SSDI

Medical evidence is a cornerstone in proving a Social Security disability claim. However, some individuals are sometimes not able to receive the necessary treatment due to various factors including lack of medical insurance or other economic barriers. Social Security Ruling 82-59 addresses the issue of failure to follow prescribed treatment. The ruling states in pertinent part: An individual who would otherwise be found to be under a disability, but who fails without justifiable cause to follow treatment prescribed by a treating source which the Social Security Administration (SSA) determines can be expected to restore the individual’s ability to work, cannot be [sic] virtue of such “failure” be found to be under a disability. (SSR 82-59). In order to establish that an individual has failed to follow prescribed treatment, it must be shown that treatment which is clearly expected to restore capacity to engage in substantial gainful activity has been prescribed by a treating source, and the evidence of record discloses that there has been refusal to follow prescribed treatment. The Social Security Administration must determine whether the prescribed treatment can be expected to restore the claimant’s ability to work. If it is not found that the prescribed treatment is expected to restore the claimant’s ability to work, then the SSA may not use the “failure” to follow prescribed treatment as the basis for denying a claim. Further, where the SSA makes the determination of “failure,” a determination must also be made as to whether or not failure to follow the prescribed treatment is justifiable. If a claimant is able to prove their inability to follow through with prescribed treatment is justifiable, then again, the SSA may not use the “failure” to follow prescribed treatment as the basis for denying a claim.

CASE NOTE Client, a disabled veteran, filed for Social Security disability benefits in 1978 and his claim was denied. He filed a second claim in 1980 and was again denied. Client contacted us 20 years later seeking assistance in filing a new claim. Because he had not worked in over 25 years, his eligibility for disability benefits extended only through 1980; to get him benefits we would have to prove his disability began before his eligibility or coverage expired. In the course of litigating his claim, we asked that his prior claims also be reopened so as to permit disability payments back to 1978. When the administrative judge denied this claim (as the VA was unable to locate the veteran’s medical records going back to 1980) we filed an appeal and were able to track down the missing VA medical records that were misfiled in another state. Upon remand, the judge approved the claim for disability but refused to reopen the prior claims. We filed another appeal and took this case to US District Court, arguing that the claimant’s mental disabilities affected his ability to understand and act upon his previous denial, and that denying the client’s request to reopen his prior case violated his constitutional right to due process. The court agreed with our argument and sent this case back to the Social Security Administration with instruction that they extend the time limit to file an appeal on the original 1978 claim as the claimant’s mental health prevented him from understanding his legal right to appeal and prevented him from being able to sufficiently make any necessary appeal. By successfully challenging SSA’s denial of this claim and their refusal to reopen the prior claims, we were able to obtain over 25 years of back-pay for our client.