Applying for Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI) can be challenging, especially if you’ve been advised to undergo surgery but have chosen not to. The Social Security Administration (SSA) often considers whether medical treatment, including surgery, could improve your condition enough for you to return to work. If you refuse a recommended procedure, the SSA may argue that you are not doing everything possible to treat your disability, which could impact your claim. However, there are a few exceptions to this rule. Understanding how the SSA evaluates these situations can help you build a stronger case for benefits.
Why Refusing Surgery Can Impact Disability Benefits
Generally speaking, refusal to have a recommended surgery can result in you being barred from disability benefits. While you have the freedom to choose not to have surgery, the federal government reasons it does not have to award you benefits if:
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1. You have a qualifying disability under the rules of the SSDI and/or SSI programs
2. The surgery could fix your disability and allow you to work again
3. Your doctor orders it
4. Your medical records document that you were prescribed the surgery, and you refused to have it
If your situation meets the above criteria, and you do not fall into an exceptional category, the SSA could deny you benefits on the grounds that you failed to follow prescribed treatment. Keep in mind that your treating physician must order surgery. So, even though the doctors who work for the SSA will decide whether the prescribed surgery could allow you to work again, an SSA doctor cannot order you to have the surgery.
How the SSA Evaluates Prescribed Surgeries
A surgery will not be considered necessary if having it will not restore your ability to work full-time. Depending on which stage your application is in, the medical consultant at Disability Determination Services (DDS) or an Administrative Law Judge (ALJ) needs some information to determine whether the surgery would render you capable of returning to work. This includes:
- The complete reason why you refused surgery
- Why the surgery was ordered
- What the likely outcome of the surgery would be
- What the effects of not having the surgery are
The individual overseeing your case should contact your treating physician to see whether there are alternative treatments available. If there are, and you choose to follow an alternative treatment plan, the SSA cannot deny you benefits for failing to follow a prescribed treatment.
Exceptions for Failing to Follow Prescribed Treatment
As mentioned, some exceptions to the general rule exist. The following list of exceptions is not exhaustive, and the SSA will review all scenarios on a case-by-case basis before ruling on the reasonableness if you refuse to have surgery.
- Religion: If you can prove you are a practicing member of a religion that has tenets prohibiting you from undergoing surgery, you may be exempt.
- Cost: If you cannot afford your surgery, either with or without insurance, you may be able to receive an exemption so long as there is no free or subsidized healthcare provider you could reasonably use for the surgery.
- Incapacity: If you are unable to fully understand the consequences of failing to adhere to your doctor’s prescribed treatment you will likely receive an exemption.
- Medical disagreement: If you have worked with multiple doctors who disagree on what the right course of action is, including surgery, you have good reason to refuse it.
- Intense fear of surgery: If you have a fear of surgery so intense that it causes you further health complications, the SSA may grant you benefits without having surgery.
- Prior history: If you previously underwent a major surgery for the same condition with unsuccessful results, it would be unreasonable to assume that a similar surgery would bear better results now.
- High risk of losing a limb or life: If a surgery has a strong potential to result in the loss of limb or life, you should be granted an exemption.
Contact an SSDI Attorney
If you’re applying for SSDI and have refused surgery, it’s important to understand how the SSA evaluates your case and whether your decision could affect your eligibility for benefits. While there are valid reasons for refusing a procedure, you’ll need to provide strong medical evidence and legal arguments to support your claim.
Navigating the SSDI process can be complex, but you don’t have to do it alone. The experienced team at Jeffrey Freedman Attorneys can help you build a compelling case, advocate for your rights, and improve your chances of securing the benefits you deserve. Contact our office to get the guidance and support you need.