Can Social Security Deny My Disability Claim Because I Could Not Afford Medical Treatment?

Can Social Security Deny My Disability Claim Because I Could Not Afford Medical Treatment?

One of the most frustrating situations faced by many Social Security Disability claimants occurs when Social Security questions their credibility because they stopped seeing doctors, stopped taking medication, or went months—or even years—without receiving medical treatment.  For many disabled individuals, the explanation is simple:

“I could not afford it.”

This raises an important question:

Can Social Security deny a disability claim simply because a claimant could not afford medical treatment?

The answer is NO.

Federal courts have repeatedly recognized that an inability to afford medical treatment may be a legitimate explanation for treatment gaps, missed appointments, or the failure to follow prescribed treatment.

Medical evidence is generally the most important evidence in a Social Security Disability claim.  The Social Security Administration looks at:

• Medical records;
• Physician opinions;
• Hospitalizations;
• Medications;
• Specialist referrals;
• Mental health treatment;
• Diagnostic testing; and
• Ongoing treatment history.

Unfortunately, many disability claimants find themselves trapped in a vicious cycle:

• They become disabled.
• They can no longer work.
• They lose income and health insurance.
• They cannot afford treatment.
• Social Security questions why they are not receiving treatment.

The very condition that prevents a person from working may also prevent them from obtaining the medical care needed to prove their disability.  What Does Social Security Expect?

Generally speaking, Social Security expects claimants to seek appropriate treatment and follow medical advice when reasonably possible.

When reviewing a disability claim, an Administrative Law Judge may consider:

• Gaps in treatment;
• Failure to take prescribed medication;
• Failure to follow up with specialists;
• Missed appointments;
• Limited medical records; and
• Lack of ongoing treatment.

In some cases, a judge may view those issues as evidence that a claimant’s symptoms are not as severe as alleged; however, that is not the end of the inquiry.

Poverty Is Not the Same as Refusing Treatment

Federal courts have long recognized an important distinction: There is a significant difference between a claimant who refuses treatment and a claimant who cannot afford treatment.

One court famously observed: “To a poor person, a medicine that he cannot afford to buy does not exist.”  That simple statement reflects a reality faced by many disabled individuals.

A claimant who lacks insurance, cannot afford medications, or cannot pay for specialist visits may have little choice but to go without treatment.

Social Security Must Consider the Reason for Treatment Gaps

A treatment gap does not automatically mean a claimant is exaggerating symptoms.  Before drawing a negative inference, Social Security should consider whether there is a legitimate explanation for the lack of treatment.

Examples may include:

• Loss of health insurance;
• Financial hardship;
• Inability to afford medication;
• Lack of transportation;
• Lack of access to specialists;
• Mental illness affecting treatment compliance; or
• The closure of free or low-cost treatment programs.

The important question is not simply “Did treatment occur?”  The important question is: “Why did treatment not occur?”

A Real-World Example

Consider a claimant suffering from severe bipolar disorder.  For years, medication helps control the symptoms, but does not “cure” the condition.  Eventually, the claimant loses their job and company provided health insurance, and without access to insurance coverage they can no longer afford the medication.  Without treatment, symptoms worsen.

Later, Social Security points to the treatment gap and argues that the claimant’s condition must not have been serious because treatment was not sought.  The flaw in that reasoning is obvious.  The claimant did not stop treatment because they were healthy, they stopped treatment because they could not afford it.

Federal courts have repeatedly recognized that distinction.

Mental Illness Often Makes the Problem Worse

This issue frequently arises in mental health cases.

Conditions such as:

• Bipolar disorder;
• Major depression;
• Anxiety disorders;
• PTSD;
• Schizophrenia; and
• Schizoaffective disorder

may themselves interfere with treatment compliance.

A claimant suffering from severe mental illness may have difficulty:

• Keeping appointments;
• Following treatment plans;
• Consistently taking medication; or
• Recognizing the need for treatment.

In these situations, treatment gaps may actually reflect the severity of the illness rather than an absence of symptoms.

What if the claimant gets access to health insurance later?

Many people assume that once a claimant obtains insurance, access to treatment becomes easy; unfortunately, that is often not the case.  Even with insurance, claimants may face:

• Deductibles;
• Copayments;
• Expensive medications;
• Specialist fees;
• Transportation costs; and
• Out-of-network expenses.

The fact that a claimant has insurance does not necessarily mean treatment is affordable.

What Evidence Can Help?

If financial hardship has affected your treatment history, important evidence may include:

• Medical records documenting inability to afford treatment;
• Loss of insurance records;
• Evidence of medication costs;
• Applications for charity care;
• Testimony regarding financial hardship;
• Statements from treating physicians; and
• Testimony from family members familiar with the claimant’s situation.

These facts may help explain treatment gaps that might otherwise be misunderstood.

This Issue Arises More Often Than Many People Realize

Our firm has handled Social Security Disability appeals involving situations where claimants lost access to medical care, could not afford medication, or lacked insurance coverage. In some cases, Social Security relied heavily upon treatment gaps or medication noncompliance while overlooking evidence that the claimant simply lacked the financial resources necessary to obtain care.

Federal courts have recognized that disability claims must be evaluated fairly and that poverty can be a legitimate explanation for gaps in treatment.

A claimant should not be denied benefits simply because they were unable to afford the medical care they desperately needed.

If Social Security has questioned your credibility because of treatment gaps, missed appointments, medication noncompliance, or limited medical records, it is important to understand that financial hardship may be a valid explanation.

A disability claim should be evaluated based upon all of the evidence—not merely on whether a claimant had the financial ability to obtain treatment.

The inability to afford medical care does not prevent a person from being disabled.

If your disability claim (SSDI or SSI) has been denied, or if you have questions about treatment gaps, medication compliance, financial hardship, or an appeal of an unfavorable decision, don’t hesitate to contact the experienced attorneys at Powell and Denny today for a free consultation; and remember, virtual appointments are available through Zoom so you can meet with one of the attorneys of Powell and Denny from wherever you live, and that there is no fee unless you win.

Powell and Denny: We Work When You Can’t.

Offices in Birmingham and Huntsville, Alabama.