When filing an SSDI claim in Illinois, the Social Security Administration requires documented medical evidence of your disability. If your claim is approved, you must follow a prescribed treatment plan by a licensed medical professional or risk losing your disability benefits.

The Consequences of Not Following Your Prescribed Treatment Plan

In Illinois, if you become disabled due to an illness or injury, you are entitled to file for disability benefits with the Social Security Administration (SSA), the federal agency that handles disability claims. Social Security disability insurance (SSDI) is available to any worker who has accumulated a certain number of work credits and made payments toward Social Security taxes.

SSDI claims in Illinois are handled by the Bureau of Disability Determination Services (DDS), the state agency that makes the initial determinations about a claimant’s eligibility for benefits. When an SSDI claim is submitted, DDS reviews the application and gathers the applicant’s medical information to validate the claim. To qualify for SSDI benefits, claims must show documented medical evidence of a physical or mental disability. This evidence must be provided by a licensed medical professional who conducts a thorough exam.

During the disability determination process, DDS often schedules a consultative examination (CE) for the applicant. A CE is a medical examination performed by a licensed physician who is hired by the Social Security Administration. To approve the claim, DDS must review the outcome of the CE and evaluate the claimant’s medical condition, prognosis, and treatment plan.

Failure to Follow a Treatment Plan

If DDS approves your SSDI claim for benefits, you are required to follow a treatment plan provided by a licensed physician. Failure to follow a treatment plan can result in disability denial. According to the SSA regulations and guidelines, individuals who apply for disability benefits and have a disabling condition may be denied benefits for the following reasons:

1.      They fail to follow their prescribed treatment plan

2.     The prescribed treatment plan is expected to restore their ability to work

In addition, the SSA will determine the following facts that can impact benefits:

  • If the condition has lasted or is expected to last for at least 12 months or result in death
  • If the condition precludes the individual from performing substantial gainful activity (SGA)
  • If treatment is prescribed that is expected to restore the individual’s future ability to perform substantial gainful activity (SGA)

When reviewing an SSDI claim, the SSA does not deny a claim based solely on the applicant’s failure to follow treatment. The SSA must first determine whether the treatment is expected to restore the applicant’s ability to work. If the treatment is not expected to restore the applicant’s ability to work, failure to follow the prescribed treatment is irrelevant. If the treatment is relevant and expected to restore the individual’s ability to work, the SSA will determine whether the applicant has good cause for the failure to follow the prescribed medical treatment.

Providing Notification

Before the SSA can deny an SSDI claim based on failure to follow a prescribed medical treatment, they are required to notify the claimant and their treating physician. The SSA will ask questions about the claimant’s treatment, diagnosis, prognosis, and the probable course of the medical condition both with and without treatment. They will also ask why the claimant is not following the prescribed treatment and if there is good cause. If a good cause for failure to follow the treatment is documented, the SSA can’t deny the claim. Examples of a good cause may include the claimant’s inability to afford the treatment, fear of pain or surgery, or mental impairments that prevent rational decisions.

If the SSA finds the claimant’s failure to follow treatment relevant, the claimant will be notified and the claim will be delayed for 30 days. During these 30 days, the claimant will be encouraged by the SSA and medical professionals to undergo the prescribed treatment. If treatment does not proceed within 30 days, the SSA will deny the claimant’s SSDI claim.

Acceptable Reasons for Not Following Your Prescribed Treatment

According to SSA statistics, over 50% of disability claims are denied each year. Common mistakes that can destroy your Social Security disability case include the failure to follow prescribed medical treatment from a licensed medical professional. SSA statistics also show that once an applicant’s SSDI claim has been denied in the past, it’s common for the claim to be denied again.

If you file for SSDI benefits and your claim is approved, it’s essential to follow your prescribed medical treatment plan. If you are unable to do this, you should contact the SSA or DDS in Illinois to explain your situation. They will contact your doctor or your Social Security disability attorney to discuss a solution so you don’t lose your disability benefits. If you are approved for SSDI benefits, but unable to follow your prescribed treatment plan, you should contact your DDS office as soon as possible. You must make sure that the SSA is informed about the reason you’re refusing treatment. Good reasons for failing to comply with treatment include:

  • Medical treatments or procedures that are not affordable
  • Side effects of prescribed medications that make you sick
  • Addiction risks to opioids and other drugs
  • Previous surgery that was ineffective but prescribed again
  • Disagreement by your doctors on the proper course of treatment
  • Proposed treatment or surgery with a high risk of amputation or death
  • Prescribed treatment that’s against your religious beliefs

Common Reasons SSDI Benefits Are Denied or Terminated

In Illinois, SSDI claims are commonly denied for the following:

Failure to Meet the Basic Eligibility Requirements

When you apply for Social Security disability benefits, you must meet the basic eligibility requirements. To qualify for SSDI benefits, you must have worked in jobs covered by Social Security and have a medical condition that meets Social Security’s strict definition of disability, as defined in the SSA list of medical conditions. SSDI benefits are only available to workers who meet eligibility requirements, and benefits are not payable for short-term or part-time disabilities.

Inadequate Medical Documentation

Approval for an SSDI claim requires medical evidence that shows an impairment or disability that prevents the applicant from working. The SSA requires medical records from a licensed physician showing a medical diagnosis due to the impairment, medical exams, prescribed treatment plans, prescription medications, and a prognosis for returning to work. A Social Security disability attorney knows how to prove you can’t work so your claim will be approved.

Failure to Follow a Medical Treatment Plan

Medical records and treatment plans for improvement in your condition are essential for SSDI claims and benefits. Failure to follow your doctor’s prescribed treatment plan are common reasons for disability denial. Not participating in a medical treatment plan may indicate the possibility of a fraudulent claim or a lack of interest to improve your condition and return to work.

Lack of Communication With the SSA

During the application and approval process for SSDI benefits, it’s important to stay in contact with the SSA or your local DDS office. If you receive phone calls or mail asking for follow-up information on your SSDI claim, you should respond as soon as possible. Delayed communications will slow down the disability determination process, delay approval of benefits, and possibly cause Social Security payment errors in your benefits.

When to Contact an Attorney

If you are at risk of losing your SSDI benefits due to failure to follow your prescribed treatment plan, an experienced Social Security disability attorney can help. Disability attorneys specialize in cases that involve all types of physical, mental health, and neurological disorders, as well as chronic illnesses that are listed in the SSA Blue Book. They can contact the SSA or the DDS in Illinois on your behalf to resolve issues that can impact your SSDI claim.

If your disability claim is denied, an attorney can file three different types of appeals to get your denied claim overturned and get your disability benefits approved. The appeals process can be lengthy, up to 8 or 9 months, depending on how many appeals you must file and the court’s availability to hear your case. However, working with a disability attorney can increase your chances of approval because your attorney will know what types of information the court requires and how to successfully deal with the Illinois court system.

If you need help with SSDI claims and benefits in Illinois, contact us today. Our experienced Chicago Social Security disability attorneys will work to get your benefits approved.