If you have a physical impairment that could be improved by surgery but you refuse to have the operation, you may be barred from receiving Social Security Disability benefits (both Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI)), based on that refusal. Although it's every individual’s right to choose what health care procedure they have performed, the government doesn't have to pay you benefits if you don't follow recommended treatment. Of course, there are some exceptions.
When You Can Be Denied for Failure to Follow Treatment
If having surgery could fix your impairment and allow you to return to work, and your doctor has recommended it, your refusal to have the surgery may prevent you from receiving disability benefits.
For the Social Security Administration (SSA) to be able to deny you benefits based on "failure to follow prescribed treatment," the following must be true:
- Your impairment prevents you from doing any work.
- The impairment has lasted or is expected to last at least 12 months.
- Your treating doctor has prescribed surgery to treat your condition.
- The surgery is expected to restore your ability to work.
- There is documentation (in your medical records) that you have been prescribed the surgery and you have refused it.
Who prescribed the surgery? It is important to note that the surgery must be prescribed by your treating physician. This means that Social Security Administration (SSA) cannot have one of their physicians, who have not provided you with treatment, prescribe a surgery that your treating physicians have not. The SSA, however, will have the final decision as to whether or not the prescribed surgery would restore your ability to work.
Will surgery restore your ability to work? Before SSA makes this final decision, the agency must:
- Get a full reason from you as to why you are refusing to have the surgery. This includes making sure you understand why the surgery was prescribed, the predicted outcome of the surgery, and the effects of refusing the surgery, and
- Speak with your treating physician to find out what you were told by your physician and other options you were given by that physician.
Individuals who are following alternative treatment recommendations of their physician, rather than having the surgery, cannot be considered to be failing to follow prescribed treatment.
Before an applicant is denied benefits based on failure to follow prescribed treatment, the SSA will explain to the applicant that he or she must have the surgery in order to qualify for disability benefits.
Exceptions: When a Surgery Refusal Can't Cause a Denial
There are exceptions to the failure to follow prescribed treatment rule. These exceptions include the following.
- Religion. The surgery is against your religion. In order to meet this exception, you will be asked to provide proof that you are affiliated with the church and that your religion's views on surgery is well documented (meaning it is ordinarily known to those who are familiar with the teachings of your religion). Such proof can be provided by an official of your religious organization.
- Cataract surgery. The surgery is for cataracts in one eye, but the other eye has severe loss of vision and cannot be corrected.
- Fear. Your fear of surgery is so intense that having the surgery would cause you more harm than good. To prove this exception, your treating physician must have enough contact with you that he or she is familiar with the magnitude of your fear. If your treating physician does not know you well enough to know whether the surgery would do you more harm than good, the SSA may want an independent examination by a psychiatrist. Simple fear of the risks of surgery or knowledge of another who had a similar surgery with poor outcome is not enough to meet this exception.
- Affordability. You are unable to afford the surgery and there are no places in your local community to have the surgery done for free or low cost. To prove this exception, you must show that you do not have the financial means to afford surgery and you have looked into all possible low-cost or no cost treatment options.
- Conflicting advice. Another treating physician advises against the prescribed surgery.
- Previous unsuccessful surgery. You have already had major surgery for the impairment that was unsuccessful and another major surgery is prescribed for the same impairment.
- High risk. There is a high degree of risk associated with the surgery because of the extreme or unusual nature of the surgery. Examples of such surgeries include organ transplants or open heart surgery.
- Amputation. The surgery is for amputation of an extremity that is at the ankle or above.
The SSA may accept other reasonable excuses on a case-by-case basis. The SSA will make a full evaluation in every case to determine if your reason for not having the surgery is an acceptable exception.
Which Disability Listings Require You to Have Surgery
One way in which you can be approved for disability benefits is by meeting the requirements of a disability listing from the Social Security “Blue Book,” which is a list of impairments that are so severe that you will automatically be approved for benefits if you have all of the requirements found in that listing.
Those who refuse to have surgery won't be able to meet certain listings. Some of those listings include:
- Reconstructive surgery of a major weight-bearing joint
- Heart transplant
- Liver transplant
- Certain cancer listings, such as cancers treated by bone marrow or stem cell transplantation.
However, you may still be eligible for disability benefits even if you cannot meet a listing due to refusing surgery. The other ways in which you can qualify for benefits is by equaling a listing or proving you are unable to do any work.