II-5-3-1.Good Reason for Failure to Follow Prescribed Treatment

Appeals Council Interpretation

SUBJECT : Good Reason for Failure to Follow Prescribed Treatment
     
ISSUE : Can the existence of a psychiatric impairment provide good reason for a claimant's failure to follow prescribed treatment?
     
DISCUSSION : Note: The terms “justifiable cause” as used in SSR 82-59 and “good reason” as used in 20 CFR 404.1530(b) and 416.930(b) should be considered synonymous.
     
    Social Security Administration Regulations at 20 CFR 404.1530 and 416.930 and Social Security Ruling 82-59 provide that a claimant will be found not disabled if he fails, without good reason, to follow prescribed treatment which can restore the ability to work. While these sources give examples of good reasons for not following prescribed treatment, none of the examples mentions or addresses psychiatric causes. However, neither the regulations nor the ruling specifically gives an all-inclusive list of good reasons. Moreover, SSR 82-59 states that a full evaluation must be made in each case to determine whether the individual's reason(s) for failure to follow prescribed treatment is justifiable. The ruling also provides that if the issue of “failure” arises at the hearing or Appeals Council levels, and such issue has not been fully developed through testimony and/or evidence submitted, a favorable decision will be issued provided 12 months have expired since onset. The case will then be referred for development of failure to follow prescribed treatment.
     
    The existence of a psychiatric impairment may provide good reason for a claimant's failure to follow prescribed treatment. An example of such would be a paranoid schizophrenic with a highly organized delusional system which leads him to believe that people are attempting to poison him, and that medication prescribed by a physician is part of the poisoning “plot.”
     
INTERPRETATION : If a claimant has a psychiatric impairment and his refusal to follow prescribed treatment is based on that impairment or that impairment and a combination of other impairments, the Appeals Council may find that such impairment is a good reason for not following prescribed treatment.
     
APPLICATION : The Appeals Council will apply this interpretation in all cases that come before it involving the same issue.
     
EFFECTIVE DATE : May 20, 1982
     
CROSS-REFERENCE : 20 CFR 404.1530 and 416.930. HALLEX I-2-5-34 A.