
This list is not comprehensive. The SSA may also consider any other good cause asserted.
The Bottom Line on Medical Treatment and SSD
It’s possible to secure SSD benefits even if you haven’t sought medical care and don’t have consistent medical records. But, the process is more challenging and it’s all the more important that you understand exactly what the SSA is looking for and how you can best provide that information.
To learn more about how an experienced SSD benefits advocate at Disability Help Group can help, call 800-800-3332 or fill out our contact form HERE for a FREE case evaluation.
FAQ: Social Security Disability and Medical Treatment
- Do you need ongoing medical treatment to qualify for Social Security disability? No, there’s no rule in SSA’s eligibility criteria requiring ongoing treatment. You qualify based on whether your condition prevents substantial gainful activity and has lasted or is expected to last at least 12 months. But without consistent medical records, your claim is harder to prove.
- Can your SSD claim be denied for not following a treatment plan? Yes. If the SSA determines you would otherwise qualify, your doctor prescribed a treatment plan, and you didn’t follow it, your claim can be denied on those grounds unless you had good cause or the SSA determines the treatment wouldn’t have returned you to work.
- What counts as good cause for not following prescribed treatment? The SSA recognizes several: inability to afford treatment, conflicting advice from another doctor, religious convictions, prior failed surgery of the same type, concern about opioid addiction, and high risk of death or amputation from recommended surgery. The list isn’t exhaustive other reasons can qualify.
- What medical records can you use if you haven’t seen a doctor regularly? Older diagnosis records, emergency room or urgent care visits, and inpatient hospital records all count. Personal logs, tracking seizures, panic attacks, blood pressure, or how your condition affects daily activity, can support your claim, though they don’t replace medical records.
- What should you do before filing for SSD if you have gaps in your medical history? See a doctor before filing if you haven’t been receiving care. An advocate can assess what records you have, identify what’s missing, and may recommend resuming treatment or completing additional testing before you submit your application.
