Issued: November 15, 2000 (Revised)
Expires: No expiration date
I. Purpose
This Temporary Instruction (TI) sets forth procedures for implementing the
parties' joint Stipulation and Order of Settlement, approved by the United
States District Court for the Western District of North Carolina on March
21, 1994, in the Hyatt v. Shalala class action involving the standard for
evaluating complaints of pain in disability claims.
Adjudicators throughout the country must be familiar with this TI because
Hyatt class members who now reside outside North
Carolina must have their cases processed in accordance with the
requirements of the Stipulation and Order of Settlement.
II. Background
On December 19, 1985, the Office of Hearings and Appeals (OHA) issued
Interim Circular (I.C.) No. 163 (Revised), subsequently incorporated into
HALLEX as TI 5-4-4, to implement the
Fourth Circuit's order of March 20, 1985, and the district court's
implementation order of June 25, 1985. The class of individuals granted
relief by those orders later became known as the
Hyatt I class.
On August 9, 1988, OHA issued Supplement A to I.C. 163, also incorporated
into HALLEX as TI 5-4-4, to implement the
Fourth Circuit's order of December 5, 1986, and the district court's
implementation orders of December 10, 1987, and February 5, 1988. The
class of individuals granted relief by those orders became known as the
Hyatt II class.
On July 28, 1988, before OHA issued its Hyatt II
instructions, the Secretary had filed a report with the district court
regarding SSA's implementation instructions for
Hyatt II. On August 9 and August 31, 1988,
plaintiffs filed motions with the district court challenging the
Secretary's pain standard as enunciated in
Social Security Ruling (SSR)
88-13, and in the Program Operations Manual System (POMS). On
October 7, 1988, the district court issued an order directing SSA to cease
denying cases based on a lack of objective evidence concerning the degree
and intensity of pain. On March 31, 1989, the district court ordered the
Secretary to: 1) rescind SSR
88-13 and the POMS instructions for evaluating pain; 2) use a
ruling issued by the court for evaluating North Carolina disability claims
involving pain; and 3) extend the class closing date to include denials
issued before implementation of the court-ordered ruling.
On March 30, 1990, following the Secretary's appeal of the district
court's order, the Fourth Circuit upheld the district court's order
rescinding the affected POMS sections in the Fourth Circuit. The court
indicated that the district court's objections to
SSR 88-13 were valid
but held that it was unnecessary to set the ruling aside if SSA undertook
certain actions. The court held that
SSR 88-13 could remain
in effect if SSA amended the ruling to make it clear that it is not a
reiteration of previous policy and that it has a more current effective
date. The Fourth Circuit extended the class closing date until the date
when the Secretary would implement its order.
On August 6, 1990, SSA published
SSR 90-1p, which
superseded SSR 88-13 in
the Fourth Circuit. On February 1, 1991, the district court held that
SSR 90-1p did not comply
with the mandate of the Fourth Circuit and ordered the Secretary to amend
the ruling to comply with the Fourth Circuit's decision. On May 1, 1991,
the district court adopted a new implementation order proposed by
plaintiffs. The Secretary appealed the district court's orders to the
Fourth Circuit.
On November 14, 1991, SSA published expanded regulations, effective
nationwide, concerning the evaluation of subjective complaints, including
pain. While the Secretary's appeals were pending before the Fourth
Circuit, the parties reached agreement regarding settlement, and on March
21, 1994, the district court approved the parties' joint Stipulation and
Order of Settlement. The class of individuals granted relief by the
settlement is referred to as the Hyatt III
class.
On October 31, 1995, SSA published
SSR 95-5p, which
superseded both SSR
88-13 and SSR
90-1p, and clarified that the Agency's policies considering
allegations of pain in assessing residual functional capacity and of
requiring explanations of the conclusions reached about pain, apply to the
evaluation of all symptoms, not just pain.
SSR 95-5p also clarified
that SSA's policies apply to the preparation of the individualized
functional assessment in the evaluation of disability for individuals
under age 18 claiming benefits under title XVI of the Social Security Act
(the Act) as well as to the assessment of RFC for other persons claiming
benefits based on disability under title II or title XVI of the Act; and
that an explanation of the functional impact of symptoms, such as pain,
when applicable, is required.
On June 28, 1996, plaintiffs filed their first motion to enforce the March
21, 1994 settlement order. They argued that SSA was incorrectly denying
class membership to various claimants pursuant to subparagraph 1(b)(i) of
the settlement order. SSA interpreted this subparagraph to permit the
denial of class membership if the entire period covered by the
Hyatt III claim was already readjudicated by SSA on
or after November 14, 1991.
On July 2, 1996, SSA published
SSR 96-7p, which
superseded SSR 95-5p and
clarified when the evaluation of symptoms, including pain, under
20 CFR 404.1529
and 416.929
requires a finding about the credibility of an individual's statements
about pain or other symptom(s) and its functional effects; explained the
factors to be considered in assessing the credibility of the individual's
statements about symptoms and stated the importance of explaining the
reasons for the finding about the credibility of the individual's
statements in the disability determination or decision.
On August 1, 1996, any organization that received funding from the Legal
Services Corporation may not participate in any class action against the
Federal government. See P.L. 104-134, sections 504(a)(7), 503(b)(2)(B),
110 Stat. 1321 (1996). As a result, Legal Services of Southern Piedmont
withdrew as representative of the Hyatt class and Carlene McNulty, Esq. of
the North Carolina Justice and Community Development Center entered her
appearance as counsel on behalf of the plaintiff class.
On October 31, 1996, plaintiffs filed their second motion to enforce the
parties' March 21, 1994 settlement order. In this motion, plaintiffs
alleged that SSA was improperly denying Hyatt III
class membership relief to anyone who withdrew or failed to pursue a
request for Hyatt II relief.
On November 4, 1996, SSA and the attorneys representing the plaintiff
class entered into an agreement supplementing the
Hyatt Settlement Order of March 21, 1994 as it
pertains to reassessment cases. The agreement is enforceable by the court
and indicates that a new reassessment determination will be made for
certain subclass denials.
On September 13, 1999, the district court held a hearing on plaintiffs'
1996 motions to enforce the March 21, 1994 settlement order. The court
issued an order from the bench in which it agreed with plaintiffs and
ordered them to draft a proposed order containing the relief which they
requested and to send it to SSA for review. Any disagreements between the
parties in the proposed order would be resolved by the court.
On October 21, 1999, the district court issued its order containing the
relief which plaintiffs requested. The order states that SSA may not deny
class membership when:
(1) a subsequent claim was adjudicated by an Administrative Law Judge
(ALJ) or Appeals Council Judge (AAJ) on or after August 6, 1990 or by the
Disability Determination Services (DDS) on or before November 14, 1991,
unless:
•
it is clear that the DDS/ALJ/AAJ reopened and readjudicated the entire
period covered by the Hyatt III claim
and
•
the notice of determination/decision identified the claim that had been
reopened and readjudicated, or
(2) the claimant was a Hyatt (HY) responder and
before receiving a final determination/decision under HY, withdrew or
failed to pursue HY relief.
(3) A subsequent claim also adjudicated a Hyatt III
claim based upon an amended onset date of disability, unless the
Hyatt III claim was reopened and was in the process
of being adjudicated at the time the claimant amended his/her onset
date.
III. Guiding Principles
The settlement order expressly provides that all readjudications and
reassessments of Hyatt claims must be in accordance
with §§ 201
through 233 and
1601 through
1635 of the Social
Security Act, as amended, the rules, regulations, policies and procedures
pertaining thereto, the national regulations for the evaluation of pain
(20 CFR §§
404.1529 and
416.929) and the
settlement order.
Paragraph 10.e. of the settlement order further provides:
In readjudicating and reassessing Class Claims pursuant to this Settlement
Order, all adjudicators in and for the State of North Carolina shall apply
the national regulations for the evaluation of pain
[20 CFR §§
404.1529 and
416.929] in a
manner consistent with the following standard:
ONCE AN UNDERLYING PHYSICAL OR MENTAL IMPAIRMENT THAT COULD REASONABLY BE
EXPECTED TO CAUSE PAIN IS SHOWN BY MEDICALLY ACCEPTABLE OBJECTIVE
EVIDENCE, SUCH AS CLINICAL OR LABORATORY DIAGNOSTIC TECHNIQUES, THE
ADJUDICATOR MUST EVALUATE THE DISABLING EFFECTS OF A DISABILITY CLAIMANT'S
PAIN, EVEN THOUGH ITS INTENSITY OR SEVERITY IS SHOWN ONLY BY SUBJECTIVE
EVIDENCE. IF AN UNDERLYING IMPAIRMENT CAPABLE OF CAUSING PAIN IS SHOWN,
SUBJECTIVE EVIDENCE OF THE PAIN, ITS INTENSITY OR DEGREE CAN, BY ITSELF,
SUPPORT A FINDING OF DISABILITY. OBJECTIVE MEDICAL EVIDENCE OF PAIN, ITS
INTENSITY OR DEGREE (I.E., MANIFESTATIONS OF THE FUNCTIONAL EFFECTS OF
PAIN SUCH AS DETERIORATINGNERVE OR MUSCLE TISSUE, MUSCLE SPASM, OR SENSORY
OR MOTOR DISRUPTION), IF AVAILABLE, SHOULD BE OBTAINED AND CONSIDERED.
BECAUSE PAIN IS NOT READILY SUSCEPTIBLE OF OBJECTIVE PROOF, HOWEVER, THE
ABSENCE OF OBJECTIVE MEDICAL EVIDENCE OF THE INTENSITY, SEVERITY, DEGREE
OR FUNCTIONAL EFFECT OF PAIN IS NOT DETERMINATIVE.
In readjudicating or reassessing Hyatt III class
member claims that involve hypertension or diabetes, adjudicators must
evaluate the condition in a manner consistent with the holding in
Martin v. Secretary of HEW, 492 F.2d 905 (4th Cir.
1974). Adjudicators must fully consider the disabling effects of
hypertension or diabetes without requiring the presence of end-organ
damage for a finding of disability.
Administrative Law Judge (ALJ) and Appeals Council decisions must
expressly state the standard used in readjudicating or reassessing
Hyatt III class claims.
B. Treatment of Pending Hyatt II Claims
Individuals with pending Hyatt II class claims need
not respond to a Hyatt III notice to be considered
under the March 21, 1994 settlement order. Adjudicators will treat these
individuals as primary subclass members and must give them priority.
C. Right to File New Claim or Request Reopening
Class members retain their usual rights to file a new application or
request for reopening.
IV. Definition of Hyatt Class
A. Class Definition - General
All individuals who responded to a Hyatt III
notice, including those previously denied class membership under the March
21, 1994 court order, are class members as a result of the October 21,
1999 court order unless he or she can be excluded pursuant to
Part IV.C. The type of review that a
member is entitled to receive depends on whether he or she is a Primary
Subclass or Settlement Subclass Member.
The Primary Subclass consists of all individuals:
•
whose claims which included allegations of pain were finally denied or
terminated on or after July 7, 1981, and before August 6, 1990;
•
provided, however, that an ALJ decision issued before August 6, 1990,
shall be considered final for the subclass membership purposes if the
Appeals Council denied a request for review of the ALJ decision on or
after August 6, 1990.
Members of the Primary Subclass will have their claims reopened. Primary
Subclass members receive full appeal rights. Also, a claimant is a Primary
Subclass member even if his/her Hyatt III claim was
reopened or readjudicated in a decision on a subsequent application after
August 6, 1990.
The settlement subclass consists of individuals whose class claims were
finally denied or whose benefits were terminated at the initial or
reconsideration level by the North Carolina Disability Determination
Service (DDS) on or after August 6, 1990, and before November 14,
1991.
3. Settlement Subclass Denials Subject To A New Reassessment
Settlement subclass denials subject to a new reassessment are those of
individuals whose claims were denied on reassessment by the North Carolina
DDS under Hyatt III prior to May 21, 1996.
Not all members of the Settlement Subclass are entitled to a review. Only
Settlement Subclass members whose claims were finally denied or terminated
at the initial or reconsideration level of review are entitled to a review
of their class claims. The type of review is a disability determination.
Settlement Subclass members have limited appeal rights.
C. Exclusions from Class Definition
As the result of the October 1999 court order, SSA has decided to no
longer screen claims for Hyatt III class
membership. Consequently, class membership screening has been eliminated.
Thus, all future claims will receive a Hyatt III merits
determination/decision, unless in the processing of a claim, it is found
that Hyatt III relief is clearly inappropriate.
That is,
•
No application for disability benefits under title II and/or title XVI was
filed;
•
No final medical determination was issued by a NC adjudicator (DDS, ALJ,
AAJ) between July 7, 1981 and November 13, 1991. (A non-medical
determination/decision is one based on fraud, insufficient quarters of
coverage, excess income or resources, substantial gainful activity (SGA)
or any other reason not related to proof of disability, unless the claim
was a concurrent claim filed in connection with a class claim. Also, in
the preceding sentence, the term “final” does not include
Hyatt III claims reopened or redjudicated prior to
September 30, 1999. Such claims are entitled to
Hyatt III relief.)
In addition, a claimant is not eligible for class membership review based
on the March 21, 1994 order if:
•
The individual received a class membership notice pursuant to either the
prior Hyatt order dated June 25, 1985, or December
10, 1987,but failed to timely respond to that class membership notice.
(Individuals who failed to file a response to these notices may have their
Hyatt III claims reviewed if they establish good
cause for not responding sooner. Failure to receive a notice may
constitute good cause.)
A claim will not be excluded as a class claim for failure to respond to a
notice pursuant to the order dated June 25, 1985, if an individual
establishes that he/she responded to a notice issued pursuant to the Hyatt
order dated March 27, 1984. Good cause notices to the
“postcard” responders were processed through Central
Office.
An AAJ denial of a request for review, while not the “final”
decision of the Commissioner must be reopened as a decision if it would
permit class membership, e.g., if the ALJ's decision was before 7/7/81 and
the AAJ denied review during the Hyatt III period, the claimant is
entitled to Hyatt III relief. An AAJ denial of
request for review must not be considered a decision if it would preclude
class membership, e.g., if the ALJ's decision was before 8/6/90 and the
AAJ denied review on or after that date, the claimant is also entitled to
Hyatt III relief.
Also, a non-medical determination/decision is one based upon fraud,
insufficient quarters of coverage, excess income of resources, substantial
gainful activity (SGA) or any other reason not related to proof of
disability, unless the claim was a concurrent claim filed in connection
with a class claim.
Failure to timely appeal a DDS determination or an ALJ or Appeals Council
decision is not a basis for denying class relief. In addition, a claimant
will not be denied relief on the basis of having received an unfavorable
court decision on his or her claim unless the court expressly ruled on the
issue of the standard applicable to subjective complaints of pain.
V. Determination of Class Membership and Preadjudication
Actions
A. Notification of Potential Class Members
SSA sent notices on or about November 17, 1994, to all potential class
members identified by computer run. Notices returned as undeliverable were
mailed a second time if SSA obtained an updated address.
In addition to mailing notices to claimants, SSA mailed information
regarding the class to members of the North Carolina State Bar. SSA
publicized Hyatt III relief through radio and
television public service announcements, press releases to North Carolina
newspapers, and posters placed in North Carolina Department of Social
Services offices, SSA field offices (FOs), all offices of the North
Carolina DDS, hospital emergency rooms and state and county senior
citizens centers in North Carolina.
In OHA, every hearing office (HO) servicing North Carolina residents
publicized the availability of relief under Hyatt
III by displaying posters which will be provided by SSA Headquarters. The
HOs displayed the posters for a 90-day period beginning with the date of
the initial mailing of notices to potential class members, and again for
another 30-day period beginning with the date of the second mailing of
class notices.
Finally, every HO servicing North Carolina residents has prominently
displayed applications for Hyatt class membership
in their waiting areas (Attachment 1). The HOs displayed the
Hyatt applications for a period of two years
commencing with the date SSA mails the initial class notices.
B. Requests for Readjudication
Individuals had 120 days from the receipt of the notice of potential class
membership to request that SSA readjudicate or reassess their claims under
the terms of the Hyatt III order. SSA presumed that
the individual received the notice five days after mailing, unless the
individual establishes that receipt actually occurred later. The SSA FOs
will develop for good cause and determine, pursuant to
20 CFR §§
404.911 and/or
416.1411, whether
good cause exists.
Individuals who did not receive a notice of potential class membership in
the mail had two years from the date SSA mailed the initial class notices
to complete and return an application for Hyatt
class membership pursuant to the Hyatt III
settlement order. The SSA FOs will develop for good cause and determine,
pursuant to 20 CFR
§§ 404.911 and/or
416.1411, whether
good cause exists.
The court order required that HO personnel give Attachment 1 to any
individual who inquires in any way, in person or by telephone, about the
Hyatt case and assist that individual in completing
the application. If the individual is unclear about whether they wish to
apply for class review, treat the inquiry as a request for review. Do not
try to dissuade anyone from requesting review. The HO will accept the
application, date it, verify the claimant's Social Security number and
determine whether the claimant has any potential
Hyatt III class claims located in the HO in
connection with a subsequent claim that is pending (hereinafter, a
“current claim”).
The HO will send the application for Hyatt III
class membership, along with an explanation of which
Hyatt III files, if any, are located in the HO and
which are still needed, to:
Office of Central Operations (OCO)
Attn:
Hyatt Coordinator
P.O. Box 32909
Baltimore, MD
21241-2909
The OCO Hyatt Coordinator will determine whether SSA previously sent the
claimant a Hyatt III notice and, if appropriate,
will generate an alert to request any missing claim file(s) (see
Part C. below). In most instances, OCO
will forward the alert and any claim files to the Office of Appellate
Operations (OAO) for coordination (see
Part D. below). The HO should not delay
processing a current claim awaiting potential class claim(s). The claim
consolidation procedures in Part VI.B.
below do not apply unless all potential Hyatt III
claim files are in the HO.
C. SSA Central Office Issuance of Alerts and Screening or Transfer of
Files to Another Screening Component
SSA Central Office will generate alerts for all
Hyatt III responders. See Attachment 2 for a sample
Hyatt III alert. In general, OCO will associate the
alerts with all claim files relating to the Hyatt
III timeframe and forward to the appropriate FO, DDS or HO for
adjudication.
For those individuals who respond untimely, either to a notice or as a
result of some other source of information, the alert will indicate that
good cause development is necessary. The SSA FOs will develop for good
cause and determine, pursuant to
20 CFR §§
404.911 and/or
416.1411, whether
good cause exists. In cases involving a mental impairment, FOs will also
consider the requirements of
SSR 91-5p and
Acquiescence Ruling
90-4(4).
If a current claim is pending in OHA, and OCO cannot locate the
Hyatt class claim, OCO will contact the OHA
component having jurisdiction over the current claim to determine if the
prior file is associated with the current claim, and, if so, will forward
the alert to OHA for a consolidation determination. If the current claim
is pending at the HO or OAO, forward the Hyatt
class claim to the appropriate HO or OAO branch for a consolidation
determination as set forth in Part VI.B.
or Part VI.C.
If the current claim is no longer pending in OHA but the potential
Hyatt class claim is being stored in OHA
Headquarters along with the current claim, i.e., awaiting potential filing
of a request for Appeals Council review or a civil action, OHA should ask
OCO to forward the alert to OAO at the following address:
Office of Hearings and Appeals
Office of
Appellate Operations
One Skyline Tower, Suite 701
5107
Leesburg Pike
Falls Church, VA 22041-3200
ATTN:
OAO Class Action Coordinator
1. Alerts Received in OHA
For each alert received, the HO or OAO branch, as appropriate, will make a
determination as to consolidation.
If the HO receives an alert only, or an alert associated with a prior
claim file(s), and it no longer has the current claim file, the HO will
return the alert and any prior claim file(s) to the OAO Class Action
Coordinator (see address in Part V.C.
above) and advise the Coordinator of what action was taken on the current
claim and its destination. The Coordinator will determine the current
claim file location and, if it is being stored in OHA Headquarters, will
forward the alert and any accompanying prior claim file(s) to the
responsible OAO Branch and flag the files for association and possible
consolidation using Attachment 3.
If an OAO branch receives an alert only, or an alert associated with a
prior claim file(s), and it no longer has the current claim file, or
responsibility for the claim file (i.e., the file is in a Docket and Files
Branch or minidockets) the branch will determine the location of the
current claim file. If the current claim file is located elsewhere within
OHA, the OAO branch will flag the files for association and possible
consolidation using Attachment 3, forward the alert and any accompanying
prior claim file(s) to the current OHA location, and advise the OAO Class
Action Coordinator of its actions.
As a result of the district court's October 21, 1999 order, SSA eliminated
the prior screening procedures for Hyatt III cases.
All Hyatt III cases, including those cases that
have been previously denied class membership, will receive a merits
decision unless in the processing of a claim, the North Carolina DDS or
OHA finds that Hyatt III relief is clearly
inappropriate because:
•
no application for disability benefits under title II and/or title XVI was
filed, or
•
no final medical determination was issued by NC adjudicator (DDS, ALJ,
AAJ) between July 7, 1981 and November 13, 1991. (A non-medical
determination/decision is one based on fraud, insufficient quarters of
coverage, excess income or resources, substantial gainful activity (SGA),
or any other reason related to proof of disability, unless the claim was a
concurrent claim filed in connection with a class claim. Also, in the
preceding sentence, the term “final” does not include
Hyatt III claims reopened and readjudicated prior
to September 30, 1999.) Such claims are entitled to
Hyatt III relief.
In all cases in which the ALJ is required to issue a merits decision, the
claimant must be offered the opportunity to participate in a hearing.
These cases may not be dismissed even if the ALJ believes that the
claimant has erroneously been determined to be a class member.
In addition, in cases in which the claimant amended his/her onset date and
an ALJ has previously issued a fully favorable decision, the ALJ is
required to issue a new decision regarding the period from the original
onset date to the amended onset date.
Any class member files which meet one of the exceptions (bulleted above)
will be sent to the Litigation Staff Hyatt III
Coordinator using Attachment 4. Litigation Staff will double check to make
sure that one of the exceptions applies. A notice will be sent to the
claimant, class counsel, and to the claimant's representative, if any,
informing the claimant that he/she is not entitled to relief using
Attachment 5. If SSA does not receive an objection to the notice within
120 days, the denial regarding class membership will be final. In cases in
which an objection is made, Litigation Staff will provide the claim
file(s) to the Office of the General Counsel. OGC will send the claim
file(s) or pertinent materials supporting the ineligibility determination
to the Raleigh, North Carolina district office for class counsel's review.
OGC will then negotiate with class counsel regarding SSA's determination
that the claimant is not a class member entitled to relief. If the parties
cannot reach an agreement, class counsel may file its objections with the
district court.
3. Acknowledgment Letters
For all claimants who are entitled to receive a
Hyatt merits determination, the HO will follow the
normal procedures for informing a claimant that it has received a
Hyatt case which will be scheduled for a hearing
including sending out standard acknowledgment letters. In the first
paragraph of the acknowledgment letter, appropriate
Hyatt language should be inserted (see Attachment
6) for sample language.
4. Procedures for Locating Claimants Whose Whereabouts are
Unknown
If the claimant's whereabouts are unknown anytime during the
redetermination/readjudication process, make reasonable efforts to locate
the claimant. Follow the procedures in
HALLEX
HA 01240.025 C. If the
claimant's whereabouts are still unknown after following the procedures in
HALLEX
HA 01240.025 C.,
contact the local field office for further assistance.
5. Primary Subclass Member Claims
If there is a current claim pending before an ALJ, and the HO determines
that the claimant is a primary subclass member, the ALJ will consider
whether claim consolidation is appropriate as provided in
Part VI.B. below. If there is a current
claim pending before the Appeals Council, and OAO determines that the
claimant is a primary subclass member, OAO will follow the procedures in
Part VI.C. below.
If there is no current claim pending in OHA, and the OAO branch determines
that the claimant is a primary subclass member, the OAO branch will send
all available files to the DDS or HO, as appropriate, after expiration of
the period for requesting review or filing a civil action and advise the
OAO Class Action Coordinator of its action. (See
Part VI.A. below.)
6. Settlement Subclass Member Claims
If there is a current claim pending before an ALJ or the Appeals Council
and the HO or OAO determines, following issuance of an ALJ decision or
completion of the Appeals Council's action on a current claim, that the
claimant is a settlement subclass member, the HO or OAO will send the
settlement subclass claim to the DDS, after disposition of the current
claim, for the DDS to conduct its reassessment and advise the OAO Class
Action Coordinator of its action.
If there is no current claim pending in OHA, and the OAO branch determines
that the claimant is a settlement subclass member, the OAO branch will
send all available files to the DDS for reassessment after expiration of
the period for requesting review or filing a civil action and advise the
OAO Class Action Coordinator of the action taken.
7. Settlement Subclass Denials Subject To A New Reassessment
In the course of normal processing, the HO will identify settlement
subclass cases which were denied by the NCDDS before May 21, 1996, whether
or not they have been identified by class counsel, and process them
pursuant to Part VII.B. below.
8. Required Decisional Language for Non-Qualifying
Hyatt Claims
If the earliest application that a claimant filed within the
Hyatt III period (July 7, 1981 through November 13,
1991) is not a Hyatt III eligible claim, include
the following language in the procedural history of the case. “We
did not review your claim(s) on (fill in date of claim(s) ineligible for
Hyatt III review) because (fill in reason claim(s)
was not eligible for Hyatt III review). We reviewed
your claim(s) filed after that date.” (See
HALLEX
HA 01280.025 C. for the
content and format of an ALJ decision.)
E. Special Procedures for Class Member Claims Pending in Court as of
May 21, 1994
The Hyatt III Stipulation and Order of Settlement
became effective on May 21, 1994, the 61st day after approval by the
court. OGC is responsible for screening all North Carolina civil actions
that were pending as of May 21, 1994, and offering all plaintiffs who are
Hyatt III class members the option to choose
between obtaining another administrative review pursuant to the settlement
order or continuing with the civil action. If the class member elects
another administrative review, the class member and the Secretary will
stipulate to a remand of the class member claim under sentence four of
§ 205(g) of the
Social Security Act for readjudication under the settlement order. If the
class member elects to proceed with the court case, he or she waives any
right to a readjudication or reassessment under the settlement
order.
VI. Processing and Readjudication of Primary Subclass Member
Claims
A. No Current Claim Pending
The DDS will readjudicate primary subclass member claims that the DDS
finally determined. If the claimant is not satisfied with the DDS
readjudication, he or she is entitled to request an ALJ hearing with full
appeal rights.
ALJs will readjudicate primary subclass member claims that an ALJ, the
Appeals Council or a Federal court finally decided. If the claimant is not
satisfied with the ALJ's decision, he or she is entitled to request
Appeals Council and judicial review.
For claimants with more than one primary subclass claim, ALJs will
readjudicate all claims if at least one of the claims was finally decided
by an ALJ, the Appeals Council or a Federal court.
B. Current Claim Pending in HO (Consolidation Procedures)
Even claims subject to consolidation should be consolidated only to the
extent practicable. Thus, if consolidation would unreasonably delay a
decision on the current claim, consolidation is not required.
1. Hearing Held but Decision Not Issued
Except as noted below, if a primary subclass member has a request for
hearing pending on a current claim and the ALJ has already held a hearing
but not yet issued a decision, the ALJ will not consolidate the Hyatt case
with the appeal on the current claim.
The ALJ will consolidate the claims if the ALJ is prepared to issue a
fully favorable decision on the current claim, and this decision would
also be fully favorable with respect to all the issues raised by the
Hyatt claim.
If the claims are not consolidated, follow
Part 5 below. If the claims are
consolidated, the ALJ will issue one decision that addresses both the
issues raised by the hearing on the current claim and those raised by the
Hyatt claim. The ALJ's decision on the consolidated
claims must clearly indicate that the ALJ considered the
Hyatt claim pursuant to the
Hyatt order.
2. Hearing Has Been Scheduled but Not Held, and All Remand
Cases
Except as noted below, if a primary subclass member has a request for
hearing pending on a current claim and the ALJ has scheduled but not held
a hearing, and in all remand cases, the ALJ will consolidate the
Hyatt case with the appeal on the current
claim.
The ALJ will not consolidate the claims if:
•
the current claim and the Hyatt claim do not have
any issues in common; or
•
a court remand contains a court-ordered time limit, and it will not be
possible to meet the time limit if the claims are consolidated.
If the claims are consolidated, follow
Part 4. below. If the claims are not
consolidated, follow Part 5. below.
Except as noted below, if a primary subclass member has an initial request
for hearing pending on a current claim and the HO has not yet scheduled a
hearing, the ALJ will not consolidate the Hyatt
case with the current claim. Instead, the ALJ will dismiss the request for
hearing on the current claim and forward both the
Hyatt claim and the current claim to the DDS for
consolidation and further action (see
Part 5. below).
If the hearing has not been scheduled because the claimant waived the
right to an in-person hearing,and the ALJ is prepared to issue a fully
favorable decision on the current claim, and this decision would also be
fully favorable with respect to all the issues raised by the
Hyatt claim, the ALJ will consolidate the
claims.
4. Actions if Claims Consolidated at ALJ Level
When consolidating a Hyatt claim with a current
claim, the issue before the ALJ is whether the claimant was disabled at
any time from the earliest alleged onset date through the present (or, if
earlier, through the date the claimant last met any applicable insured
status, age or prescribed period requirements).
If the ALJ consolidates the Hyatt claim with the
current claim, the ALJ will:
•
give proper notice of any new issues(s) as required by
20 CFR §§
404.946(b) and
416.1446(b) if
the Hyatt claim raises any additional issue(s) not
raised by the current claim; and
•
issue one decision that addresses both the issues raised by the request
for hearing on the current claim and those raised by the
Hyatt claim (the ALJ's decision must clearly
indicate that the ALJ considered the Hyatt claim
pursuant to the Hyatt order and expressly state the
standard used).
Class counsel must be sent copies of all merits determinations and
decisions. The ALJ must consider SSA's failure to send a copy of a
Hyatt III determination to class counsel when
making a good cause determination as to whether a request for hearing was
timely filed.
5. Actions if Claims Not Consolidated at ALJ Level
If the ALJ does not consolidate the Hyatt claim
with the current claim because: 1) a hearing has already been held, 2) the
claims do not have any issues in common, or 3) there is a court-ordered
time limit, and the primary subclass member claim was finally denied at
the initial or reconsideration level, the ALJ will:
•
request DDS review by attaching a copy of Attachment 7 to the
Hyatt claim file and mailing the file to the North
Carolina DDS;
•
retain a copy of Attachment 7 in the current claim file; and
•
take the necessary action to complete the record and issue a decision on
the current claim.
If the ALJ does not consolidate the Hyatt claim
with the current claim because: 1) a hearing has already been held, 2) the
claims do not have any issues in common, or 3) there is a court-ordered
time limit, and the primary subclass member claim was finally denied by an
ALJ, the Appeals Council or a Federal court, the HO will process the
claims independently.
If common issues exist but the DDS must consolidate the
Hyatt claim with the current claim because the
hearing has not yet been scheduled, the ALJ will:
•
dismiss the request for hearing on the current claim without prejudice,
using the language in Attachment 8 and the covering notice in Attachment
9, and
•
send both the Hyatt claim and the current claim to
the North Carolina DDS for consolidation and further action using
Attachment 10.
If the DDS does not issue a fully favorable determination on the
consolidated claims, the settlement order provides that the claimant is
automatically entitled to an ALJ hearing. In this situation, the DDS will
return the files to the HO.
On receipt of the files, the ALJ will vacate the prior dismissal of the
request for hearing and will schedule the consolidated claims for hearing,
using the original request for hearing date to determine scheduling
priority.
Class counsel must be sent copies of all merits determinations and
decisions. The ALJ must consider SSA's failure to send a copy of a
Hyatt III determination to class counsel when
making a good cause determination as to whether a request for hearing was
timely filed.
C. Current Claim Pending at the Appeals Council (Consolidation
Procedures)
Even claims subject to consolidation should be consolidated only to the
extent practicable. Thus, if consolidation would unreasonably delay a
decision on the current claim, consolidation is not required.
Except as noted below, if a primary subclass member has a current claim
pending before the Appeals Council, the Appeals Council will not
consolidate the Hyatt claim with the current claim.
Instead, if the primary subclass member claim was finally denied at the
initial or reconsideration level, the Appeals Council will use Attachment
7 to forward the Hyatt claim to the North Carolina
DDS for readjudication. If the primary subclass member claim was finally
denied by an ALJ, the Appeals Council or a Federal court, the Appeals
Council will forward the Hyatt claim to the
servicing HO for readjudication.
If the Appeals Council is prepared to issue a fully favorable decision on
the current claim, and this decision would be fully favorable with respect
to all issues raised by the Hyatt claim, the
Appeals Council will consolidate the claims, state in its decision that it
is reopening the final determination or decision on the
Hyatt claim and issue a decision that adjudicates
both applications.
The March 21, 1994 court order sets forth four types of primary subclass
claims to be given priority in processing. The following order of priority
processing applies to primary subclass member claims that were pending as
of May 21, 1994, the effective date of the court order. Because
Hyatt III primary subclass member claims, by
definition, must have been finally denied by SSA before August 6, 1990,
the only Hyatt III
claims that potentially could have been pending as of May 21, 1994, are
claims that were pending judicial review as of that date. Adjudicators
must also give priority to any previously uncompleted
Hyatt II
readjudications which are now being completed under the
Hyatt III implementation procedures. See
Part III.B. above.)
The October 21, 1999 order (see Attachment 24) requires to the extent
practicable, at each stage of class membership review and merits
adjudication, SSA shall accord priority to the cases entitled to relief
over other Hyatt III implementation.
First Priority:
Hyatt claims pending at the ALJ hearing level as of
May 21, 1994, that are consolidated with current claims and returned to
the DDS for review under the procedures in
Parts B.3. and
B.5. above. This priority also applies to
the automatic right to an ALJ hearing for unfavorable DDS determinations
in these cases.
Second Priority:
Hyatt claims pending in court as of May 21, 1994,
that are remanded for Hyatt readjudication under
the procedure described in Part V.E.
above. The court order provides that the Appeals Council may decide these
claims on remand if a favorable decision on the record can be
rendered.
Third Priority:
Hyatt claims pending before the Appeals Council as
of May 21, 1994. The Appeals Council must make a good faith effort to
issue a decision on the record or remand the claim to an ALJ within 90
days after receipt of the claim file, reconstructed claim file, or (if the
Appeals Council already has the file) the claimant's request for
Hyatt review. If the Appeals Council remands to an
ALJ, the ALJ must make a good faith effort to schedule a hearing within
120 days of the date of the Appeals Council's remand order.
Fourth Priority:
Hyatt claims pending before an ALJ as of May 21,
1994. The ALJ must make a good faith effort to schedule a hearing within
120 days of the date of receipt in the HO of the claim file, reconstructed
claim file, or (if the HO already has the file) the claimant's request for
Hyatt review.
The Hearing Office Chief ALJ will assign all other
Hyatt III claims in order of:
•
the date of the request for Hyatt review by SSA
(for cases coming to OHA as the first level of review), or
•
the date of the request for hearing (for cases on appeal following a DDS
denial), consistent with the usual assignment procedures in
HALLEX
HA 01210.055 and
HA 01210.057.
E. Type of Review and Period to Be Adjudicated
Primary subclass members are entitled to a full reopening of their
Hyatt claims. In conducting readjudications of
primary subclass member claims, adjudicators must consider the issue of
whether the claimant was disabled at any time from the earliest alleged
onset date through the present (or, if earlier, through the date any
applicable insured status, age or prescribed period requirements were last
met). All Hyatt decisions must indicate the dates
of all applications reopened under Hyatt, as well
as indicating the type of benefit sought in each claim.
In readjudicating Hyatt class member claims of
individuals who have received or are receiving disability benefits,
adjudicators must limit their consideration to the period(s) before or
after any periods for which the claimant has already been found disabled.
Adjudicators may not disturb the favorable portions of previous decisions
or determinations.
The court order provides that the medical record of each primary subclass
member claim must be fully developed for the entire period at issue, using
treating physicians whenever possible and employing consultative examiners
when necessary (see 20
CFR §§ 404.1519 through
404.1519t,
404.1527,
416.919 through
416.919t and
416.927).
F. Developing Evidence of Work Activity
If the screening process reveals SGA-level work activity after the prior
final decision, the adjudicator must develop the issue to the extent
needed in order to evaluate disability throughout the entire period at
issue.
G. Readjudication of Reconstructed Claims
If SSA is unable to fully reconstruct a primary subclass member claim
file, adjudicators must readjudicate the claim based on current medical
evidence. If the claimant was found disabled based on a claim filed after
the Hyatt III claim was filed, adjudicators will
infer, in the absence of substantial evidence to the contrary, that the
claimant became disabled as of the earliest date on which all other
requirements for disability benefits (including filing a claim) were met.
Substantial evidence to the contrary may include, but is not limited to,
evidence of a traumatic onset of disability or a new impairment or a
contrary medical judgment. If the claimant was found not disabled based on
a claim filed after the Hyatt III claim was filed,
or the claimant's subsequent claim is still pending, and evidence of the
past condition is not readily available, the adjudicator will presume that
the claimant's past condition and impairments were as they are currently
if such presumption is reasonable based on the nature of the
impairment.
H. Effectuating Decisions After OHA Action
If a fully favorable medical decision was issued either because of a
subsequent application or a previous Hyatt III
reopening, the OHA adjudicator will complete the Favorable Decision
Worksheet and Transmittal (see Exhibit 11) and forward the folder to the
appropriate field office for payment verification.
VII. Processing, Reassessment and Appeal of Settlement Subclass Member
Claims
A. Initial Processing of Settlement Subclass Member Claims
1. DDS Processing and Reassessment
Settlement subclass members are entitled to a reassessment by the North
Carolina DDS of their Hyatt claims. The period to
be reassessed is limited to the period adjudicated in the initial or
reconsideration determination that resulted in the claimant's settlement
subclass membership. In conducting the reassessment, the DDS will review
the evidence on which the prior final determination was based, as well as
any new evidence submitted by the individual (see Attachment 12). If the
DDS determines that it cannot reassess the claim based on the existing and
any new evidence, the DDS will develop any additional evidence needed to
reassess the determination on the previously adjudicated period.
If the DDS reassessment results in a finding that the claimant became
disabled at any time during the previously adjudicated period, the DDS
will treat the claim as a primary subclass member claim, i.e., it will
rule through the current date.
2. OHA Processing of Appeals
If a settlement subclass member claim is being treated as a primary
subclass member claim because the DDS determines that the claimant was
disabled for at least part of the reassessment period, the claimant has
the same full appeal rights as a primary subclass member. Appeals of
partially favorable determinations to the OHA level will be treated the
same as those for primary subclass members.
If the DDS reassessment results in a finding that the claimant was not
disabled, the settlement subclass member may request a reassessment
hearing by an ALJ by filing a request within 60 days from the date of
receipt of the DDS notice of reassessment. The ALJ will only grant the
claimant's request for a reassessment hearing if the ALJ determines that
there is new and material evidence relating to the reassessment period.
The claimant has 105 days from receipt of the DDS notice of reassessment
to submit new and material evidence to the ALJ. The ALJ will apply
20 CFR §§
404.911 and
416.1411 in
determining whether there is good cause for late filing of a request for
hearing or submitting additional evidence.
a. New and Material Evidence
Evidence is “new and material” for purposes of processing
settlement subclass member claims if: 1) the adjudicator who made the
initial or reconsideration determination that resulted in the claimant's
settlement subclass membership did not consider it, and 2) the evidence,
by itself or with the other evidence before the ALJ, would warrant a
change in any finding pertinent to any matter at issue or a change in the
ultimate decision.
To be found “new and material” by an ALJ, the evidence need
not have first been submitted to the ALJ. The ALJ may determine that
evidence submitted to the DDS, or developed by the DDS, in connection with
the reassessment of the settlement subclass member claim is new and
material. Subjective evidence relating to pain may qualify as new and
material evidence.
If the ALJ determines that there is no new and material evidence, he or
she will dismiss the claimant's request for a reassessment hearing using
the order in Attachment 13 and transmittal notice in Attachment 14. In
addition to the usual addressees, the HO must send a copy of the dismissal
to class counsel at the address shown in Attachment 9.
There is no right to request further review, i.e., no right to Appeals
Council or judicial review. However, a court may review the Secretary's
adjudication in an individual case in connection with a claimant's action
to enforce the provisions of the settlement order.
If the ALJ determines that there is new and material evidence, he or she
will schedule and hold a hearing and reassess the previously considered
period. The ALJ must decide whether the final denial is in accordance with
the applicable provisions of the Act, regulations and rulings, as
indicated in Part III.A. above. If the
ALJ cannot reassess the claim based on the evidence of record, including
the new and material evidence and any evidence adduced at the hearing, the
ALJ will obtain any necessary additional evidence relevant to the time
period being reviewed.
If the ALJ finds that the claimant did become disabled at any time during
the reassessment period, the claim will be treated as a primary subclass
member claim, and the ALJ will rule through the date of the decision (or,
if earlier, the date the claimant last met any applicable insured status,
age or prescribed period requirements). The claimant in this situation
will have the usual rights to request Appeals Council and judicial
review.
If the ALJ finds that the claimant did not become disabled at any time
during the reassessment period, the ALJ will issue a reassessment
decision, using the format in Attachment 15, with the covering notice in
Attachment 16. The HO must send a copy of the ALJ's reassessment decision
to class counsel at the address shown on Attachment 14. There is no right
to request further review of an ALJ reassessment decision, i.e., no right
to Appeals Council or judicial review.
As with primary subclass member claims, in reassessing the settlement
subclass member claims of individuals who have received or are receiving
disability benefits, adjudicators must limit their consideration to the
period(s) before or after any periods for which the claimant has already
been found disabled. Adjudicators may not disturb the favorable portions
of previous decisions or determinations.
B. Settlement Subclass Denials Subject To A New Reassessment
1. DDS Processing and Reassessment
For all individuals determined to have been issued
Hyatt III reassessment determinations prior to May
21, 1996, the prior reassessment determination will become void and a new
determination will be made (except as provided in
Part VII. B.2. below). The new
reassessment determination shall be performed by a different adjudicative
team than that which made the prior reassessment determination. A notice
of determination will be sent to the individual regarding the new
reassessment determination and will include the opportunity to appeal
pursuant to Part VII. A.2. above.
2. OHA Processing of Appeals
a.
If the settlement subclass denial subject to a new reassessment has been
scheduled for a hearing, or a hearing has been held, the claim will
continue to be processed by OHA under existing
Hyatt III procedures noted in
Part V.D.2.c. above.
b.
If the settlement subclass denial subject to a new reassessment has not
yet been scheduled for a hearing, OHA will make a determination whether
the “new and material evidence” requirement, noted in
Part VII.A.2.a. above, has been
met.
(1.) If the ALJ determines that there is new and material evidence, he or
she will schedule and hold a hearing and reassess the previously
considered period. The ALJ must decide whether the final denial is in
accordance with the applicable provisions of the Act, regulations and
rulings, as indicated in Part III.A.
above. If the ALJ cannot reassess the claim based on the evidence of
record, including the new and material evidence and any evidence adduced
at the hearing, the ALJ will obtain any necessary additional evidence
relevant to the time period being reviewed.
If the ALJ finds that the claimant did become disabled at any time during
the reassessment period, the claim will be treated as a primary subclass
member claim. The claimant in this situation will have the usual rights to
request Appeals Council and judicial review.
If the ALJ finds that the claimant did not become disabled at any time
during the reassessment period, the ALJ will issue a reassessment
decision, using the format in Attachment 22, with the covering notice in
Attachment 23. The HO must send a copy of the ALJ's reassessment decision
to class counsel at the address shown on Attachment 23. There is no right
to request further review of an ALJ reassessment decision, i.e., no right
to Appeals Council or judicial review.
As with primary subclass member claims, in reassessing the settlement
subclass member claims of individuals who have received or are receiving
disability benefits, adjudicators must limit their consideration to the
period(s) before or after any periods for which the claimant has already
been found disabled. Adjudicators may not disturb the favorable portions of
previous decisions or determinations.
(2.) If the ALJ determines that there is no new and material evidence, he
or she must determine whether the DDS has made a new reassessment
determination as required by the November 4, 1996 signed agreement between
the parties (Attachment 17).
If the ALJ finds that the DDS has not made a new reassessment
determination as required by the November 4, 1996 signed agreement between
the parties (Attachment 17), the case will be remanded to the DDS using
the dismissal order in Attachment 18 and the route slip in Attachment 19;
the individual will receive a new DDS reassessment determination and will
have an additional opportunity to appeal pursuant to
Part VII.B.1. above (i.e., if the claim
is again denied by the DDS the individual must ask for a new hearing and
again must proceed in accordance with
Part VII.A.2. above and provide
“new and material” evidence). The evidence submitted in
connection with the first and second DDS reassessments or the prior
reassessment appeal, as well as other evidence proffered, will be
considered in making the new and material evidence determination.
Evidence submitted at any time during the Hyatt III
review process is “new” evidence.
If the ALJ finds that the DDS has made a new reassessment determination as
required by the November 4, 1996 signed agreement between the parties
(Attachment 17), he or she will dismiss the claimant's request for a
reassessment hearing using the order in Attachment 20 and transmittal
notice in Attachment 21. In addition to the usual addressees, the HO must
send a copy of the dismissal to class counsel at the address shown in
Attachment 20. There is no right to request further review, i.e., no right
to Appeals Council or judicial review.
c.
If a decision on the merits of the reassessment claim has been made by
OHA, the claim will not be reviewed under the terms of
Parts VII. B.2.a. and b. above (NOTE: a
decision “on the merits” will not include a claim in which
the request for hearing was dismissed).
VIII. Case Coding
The HO should code both primary and settlement subclass member claims into
the Hearing Office Tracking System (HOTS) and the OHA Case Control System
(OHA CCS) as reopenings. If a class member claim is consolidated with a
current claim already pending at the hearing level (see
Part VI.B.), do not code it as a separate
hearing request. Instead, change the hearing type on the current claim to
a reopening.
Code current claims that are dismissed for consolidation with primary
subclass member claims and readjudication by the DDS as
“administrative” dismissals (code ADDI). If these claims are
later returned by the DDS because the consolidated determination is not
fully favorable, code the hearing type as a new request for hearing (or a
second or subsequent claim, if appropriate). Do not code as a reopening.
Use the original request for hearing date to ensure prompt
processing.
Code settlement subclass member claims that are dismissed because the
claimant did not submit new and material evidence as “other”
dismissals (code OTDI). Code Hyatt III reassessment decisions in
settlement subclass member claims as unfavorable affirmations.
The HO must code cases in which an ALJ conducts the first review under
Hyatt III as “H3” in the HOTS
“Class Action” field. Leave the Class Action field blank if
the DDS conducted the first Hyatt III review.
Because the Hyatt III reporting will be based on
HOTS data, it is essential that the “H3” code be used
correctly.
No special identification coding is needed for the OHA CCS.
IX. Reconciliation of Implementation
At an appropriate time, Litigation Staff will request SSA components to
reconcile their screening activity and disposition of class member claims
with information available on CATS. Within OHA, the OAO Class Action
Coordinator is responsible for maintaining a personal computer-based
record of OHA implementation activity (i.e., a record of alerts processed
by OHA, and a record of cases screened and consolidated by OHA), as
reported by HOs and OAO.
X. Inquiries
HO personnel should direct any questions to their Regional Office.
Regional Office personnel should contact the Division of Field Practices
and Procedures in the Office of the Chief Administrative Law Judge at
(703) 605-8530. OHA headquarters personnel should contact the
Hyatt Coordinator at the Special Counsel Staff at
605-8278.
Attachments
1.
Application for Hyatt Class Membership
3.
Request for Association and Possible Consolidation
4.
Route Slip to Litigation Staff Transmitting Hyatt
III Case Not Entitled to Relief
5.
Notice of Non-Entitlement to Relief
6.
Acknowledgement Letter with Sample Hyatt III
Language
7.
Route Slip to DDS Requesting Readjudication of Primary Subclass Member
Claim
8.
Dismissal of Request for Hearing on Current Claim — Current Claim
and Primary Subclass Member Claim to Be Consolidated at DDS Level
9.
Notice Transmitting ALJ Order of Dismissal — Current Claim and
Primary Subclass Member Claim to Be Consolidated at DDS Level
10.
Route Slip to DDS Requesting Readjudication of Consolidated Claims and
Return of Files to ALJ if Less Than Fully Favorable Determination
Issued
11.
Hyatt III Favorable Decision Worksheet and
Transmittal
12.
December 19, 1996 Hyatt Desk Guide
13.
Dismissal of Request for Hearing in Settlement Subclass Member Case
— No New and Material Evidence Submitted
14.
Notice Transmitting ALJ Order of Dismissal in Settlement Subclass Member
Case
15.
ALJ Reassessment Decision in Settlement Subclass Member Case —
Claimant Not Disabled During Reassessment Period
16.
Notice Transmitting ALJ Hyatt III Reassessment
Decision in Settlement Subclass Member Case
17.
November 4, 1996 Signed Agreement Supplementing the March 21, 1994
Settlement Order in Hyatt III.
18.
Dismissal of Request for Hearing — Remand to DDS for New
Reassessment of Settlement Subclass Denial
19.
Route Slip to DDS Requesting A New Reassessment of Settlement Subclass
Denial
20.
Dismissal of Request for Hearing in Settlement Subclass Member Case after
a New Reassessment at the DDS Level — No New and Material Evidence
Submitted
21.
Notice Transmitting ALJ Order of Dismissal in Settlement Subclass Member
Case after a New Reassessment at the DDS Level — No New and Material
Evidence Submitted
22.
ALJ Reassessment Decision in Settlement Subclass Member Case after a New
Reassessment at the DDS Level — New and Material Evidence - Claimant
Not Disabled During Reassessment Period
23.
Notice Transmitting ALJ Hyatt III Reassessment
Decision in Settlement Subclass Member Case after a New Reassessment at
the DDS Level — New and Material Evidence - Claimant Not Disabled
During Reassessment Period
24.
October 21, 1999 Order by the United States District Court for the Western
District of North Carolina
Attachment 1. Application for Hyatt Class Membership
|
APPLICATION FOR HYATT CLASS MEMBERSHIP |
Social Security may owe you disability benefits. This is because of a
recent court case called “Hyatt v.
Shalala.” If we denied your old disability claim, and
you had complaints of pain, you can ask us to look at your old claim
again.
Even if you now get money from Social Security, we may still owe you more
disability money. Even if we denied your
“Hyatt” claim before, you may get
disability money now. You cannot lose benefits for which you are eligible
by asking us for a “Hyatt”
review.
If you want us to look again at your old denied claim, fill out this form
and return it to your local Social Security field office as soon as
possible.
_ _ _ - _ _ - _ _ _ _ _ _ / _ _ /_ _
SOCIAL
SECURITY NUMBER DATE OF BIRTH (mm/dd/yy)
_ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ for
REPRESENTATIVE
PAYEE (If Applicable)
_ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _
NAME (LAST) (FIRST) (MI)
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_
ADDRESS
_ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ - _ _ _ _
CITY STATE ZIP CODE
(_ _ _) _ _ _ - _ _ _ _
TELEPHONE
NUMBER
_________________________________________ _ _ / _ _ / _ _
SIGNATURE DATE
If you have any questions, or need help, call the North Carolina
Disability Hotline (toll-free) at 1-800-638-6810.
|
For Field Office Use Only
FOs: Verify SSN, CLAIM NUMBER/BIC, and mail to:
_ _ _ - _ _ - _ _ _ _ _ _
CLAIM NUMBER BIC/MFT
ODIO, Class Action Section
ATTN: HYATT Coordinator
P.O. Box 17369
Baltimore, MD 21298-0050
|
CTWALT01 HYATT III COURT
CASE FLAG/ALERT
REVIEW PSC DOC TOE
ALERT DATE RESPONSE DATE OLD BOAN/PAN OFFICE
1340
SSN
(BOAN OR PAN) NAME BIRTH DATE REFERENCE #
FOLDER LOCATION/INFORMATION
CAN/HUN BIC/MFT CATG
TITLE CFL CFL DATE ACN
PAYEE ADDRESS
SHIP TO ADDRESS
SSA
Disability Determinations Section
Division
of Social Services
3301 Terminal Drive
P.O. Box
243
Raleigh, NC 27602
If claim is pending in OHA, then ship folder to:
Office of Hearings and Appeals
Office of
Appellate Operations
One Skyline Tower, Suite 701
5107
Leesburg Pike
Falls Church, VA 22041-3200
Attachment 3. Request for Association and Possible Consolidation
Hyatt III Court Case
ASSOCIATION NECESSARY
Claimant's name:
_____________________________________
SSN:
_____________________________________
This claimant may be entitled to relief under the Hyatt settlement order.
The attached folder location information indicates that a current claim
file is pending in your office. Accordingly, we are forwarding the
attached alert [and prior claim file(s)] for association and possible
consolidation and readjudication.
Please refer to HALLEX Temporary
Instruction 5-4-4 for additional information and instructions.
TO: ____________________________
____________________________
Attachment 4. Route Slip to Litigation Staff Transmitting
Hyatt III Case Not Entitled to Relief
|
ROUTING AND TRANSMITTAL SLIP |
DATE: |
|
TO:
1. OPB Litigation Staff, Hyatt Coordinator
|
|
|
INITIALS |
|
|
DATE |
|
|
3-K-26 Operations Building |
|
|
6401 Security Boulevard |
|
|
Baltimore, MD 21235-6401 |
|
|
|
|
|
XX |
ACTION |
|
FILE |
|
NOTE AND RETURN |
|
|
APPROVAL |
|
FOR CLEARANCE |
|
PER CONVERSATION |
|
|
AS REQUESTED |
|
FOR CORRECTION |
|
PREPARE REPLY |
|
|
CIRCULATE |
|
FOR YOUR INFORMATION |
|
SEE ME |
|
|
COMMENT |
|
INVESTIGATE |
|
SIGNATURE |
|
|
COORDINATION |
|
JUSTIFY |
|
|
REMARKS
Claimant: ________________________ SSN:
_____________________________
The attached Hyatt III claim is not entitled to relief because
_________________________________________________________________________
________________________________________________________________________.
Accordingly, we are sending the claim file to your office for review. SEE
HA 01540.004 V.D.2.c.
Attachment
DO NOT use this form as a RECORD of approvals, concurrences, disposals,
clearances, and similar actions.
|
FROM:
Office of Hearings and Appeals
___________________________________________
|
SUITE/BUILDING |
|
PHONE NUMBER |
|
OPTIONAL FORM 41 (Rev. 7-76)
*U.S.GPO:1985-0-461-274/20020 Prescribed by GSA
FPMR (41 CFR) 101-11.206
|
Attachment 5. Notice of Non-Entitlement to Relief
|
|
[Name and Address of Component] |
|
|
|
|
|
Date: |
|
|
Claim Number: |
Dear :
We looked at your case as the result of a class action court case in North
Carolina called Hyatt. We looked at your case even
if we looked at it earlier and sent you a letter saying you were not
entitled to Hyatt review.
As a result of reviewing your case, we found that you are not entitled to
a Hyatt review. This means that we will not review
your old disability case again.
IF YOU DISAGREE
You, or your representative, have
120 days from the date you receive this
notice to write to Social Security to request review of this
decision.
If you want Social Security to review this decision, please write
to:
Social Security Administration
Office of
the General Counsel
Room 617 Altmeyer
6401 Security
Boulevard
Baltimore MD 21235-6401
THE REASON YOU ARE NOT ENTITLED TO HYATT REVIEW IS BECAUSE:
We have no evidence that you ever filed an application for Social Security
disability insurance benefits under either title II or title XVI of the
Social Security Act. Your application was for
________________________________________________________________________.
You did not receive a less than fully favorable determination/decision
(choose one) by a North Carolina adjudicator on or after July 7, 1981 and
before November 14, 1991. The final determination/decision (choose one) on
your claim was (fill in the reason the claimant does not qualify for Hyatt
review) ______________________________________________________ and
_________________________________________________________________________
_________________________________________________________________________
________________________________________________________________________.
You did not receive a medical denial/determination. The final
determination/decision was based on _____________________________
_________________________________________________________________
_________________________________________________________________
_______________ Remember, you only have 120 days to ask us to review the
decision. If you do not contact us within 120 days, this decision will
become final.
IF YOU NEED HELP
If you have questions or want help, you should contact:
1.
Your lawyer or representative; or
2.
The lawyers for the Hyatt class:
Hyatt Attorney
North Carolina Justice
and
Community Development Center
224 South Dawson Street
P.O.
Box 28068
Raleigh, NC
27611
1-800-299-8619
Telephone:
1-800-299-8619
INFORMATION ABOUT FILING A NEW APPLICATION
If you think you are disabled now, you may file a new application. A new
application is not the same as asking us to review your claim under Hyatt.
In the new application, you may not be able to receive disability benefits
for the period of time you asked for in your prior claim. If you decide to
file a new application, contact any Social Security office.
cc: Claimant's Representative
Hyatt Attorney
Attachment 6. Acknowledgment Letter with Sample Hyatt III
Language
|
|
Office of Hearings and Appeals |
|
|
[Insert address] |
|
|
[Insert date] |
Dear :
Insert the following language if the notice is to be sent to the claimant:
We are currently looking at your case as the result of a class action
court case in North Carolina called Hyatt. Your
case will be reviewed even if we looked at it earlier and sent you a
letter saying you are not entitled to review. A notice of the time and
place of the hearing will be sent to you at least twenty (20) days before
the hearing date.
If the claimant is deceased and the claimant's estate is to be notified, insert the following language:
To the Estate of :
We are currently looking at [enter name of claimant]'s case as the result
of a class action court case in North Carolina called
Hyatt.
[Enter name of claimant's] case will be
reviewed even if we looked at it earlier and sent
[him/her] a letter saying that
[he/she] was not entitled to a
review.
Our records show that the Hyatt class member is now
deceased and that [he/she] did not leave
a surviving spouse. Additional benefits may be due if the
Hyatt claim is approved. If the claimant's child,
parent or executor of the estate wishes to pursue this claim, please
complete and return the enclosed substitute of party form within ten days.
If this form is not returned, we will assume that no one is interested in
pursuing this claim, and the Hyatt claim will be
dismissed. A notice of the time and place of the hearing will be sent to
you at least twenty (20) days before the hearing date.
The Hearing
At the hearing, you may present your case to the Administrative Law Judge
(ALJ) who will hear and decide it. The ALJ will consider the issue(s) you
have raised and the evidence now in your file. In addition, you have the
right to give us any additional evidence relating to an earlier claim that
was not previously considered. The ALJ may consider other issues as well
and, if necessary, change parts of the previous decision that were
favorable to you. The Notice of Hearing will state the issues the ALJ
plans to consider at the hearing.
Because the hearing is your time to show the ALJ that the issues should be
decided in your favor, we need to make sure that your file has everything
you want the ALJ to consider. We can help you get needed evidence. After
the ALJ reviews the evidence in your file, he or she may request more
evidence to consider at your hearing.
Your Right to Representation
You may choose to be represented by a lawyer or other person. A
representative can help you get evidence, prepare for the hearing, and
present your case at the hearing. If you decide to have a representative,
you should find one immediately so that he or she can start preparing your
case.
Attachment 7. Route Slip to DDS Requesting Readjudication of Primary Subclass
Member Claim
|
ROUTING AND TRANSMITTAL SLIP |
DATE: |
|
TO:
1. North Carolina Disability Determination Section
|
INITIALS |
DATE |
|
2. |
|
|
|
3. |
|
|
|
4. |
|
|
|
|
|
|
|
XX |
ACTION |
|
FILE |
|
NOTE AND RETURN |
|
|
APPROVAL |
|
FOR CLEARANCE |
|
PER CONVERSATION |
|
|
AS REQUESTED |
|
FOR CORRECTION |
|
PREPARE REPLY |
|
|
CIRCULATE |
|
FOR YOUR INFORMATION |
|
SEE ME |
|
|
COMMENT |
|
INVESTIGATE |
|
SIGNATURE |
|
|
COORDINATION |
|
JUSTIFY |
|
|
REMARKS
Claimant: ________________________ SSN:
_____________________________
The attached Hyatt III primary subclass member
claim will not be consolidated with a current claim pending at OHA
because
_________________________________________________________________________
________________________________________________________________________.
Accordingly, we are sending the claim file to your office for
readjudication.
SEE POMS DI 32548.015 B.1.
Attachment
DO NOT use this form as a RECORD of approvals, concurrences, disposals,
clearances, and similar actions.
|
FROM:
Office of Hearings and Appeals
___________________________________________
|
SUITE/BUILDING |
|
PHONE NUMBER |
|
OPTIONAL FORM 41 (Rev. 7-76)
*U.S.GPO:1985-0-461-274/20020 Prescribed by GSA
FPMR (41 CFR) 101-11.206
|
Attachment 8. Dismissal of Request for Hearing on Current Claim — Current
Claim and Primary Subclass Member Claim to Be Consolidated at DDS
Level
SOCIAL SECURITY ADMINISTRATION
OFFICE
OF HEARINGS AND APPEALS
ORDER OF DISMISSAL
|
IN THE CASE OF: |
CLAIM FOR: |
|
_________________________ |
_________________________ |
|
(Claimant) |
|
|
_________________________ |
_________________________ |
|
(Wage Earner) |
|
This case is before the Administrative Law Judge pursuant to a request for
hearing filed on __________________ with respect to the application(s)
filed on ________________.
In accordance with the Stipulation and Order of Settlement negotiated by
the parties and approved by the United States District Court for the
Western District of North Carolina in the case of Hyatt v.
Shalala, No. C-C-83-655-MU (W.D. North Carolina, March 21,
1994), the claimant has requested readjudication of the final
(determination/decision) on the prior application(s) filed on
______________. The claimant has been identified as a
Hyatt class member and is entitled to have the
final administrative denial of the prior application(s) reviewed under the
terms of the Stipulation and Order of Settlement. Because the claimant's
current claim shares certain issues in common with the prior claim, the
undersigned hereby dismisses without prejudice the request for
hearing.
The claimant's current application(s) will be associated with the prior
claim(s) and forwarded to the North Carolina Disability Determination
Section which will conduct the Hyatt readjudication
and redecide the current application at the reconsideration level.
The North Carolina Disability Determination Section will notify the
claimant of its new determination. If the new determination is not fully
favorable to the claimant, this order of dismissal will be vacated, the
claimant's request for hearing on the current claim will be reinstated,
and the claimant will be deemed to have requested a hearing with respect
to the readjudication of the Hyatt claim.
|
|
__________________________ |
|
|
Administrative Law Judge |
Date:
Attachment 9. Notice Transmitting ALJ Order of Dismissal — Current Claim
and Primary Subclass Member Claim to Be Consolidated at DDS Level
NOTICE OF DISMISSAL
Claimant's Name
Address
City, State Zip
Enclosed is an order of the Administrative Law Judge dismissing your
request for hearing without prejudice and returning your case to the North
Carolina Disability Determination Section which makes disability
determinations for the Social Security Administration. Please read this
notice and the Order of Dismissal carefully.
What This Order Means
The Administrative Law Judge has sent your current claim and your Hyatt
claim back to the North Carolina Disability Determination Section for
further processing. The enclosed order explains why. If the new
determination is not fully favorable to you, your request for hearing will
be reinstated.
The Next Action on Your Claim
The North Carolina Disability Determination Section will contact you to
tell you what you need to do. If you do not hear from the North Carolina
Disability Determination Section within 30 days, contact your local Social
Security office.
Do You Have Any Questions?
If you have any questions, contact your local Social Security office. If
you visit your local Social Security office, please bring this notice and
the Administrative Law Judge's order with you.
Enclosure
cc: (Name and address of representative, if any)
(Social Security Office (City, State))
Hyatt Attorney
North Carolina Justice and
Community Development Center
224 South Dawson Street
P.O.
Box 28068
Raleigh, NC 27611
Attachment 10. Route Slip to DDS Requesting Readjudication of Consolidated Claims
and Return of Files to Less Than Fully Favorable Determination
Issued
|
ROUTING AND TRANSMITTAL SLIP |
DATE: |
|
TO:
1. North Carolina Disability Determination Section
|
INITIALS |
DATE |
|
2. |
|
|
|
3. |
|
|
|
XX |
ACTION |
|
FILE |
|
NOTE AND RETURN |
|
|
APPROVAL |
|
FOR CLEARANCE |
|
PER CONVERSATION |
|
|
AS REQUESTED |
|
FOR CORRECTION |
|
PREPARE REPLY |
|
|
CIRCULATE |
|
FOR YOUR INFORMATION |
|
SEE ME |
|
|
COMMENT |
|
INVESTIGATE |
|
SIGNATURE |
|
|
COORDINATION |
|
JUSTIFY |
|
|
REMARKS
Hyatt III Case
Claimant: _________________________
SSN: _____________________________
We are forwarding the attached files to your office for consolidated
readjudication of the claimant's Hyatt III claim
and the current claim (see the Administrative Law Judge's dismissal
order).
If your review does not result in a fully favorable determination, please
return all files, after any effectuation
action, to the ________________ Hearing Office for further action on the
consolidated claims.
SEE POMS DI 32548.015 B.1. and 3.
Attachment
DO NOT use this form as a RECORD of approvals, concurrences, disposals,
clearances, and similar actions.
|
FROM:
Office of Hearings and Appeals
___________________________________________
|
SUITE/BUILDING |
|
PHONE NUMBER |
|
OPTIONAL FORM 41 (Rev. 7-76)
*U.S.GPO:1985-0-461-274/20020 Prescribed by GSA
FPMR (41 CFR) 101-11.206
|
Attachment 11. Hyatt III Favorable Decision Worksheet and
Transmittal
If a favorable medical decision was issued, complete this worksheet,
staple it to the front of the folders and ship to the servicing field
office.
TO: FO _____________ PAYMENT VERIFICATION
NEEDED
1. CLAIM NUMBER BIC/ID
_____
- ___ - _______ ______
SOCIAL SECURITY NUMBER
_____ - ___ - _______
2.
_________________________________________________________________
CLAIMANT'S NAME (FIRST, MIDDLE INITIAL, LAST)
3. FOR SOCIAL SECURITY DISABILITY INSURANCE BENEFITS (Title II):
a. Earliest Eligible* Hyatt III
Application Date
______ /______/______
b. Alleged onset date on Application identified in a.
above
______/______/_______
c.
Established disability onset date
______/______/_______
4. FOR SUPPLEMENTAL SECURITY
INCOME BENEFITS
d. Earliest Eligible*
Hyatt III Application Date
e.
Established Entitlement Date
______/______/______
NOTE: If there is an earlier
application(s) within the Hyatt III period
(July 7, 1981 - November 13, 1991) that is ineligible for
Hyatt III
review, enter the date(s) of
those claim(s) here:
______/______/______
_____/______/_______
_____/______/_______
________________________________________ ________________
Signature Component Date
Attachment 12. December 19, 1996 Hyatt Desk Guide
HYATT DESK GUIDE
(To
Be Used in HYATT Reassessment Cases Only)
ALL EXPLANATIONS MUST BE CLEARLY SET FORTH IN THE APPROPRIATE PLACE IN THE
CASE RECORD.
2.
Can impairment(s) be reasonably expected to produce alleged
symptoms?
(DI
24515.061.B.)
3.
Is impairment(s) severe? If NO, EXPLAIN.
4.
Were symptoms considered in determining severity? If NO, EXPLAIN.
(DI
24505.003.B.)
6.
If alleged symptom-related limitations or restrictions are greater than
would be expected on the basis of the physical impairment(s), was the
possibility of a medically determinable mental impairment considered? If
NO, EXPLAIN.
(DI
24515.061.B.)
8.
Does a function-by-function assessment establish the claimant is able to
perform past relevant work? If YES, DENY.
9.
Considering RFC, age, education and work experience, can the claimant
perform other work? If YES, DENY. If NO, ALLOW.
(DI
25015.020.A.)
Attachment 13. Dismissal of Request for Hearing in Settlement Subclass Member Case
— No New and Material Evidence Submitted
SOCIAL SECURITY ADMINISTRATION
OFFICE
OF HEARINGS AND APPEALS
ORDER OF DISMISSAL
HYATT III REASSESSMENT CASE
|
IN THE CASE OF: |
CLAIM FOR: |
|
_________________________ |
__________________________ |
|
(Claimant) |
|
|
_________________________ |
___________________________ |
|
(Wage Earner) |
(Social Security Number) |
This case is before the Administrative Law Judge pursuant to a request for
hearing filed on __________________ with respect to the North Carolina
Disability Determination Section reassessment of the prior denial of the
application(s) filed on ________________.
In accordance with the Stipulation and Order of Settlement negotiated by
the parties and approved by the United States District Court for the
Western District of North Carolina in the case of Hyatt v.
Shalala, No. C-C-83-655-MU (W.D. North Carolina, March 21,
1994), the claimant requested and received a reassessment of the final
determination on the prior application(s) filed on ______________. Under
the terms of the Hyatt settlement order, the
claimant may obtain a hearing on the reassessment if new and material
evidence is submitted.
[The claimant has submitted no additional evidence.] OR [The undersigned
has considered the following evidence submitted by the claimant:
(list all documents submitted by the claimant to the DDS or ALJ, or obtained by the DDS, in connection with the Hyatt III reassessment).
(Provide a statement explaining why the evidence is not new and material with respect to the reassessment period. For example: “The above-listed evidence cannot be considered 'new' within the meaning of the settlement order because it was considered by the North Carolina Disability Determination Section when it adjudicated the earliest Hyatt claim rather the reassessment claim.” OR “The above-listed evidence cannot be considered 'material' within the meaning of the settlement order because the evidence, by itself or when considered with all of the other available evidence, does not warrant a change in any finding pertinent to any matter at issue or a change in the ultimate decision.”)]
Accordingly, the claimant has not submitted new and material evidence.
Therefore, the request for hearing is hereby dismissed and the
determination dated
(insert date of DDS determination that conferred Hyatt III settlement subclass member status)
remains in effect.
|
|
__________________________ |
|
|
Administrative Law Judge |
Date:
Attachment 14. Notice Transmitting ALJ Order of Dismissal in Settlement Subclass
Member Case
NOTICE OF DISMISSAL
HYATT III REASSESSMENT CASE
Claimant's Name
Address
City, State Zip
Enclosed is an order of the Administrative Law Judge dismissing your
request for hearing. Please read this notice and the Order of Dismissal
carefully.
What This Order Means
The Administrative Law Judge will not review the denial of your prior
claim issued on ____________. The enclosed order explains why. There is no
right to any further appeal, i.e., no right to Appeals Council or judicial
review.
Information about Filing a New Application
If you think you are disabled now, you may file a new application. If you
decide to file a new application, contact any Social Security
office.
Do You Have Any Questions?
If you have any questions, contact your local Social Security office. If
you visit your local Social Security office, please bring this notice and
the Administrative Law Judge's order with you.
Enclosure
cc: (Name and address of representative, if any)
(Social Security Office (City, State))
Hyatt Attorney
North Carolina Justice and
Community Development Center
224 South Dawson Street
P.O.
Box 28068
Raleigh, NC 27611
Telephone:
1-800-299-8619
Attachment 15. ALJ Reassessment Decision in Settlement Subclass Member Case
— Claimant Not Disabled During Reassessment Period
SOCIAL SECURITY ADMINISTRATION
OFFICE OF HEARINGS AND APPEALS
HYATT III REASSESSMENT DECISION
|
IN THE CASE OF: |
CLAIM FOR: |
|
___________________________ |
___________________________ |
|
(Claimant) |
|
|
___________________________ |
___________________________ |
|
(Wage Earner) |
(Social Security Number) |
This case is before the Administrative Law Judge pursuant to a request for
hearing filed on __________________ with respect to the North Carolina
Disability Determination Section reassessment of the prior denial of the
application(s) filed on ________________.
In accordance with the Stipulation and Order of Settlement negotiated by
the parties and approved by the United States District Court for the
Western District of North Carolina in the case of Hyatt v.
Shalala, No. C-C-83-655-MU (W.D. North Carolina, March 21,
1994), the claimant requested and received a reassessment of the final
determination on the prior application(s) filed on ______________. Under
the terms of the Hyatt settlement order, a claimant
may obtain a hearing on a North Carolina Disability Determination Section
reassessment if new and material evidence is submitted.
The claimant submitted new and material evidence and a hearing was held on
__________. Pursuant to the Hyatt settlement order,
the undersigned has considered the claimant's testimony, the new and
material evidence and the evidence previously of record in this case using
the Secretary's regulations for the evaluation of pain
(20 CFR §§
404.1529 and/or
416.929) in a
manner consistent with the standard expressed by the Fourth Circuit in
Hyatt v. Sullivan, 899 F.2d 329, 337 (4th Cir.
1990). I find that the claimant was not under a disability within the
meaning of the Social Security Act at any time between
(enter the starting date of the period considered and a phrase indicating the significance of the date, e.g., the claimant's alleged onset date or the date of the claimant's application for Supplemental Security Income)
and
(enter the ending date and the significance of the ending date, e.g., the date of the DDS determination or the date that the insured status requirements were last met).
Accordingly, upon reassessment, the undersigned concludes that the
determination dated
(insert date of DDS determination that conferred Hyatt III settlement subclass member status)
is correct. Therefore, that determination remains in effect as the final
determination of the Secretary on the claimant's application filed on
________.
|
|
__________________________ |
|
|
Administrative Law Judge |
Date:
Attachment 16. Notice Transmitting ALJ Hyatt III Reassessment Decision in
Settlement Subclass Member Case
NOTICE OF HYATT III REASSESSMENT DECISION
Claimant's Name
Address
City, State Zip
Enclosed is the Administrative Law Judge's reassessment decision pursuant
to the Hyatt court order. Please read this notice
and the decision carefully.
What This Order Means
The Administrative Law Judge has reviewed the denial of your prior claim
issued on ____________ and concluded that it is correct. The enclosed
decision explains why. There is no right to any further appeal, i.e., no
right to Appeals Council or judicial review.
Information about Filing a New Application
If you think you are disabled now, you may file a new application. If you
decide to file a new application, contact any Social Security
office.
Do You Have Any Questions?
If you have any questions, contact your local Social Security office. If
you visit your local Social Security office, please bring this notice and
the Administrative Law Judge's order with you.
Enclosure
cc: (Name and address of representative, if any)
(Social Security Office (City, State))
Hyatt Attorney
North Carolina Justice and
Community Development Center
224 South Dawson Street
P.O.
Box 28068
Raleigh, NC 27611
Telephone:
1-800-299-8619
Attachment 17. November 4, 1996 Signed Agreement Supplementing the March 21, 1994
Settlement Order in Hyatt III
 |
|
Social Security
Office of the General Counsel
October 28, 1996
|
Charles McBrayer Sasser
Douglas S. Sea
Cox, Gage and
Sasser
Suite 2160
227 West Trade Street
Charlotte,
North Carolina 28202
John Wester
Robinson, Bradshaw and Hinson
1900
Independence Center
101 North Tyron Street
Charlotte,
North Carolina 28246
Carlene McNulty
North Carolina Justice and Community Development
Center
P.O. Box 28068
Raleigh, North Carolina 27611
Dear Class Counsel:
This agreement pertaining to adjudication of reassessment of cases is to
be applied in conjunction with the Hyatt
Stipulation and Order of Settlement (Civ. No. C-C-83-655-MU) filed on
March 21, 1994 (hereinafter “Hyatt Settlement
Order”) and the parties agree that the terms of this agreement are
enforceable by the court pursuant to paragraphs 14, 19 and 22 of the
Hyatt Settlement Order. This agreement does not
constitute a modification of the Hyatt Settlement
Order, but serves to supplement the Hyatt
Settlement Order as it pertains to reassessment cases.
1.
Within sixty days from the date of this agreement, class counsel will make
their best efforts to identify by name, social security number (SSN) and
BIC, the individuals whose claims were denied on reassessment by the North
Carolina Disability Determination Service (DDS) under
Hyatt III prior to May 21, 1996. The list provided
by class counsel may be overinclusive. This information will be provided
to SSA on a disc in ascii format with a record layout. Class counsel may
also send to SSA, on a disc, the names and available SSN(s) of additional
individuals (to total no more than 400 persons) who, according to class
counsel's records, may have reassessment cases covered by this agreement.
If SSA is unable to identify from the Civil Action Tracking System (CATS)
that these are cases subject to this agreement, class counsel will submit
additional evidence concerning these cases. The Office of Hearings and
Appeals (OHA) will, in the course of normal processing, identify
reassessment cases pending on appeal which were denied by the DDS before
May 21, 1996 whether or not they have been identified by class counsel and
process them pursuant to paragraph 3 below. SSA (and/or DDS) shall
determine whether these and all other individuals identified by class
counsel, SSA or the DDS have reassessment cases denied by the North
Carolina DDS under Hyatt III prior to May 21, 1996.
Later identified cases will be processed by SSA and DDS in a manner
consistent with this agreement.
2.
For all individuals determined to have been issued
Hyatt III reassessment determinations prior to May
21, 1996, the prior reassessment determination will become void and a new
determination will be made (except as provided in paragraph 3 below). The
new, complete reassessment will be performed in accordance with the terms
of the Hyatt Settlement Order, the Hyatt Program
Operation Manual System (POMS) and this agreement. The new reassessment
shall be performed by a different adjudicative team than that which made
the prior reassessment decision. A notice of determination will be sent to
the individual regarding the new reassessment determination and will
include the opportunity to appeal pursuant to paragraph 10(l)(iii) of the
Hyatt Settlement Order.
3.
Reassessment claims subject to this agreement which are pending at or have
been decided by OHA will be processed as follows:
a.
If the reassessment claim subject to this agreement has not yet been
scheduled for a hearing, or a hearing has been held, the claim will
continue to be processed by OHA under existing
Hyatt III procedures.
b.
If the reassessment claim subject to this agreement has not yet been
scheduled for a hearing, OHA will make a determination on whether the
“new and material evidence” requirement of paragraph 10(m) of
the Hyatt Settlement Order has been met.
1.
If the “new and material” evidence standard is met, the case
will remain at OHA and be processed pursuant to the
Hyatt Settlement Order.
2.
If the “new and material” evidence standard is not met, the
case will be remanded to the DDS; the individual will receive a new DDS
reassessment determination and will have an additional opportunity to
appeal pursuant to subparagraph 10(1)(iii) of the
Hyatt Settlement Order (i.e., if the claim is again
denied by the DDS and the individual must ask for a new hearing and again
must proceed in accordance with subparagraph 10(l)(iii) of the
Hyatt Settlement Order and must provide “new
and material” evidence.) If the claim is appealed, the evidence
submitted in connection with the first and second DDS reassessments or the
prior reassessment appeal, as well as other evidence proffered, will be
considered in making the new and material evidence determination.
c.
If a decision on the merits of the reassessment claim has been made by
OHA, the claim will not be reviewed under the terms of this agreement.
(NOTE: A decision “on the merits” will not include a claim in
which the request for hearing was dismissed).
4.
The DDS shall give reassessments performed subject to this agreement
(i.e., those replacing determinations made prior to May 21, 1996) priority
over other Hyatt reassessments, when
practicable.
5.
The DDS will use the attached desk guide [see Attachment 12] in performing
all Hyatt reassessments and will comply with the
guide and all referenced POMS sections in a manner consistent with the
Hyatt Settlement Order and this agreement.
6.
The DDS shall not deny any reassessment claim in which the case record
does not contain evidence that the DDS has attempted to obtain statements
from the claimant, his or her treating or examining physician(s) or
psychologist(s), and other related symptoms, and the factors described in
20 C.F.R.
§§ 404.1529(c)(3) and
416.929(c)(3)
to the degree that the information about each factor is available and
relevant to the case and the claimant or other person providing the
information has a basis to know about the factor. The notice in Exhibit 6
in POMS DI
32548.095 is not sufficient to meet this requirement.
7.
DDS will comply with Hyatt POMS
DI
32548.015D.4. concerning contacting appointed representatives in
performing reassessments. (NOTE: If there was an appointed representative
in a claim prior to the Hyatt III claim, the
representative does not have to be contacted; if there is an appointed
representative in a claim subsequent to a Hyatt III claim(s), that
representative will be contacted.) The absence of an SSA-1696-U4
(Appointment of Representative) form will not relieve the DDS from
compliance with POMS
DI
32548.015D.4. if there is another indication in the file that there
is representation.
8.
The DDS shall review and evaluate medical records or opinions submitted by
the claimant, including records or opinions submitted in connection with a
post Hyatt claim for benefits, that are dated after
the date of the denial being reassessed to determine whether they relate
to a condition that may have begun prior to the date of the prior denial.
If the claimant has informed the DDS or SSA of the existence of medical
records dated after the date of the prior denial that pertain to a
condition that may have begun prior to the date of the prior denial, the
DDS shall make “every reasonable effort” to obtain and review
the evidence. If a claimant wishes to submit medical evidence dated after
the date of the denial being reassessed, the DDS shall not discourage the
claimant from submitting the medical evidence, even if it pertains to a
condition that began after the date of the prior denial.
9.
The DDS shall document the case record as to the consideration given to
the statements of the claimant, his or her treating or examining
physician(s) or psychologist(s), and others, as set forth in
20 C.F.R. §§
404.1529 and
416.929 and the
Hyatt Settlement Order. Further, the DDS shall
follow Social Security Ruling
(SSR) 96-7p (POMS
DI 24515.066) and
prepare a finding as to the credibility of the individual's statements
about any alleged symptom(s) and its functional effects in all cases in
which the claimant's statements abut the intensity, persistence, or
limiting effects of symptoms are not substantiated by the objective
medical evidence. As described in
SSR 96-7p (POMS
DI 24515.066), the
case record must contain specific reasons for the finding on credibility,
supported by the evidence in the case record, and must be sufficiently
specific to make clear to any subsequent reviewers the weight the
adjudicator gave to the individual's statements and the reasons for that
weight.
10.
DDS shall assure that both title II and title XVI claims are reassessed
and that notice(s) addressing the Title II and Title XVI reassessment
determination(s) are issued.
11.
The DDS will follow Social Security Rulings
85-28 and
96-3p in determining
whether a claimant's medically determinable physical or mental impairment
or combination of impairments has more than a minimal effect on his or her
ability to do basic work activities. Where the claimant's alleged symptoms
can reasonably be expected to be produced by the established
impairment(s), the intensity, persistence, and limiting effects of the
symptom(s) must be considered along with the objective medical and other
evidence in determining severity. If the claim is denied at step 2 of the
sequential evaluation process, the personalized disability notice to the
claimant must include a credibility finding that is sufficiently specific
as to make clear the weight given to the claimant's statements abut his or
her symptoms in determining severity and the reasons for that
weight.
12.
DDS reassessment notices will comply with POMS
DI 32548.045 and
DI 26530.020 and
will, additionally, prominently indicate that it is a new determination
replacing the prior reassessment determination and that claimants will
have another opportunity to appeal this determination pursuant to
paragraph 10(l)(iii) of the Hyatt Settlement Order.
Copies of all notices will be contemporaneously mailed to class
counsel.
The new language added to the notice will state in bold type:
Based on an agreement with class counsel, this is a new determination
replacing the prior Hyatt determination made in
your case. YOU HAVE A NEW OPPORTUNITY TO APPEAL THIS DETERMINATION, as
explained below.
In addition, new language will be added to the SSA-831 as follows:
“This replaces the reassessment decision of
__________________.”
13.
The requirements contained above as numbers 5-11 shall be followed, as
applicable, in all other Hyatt reassessments
performed by the DDS after the date of this agreement.
14.
In conjunction with the monitoring report sent to class counsel pursuant
to paragraph 11 of the Hyatt Settlement Order, SSA
shall report to class counsel in a manner that distinguishes from other
Hyatt decisions, the results of all new
reassessment determinations made pursuant to this agreement (i.e., those
replacing those determined prior to May 21, 1996).
Our signatures below indicate our concurrence with this agreement.
|
|
Sincerely, |
|
|
/s/
Clifford C. Marshall
Assistant
United States Attorney
Room 306, United States Courthouse
100
Otis Street
Asheville, North Carolina 28801-2611
/s/
A.
George Lowe
Acting Associate General Counsel
Litigation
Division
/s/
Deborah Feustle Blair
Attorney
Office
of the General Counsel
Social Security Administration
6401
Security Boulevard
Baltimore, Maryland 21235
|
Class Counsel also indicates concurrence with this agreement by signing
below and returning this letter to the Office of the General
Counsel.
|
|
/s/
Charles McBrayer Sasser
/s/
Douglas
S. Sea
/s/
John Wester
/s/
Carlene
McNulty
Dated: November 4, 1996
|
HYATT DESK GUIDE
(To
Be Used in HYATT Reassessment Cases Only)
ALL EXPLANATIONS MUST BE CLEARLY SET FORTH IN THE APPROPRIATE PLACE IN THE
CASE RECORD.
2.
Can impairment(s) be reasonably expected to produce alleged
symptoms?
(DI
24515.061.B.)
3.
Is impairment(s) severe? If NO, EXPLAIN.
4.
Were symptoms considered in determining severity? If NO, EXPLAIN.
(DI
24505.003.B.)
6.
If alleged symptom-related limitations or restrictions are greater than
would be expected on the basis of the physical impairment(s), was the
possibility of a medically determinable mental impairment considered? If
NO, EXPLAIN.
(DI
24515.061.B.)
8.
Does a function-by-function assessment establish the claimant is able to
perform past relevant work? If YES, DENY.
9.
Considering RFC, age, education and work experience, can the claimant
perform other work? If YES, DENY. If NO, ALLOW.
(DI
25015.020.A.)
Attachment 18. Dismissal of Request for Hearing — Remand to DDS for New
Reassessment of Settlement Subclass Denial
SOCIAL SECURITY ADMINISTRATION
OFFICE OF HEARINGS AND APPEALS
ORDER OF DISMISSAL
|
IN THE CASE OF: |
CLAIM FOR: |
|
___________________________ |
___________________________ |
|
(Claimant) |
|
|
___________________________ |
___________________________ |
|
(Wage Earner) |
(Social Security Number) |
This case is before the Administrative Law Judge pursuant to a request for
hearing filed on __________________ with respect to the application(s)
filed on ________________.
In accordance with the Stipulation and Order of Settlement negotiated by
the parties and approved by the United States District Court for the
Western District of North Carolina in the case of Hyatt v.
Shalala, No. C-C-83-655-MU (W.D. North Carolina, March 21,
1994) (hereinafter
“Hyatt Settlement Order”)
and the November 4, 1996 signed agreement between the parties
supplementing the Hyatt Settlement Order, the Hyatt III reassessment
determination made prior to May 21, 1996 is void and a new reassessment
determination must be made.
Accordingly, the request for hearing is hereby dismissed and the case
remanded to the Disability Determination Section for a new reassessment
determination.
|
|
__________________________ |
|
|
Administrative Law Judge |
Date:
cc: Name and address of representative, if any
Hyatt Attorney North Carolina Justice and Community Development Center
224 South Dawson Street P.O. Box 28068 Raleigh, NC 27611
Attachment 19. Route Slip to DDS Requesting a New Reassessment of Settlement
Subclass Denial
|
ROUTING AND TRANSMITTAL SLIP |
DATE: |
|
TO:
1. North Carolina Disability Determination Section
|
INITIALS |
DATE |
|
2. |
|
|
|
3. |
|
|
|
XX |
ACTION |
|
FILE |
|
NOTE AND RETURN |
|
|
APPROVAL |
|
FOR CLEARANCE |
|
PER CONVERSATION |
|
|
AS REQUESTED |
|
FOR CORRECTION |
|
PREPARE REPLY |
|
|
CIRCULATE |
|
FOR YOUR INFORMATION |
|
SEE ME |
|
|
COMMENT |
|
INVESTIGATE |
|
SIGNATURE |
|
|
COORDINATION |
|
JUSTIFY |
|
|
REMARKS
Claimant: ________________________ SSN:
_____________________________
We are forwarding the attached files to your office for a new reassessment
determination of the claimant's Hyatt II settlement subclass denial. A
Hyatt III reassessment determination was issued prior to May 21, 1996.
Based on an agreement with class counsel, the prior reassessment
determination is void and a new reassessment determination must be
made.
Attachment
DO NOT use this form as a RECORD of approvals, concurrences, disposals,
clearances, and similar actions.
|
FROM:
Office of Hearings and Appeals
___________________________________________
|
SUITE/BUILDING |
|
PHONE NUMBER |
OPTIONAL FORM 41 (Rev. 7-76)
*U.S.GPO:1985-0-461-274/20020
Prescribed by GSA
FPMR (41 CFR) 101-11.206
Attachment 20. Dismissal of Request for Hearing in Settlement Subclass Member Case
after a New Reassessment at the DDS Level — No New and Material
Evidence Submitted
SOCIAL SECURITY ADMINISTRATION
OFFICE OF HEARINGS AND APPEALS
ORDER OF DISMISSAL
HYATT III REASSESSMENT CASE
|
IN THE CASE OF: |
CLAIM FOR: |
|
___________________________ |
___________________________ |
|
(Claimant) |
|
|
___________________________ |
___________________________ |
|
(Wage Earner) |
(Social Security Number) |
This case is before the Administrative Law Judge pursuant to a request for
hearing filed on __________________ with respect to the North Carolina
Disability Determination Section reassessment of the prior denial of the
application(s) filed on ________________.
In accordance with the Stipulation and Order of Settlement negotiated by
the parties and approved by the United States District Court for the
Western District of North Carolina in the case of Hyatt v.
Shalala, No. C-C-83-655-MU (W.D. North Carolina, March 21,
1994) (hereinafter “Hyatt Settlement
Order”) and the November 4, 1996 signed agreement between the
parties supplementing the Hyatt Settlement Order,
the reassessment determination made prior to May 21, 1996 is void and a
new reassessment determination was made on _____________. Under the terms
of the Hyatt Settlement Order and the signed agreement of November 4,
1996, the claimant may obtain a hearing on the new reassessment
determination, if new and material evidence is submitted.
[The claimant has submitted no additional evidence.] OR [The undersigned
has considered the following evidence submitted by the claimant:
(list all documents submitted by the claimant to the DDS or ALJ, or obtained by the DDS, in connection with the Hyatt III reassessment, including evidence submitted in connection with the first and second DDS reassessments or the prior reassessment appeal, as well as other evidence proffered).
(Provide a statement explaining why the evidence is not new and material with respect to the reassessment period.
For example: “The above-listed evidence cannot be considered 'new'
within the meaning of the settlement order because it was considered by
the North Carolina Disability Determination Section when it issued its
(insert date of the DDS determination that conferred Hyatt III settlement subclass member status)
determination.” OR “The above-listed evidence cannot be
considered 'material' within the meaning of the settlement order because
the evidence, by itself or when considered with all of the other available
evidence, does not warrant a change in any finding pertinent to any matter
at issue or a change in the ultimate decision.”)]
Accordingly, the claimant has not submitted new and material evidence.
Therefore, the request for hearing is hereby dismissed and the
determination dated
(insert date of DDS determination that conferred Hyatt III settlement subclass member status)
remains in effect.
|
|
__________________________ |
|
|
Administrative Law Judge |
Date:
Attachment 21. Notice Transmitting ALJ Order of Dismissal in Settlement Subclass
Member Case after a New Reassessment at the DDS Level
NOTICE OF DISMISSAL
HYATT III REASSESSMENT CASE
Claimant's Name
Address
City, State Zip
Enclosed is an order of the Administrative Law Judge dismissing your
request for hearing. Please read this notice and the Order of Dismissal
carefully.
What This Order Means
The Administrative Law Judge will not review the denial of the new
reassessment of your prior claim issued on ____________. The enclosed
order explains why. There is no right to any further appeal, i.e., no
right to Appeals Council or judicial review.
Information about Filing a New Application
If you think you are disabled now, you may file a new application. If you
decide to file a new application, contact any Social Security
office.
Do You Have Any Questions?
If you have any questions, contact your local Social Security office. If
you visit your local Social Security office, please bring this notice and
the Administrative Law Judge's order with you.
Enclosure
cc: (Name and address of representative, if any)
(Social Security Office (City, State))
Hyatt Attorney
North Carolina Justice and
Community Development Center
224 South Dawson Street
P.O.
Box 28068
Raleigh NC 27611
Telephone:
1-800-299-8619
Attachment 22. ALJ Reassessment Decision in Settlement Subclass Member Case after
a New Reassessment at the DDS Level — New and Material Evidence
Submitted - Claimant Not Disabled During Reassessment Period
SOCIAL SECURITY ADMINISTRATION
OFFICE OF HEARINGS AND APPEALS
HYATT III REASSESSMENT DECISION
|
IN THE CASE OF: |
CLAIM FOR: |
|
___________________________ |
___________________________ |
|
(Claimant) |
|
|
___________________________ |
___________________________ |
|
(Wage Earner) |
(Social Security Number) |
This case is before the Administrative Law Judge pursuant to a request for
hearing filed on __________________ with respect to the North Carolina
Disability Determination Section reassessment of the prior denial of the
application(s) filed on ________________.
In accordance with the Stipulation and Order of Settlement negotiated by
the parties and approved by the United States District Court for the
Western District of North Carolina in the case of Hyatt v.
Shalala, No. C-C-83-655-MU (W.D. North Carolina, March 21,
1994), (hereinafter “Hyatt Settlement
Order”) and the November 4, 1996 signed agreement between the
parties supplementing the Hyatt Settlement Order,
the reassessment determination made prior to May 21, 1996 is void and a
new reassessment determination was made on _____________. Under the terms
of the Hyatt Settlement Order and the signed
agreement of November 4, 1996, the claimant may obtain a hearing on the
new reassessment determination, if new and material evidence is
submitted.
The claimant submitted new and material evidence and a hearing was held on
__________. Pursuant to the Hyatt Settlement Order,
the undersigned has considered the claimant's testimony, the new and
material evidence, the evidence previously of record, and any evidence
proffered during the hearing in this case. The undersigned decided this
case in accordance with the provisions of §§
201 through
233 and
1601 through
1635 of the Social
Security Act, as amended, the rules, regulations, policies and procedures
pertaining thereto, the national regulations for the evaluation of pain
(20 CFR §§
404.1529 and
416.929) and the
settlement order.
The undersigned finds that the claimant was not under a disability within
the meaning of the Social Security Act at any time between
(enter the starting date of the period considered and a phrase indicating the significance of the date, e.g., the claimant's alleged onset date or the date of the claimant's application for Supplemental Security Income)
and
(enter the ending date and the significance of the ending date, e.g., the date of the DDS determination or the date that the insured status requirements were last met).
Accordingly, upon reassessment, the undersigned concludes that the
determination dated
(insert date of DDS new reassessment determination)
is correct.
(Insert explanation for conclusion.)
|
|
__________________________ |
|
|
Administrative Law Judge |
Date:
Attachment 23. Notice Transmitting ALJ Hyatt III Reassessment Decision in
Settlement Subclass Member Case after a New Reassessment at the DDS Level
— New and Material Evidence Submitted - Claimant Not Disabled During
Reassessment Period
NOTICE OF HYATT III REASSESSMENT DECISION
Claimant's Name
Address
City, State Zip
Enclosed is the Administrative Law Judge's reassessment decision pursuant
to the Hyatt court order. Please read this notice and the decision
carefully.
What This Order Means
The Administrative Law Judge has reviewed the denial of your prior claim
issued on ____________ and concluded that it is correct. The enclosed
decision explains why. There is no right to any further appeal, i.e., no
right to Appeals Council or judicial review.
Information about Filing a New Application
If you think you are disabled now, you may file a new application. If you
decide to file a new application, contact any Social Security
office.
Do You Have Any Questions?
If you have any questions, contact your local Social Security office. If
you visit your local Social Security office, please bring this notice and
the Administrative Law Judge's order with you.
Enclosure
cc: (Name and address of representative, if any)
(Social Security Office (City, State))
Hyatt Attorney
North Carolina Justice and
Community Development Center
224 South Dawson Street
P.O.
Box 28068
Raleigh NC 27611
Telephone:
1-800-299-8619
Attachment 24. October 21, 1999 Order of the United States District Court for the
Western District of North Carolina
[Filed Charlotte N.C.]
[October 21, 1999]
[U.S. District
Court]
[W. Dist of N.C.]
IN THE UNITED STATES DISTRICT COURT
FOR THE WESTERN DISTRICT OF NORTH CAROLINA
CHARLOTTE DIVISION
Civil Action No. C-C-83-655-MU
|
PATRICK HYATT, et al., |
) |
|
|
Plaintiffs,
|
) |
|
|
|
) |
|
|
v.
|
) |
|
|
|
) |
ORDER |
|
KENNETH S. APFEL, |
) |
|
|
Commissioner of Social Security, |
) |
|
|
Defendant.
|
) |
|
|
|
) |
|
|
_______________________________ |
) |
|
This lawsuit began in August 1983 and has been the subject of a protracted
history of litigation. On three occasions, the Fourth Circuit Court of
Appeals has upheld classwide relief ordered by the district court for
three different groups of North Carolina disability claimants, in
Hyatt I, 757 F.2d 1455 (1985),
Hyatt II, 807 F.2d 376 (1986), and
Hyatt III, 899 F.2d 329 (1990). On March 21, 1994,
this court approved a comprehensive settlement order intended by the
parties to implement Hyatt III relief and, it was hoped, to bring an end
to the litigation.
Plaintiffs' two motions, filed June 28, 1996 and October 31, 1996, are
presently before the court, seeking to enforce the March 21, 1994
Settlement Order implementing Hyatt III relief. The court has carefully
reviewed the parties' extensive briefs and exhibits and heard oral
argument on September 13, 1999. The material facts are not in
dispute.
In a nutshell, the 1994 Settlement Order provides a new chance for North
Carolina residents with complaints of disabling pain to prove entitlement
to disability benefits based on Social Security and Supplemental Security
Income (SSI) applications denied by the defendant Social Security
Administration (SSA) between July 6, 1981 and Nov. 14, 1991 (Hyatt III
claims). At issue in plaintiffs' motions are two of SSA's interpretations
of the definition of Hyatt III class membership set out in paragraph 1 of
the 1994 Settlement Order. SSA concedes it has applied the challenged
interpretations to its class membership decisions but defends those
interpretations as permissible.
According to the government's representations at the September 13, 1999
hearing, 77,717 persons have requested Hyatt III relief pursuant to the
1994 Settlement Order. 50,549 cases have received class membership
decisions. Of those, SSA estimates that between 6500 and 17,500
individuals have been denied Hyatt III class membership pursuant to the
disputed provisions of the Settlement Order. Almost five years after Hyatt
III notices were mailed, over 27,000 persons who requested Hyatt III
relief have yet to receive a class membership decision from SSA.
Paragraphs 9(a) and 9(f) of the 1994 Settlement Order provided that anyone
who meets the class definition in paragraph 1 of the Settlement Order is
eligible for class membership. The Settlement Order, paragraph 8(c),
specifies that in cases of reasonable doubt, individuals requesting Hyatt
III relief must be granted class membership. These provisions demonstrate
the parties' intent that the Settlement Order be construed to narrowly
limit the permissible grounds for SSA to deny Hyatt III class
membership.
Plaintiffs' First Motion
Plaintiffs' June 28, 1996 motion challenges SSA's interpretation of
subparagraph 1(b)(I) of the 1994 Settlement Order. Subparagraph 1(b)(I)
concerns individuals who filed both a Hyatt III claim (an application for
disability benefits denied by SSA between July 7, 1981 and November 14,
1991, which is otherwise eligible for Hyatt III relief) and a post-Hyatt
claim (an application that received a decision on the merits issued on or
after November 14, 1991, which is not eligible for Hyatt III relief).
Subparagraph 1(b)(I) of the 1994 Settlement Order provides that Hyatt III
class membership may be denied for “a (Hyatt III) claim which has
been reasserted by a subsequent application or request for reopening
covering the same period of time as the Hyatt III claim and as to which a
final determination on the merits was issued on or after November 14,
1991.”
Plaintiffs' evidence presents several examples of individuals denied class
membership pursuant to SSA's interpretation of subparagraph 1(b)(I). For
example, in December 1996, Linda Pressley was involved in an automobile
accident, which crushed her pelvis and right hip, a condition that
involved complaints of disabling pain. In December 1997, she filed an
application for SSI benefits, was denied by SSA, and did not appeal. This
is her Hyatt III claim. In 1991 and 1992 she filed three more
applications, which were denied by an administrative law judge (ALJ) in
1993. Because the ALJ denial was after November 14, 1991, the date SSA
published final regulations on the evaluation of pain, the 1991 and 1992
claims are post-Hyatt claims not eligible for Hyatt III relief.
Plaintiffs' complaint is that SSA also has denied Ms. Pressley Hyatt III
class membership for her 1987 claim, thus denying her a new opportunity to
establish entitlement to disability benefits based on that claim.
Plaintiffs' Appendix A26, M.
In class membership determination instructions negotiated by the parties
in November 1994 (Pla. App. C1), the parties agreed that class membership
denial under subparagraph 1(b)(I) is permissible only if it is clear that
a post-Hyatt decision “readjudicated the merits of the entire period
covered by the Hyatt III claim.
A denial of a request for reopening is not considered to be a readjudication.”
Pla. App. F4 (emphasis in original). The issue in dispute is what is
necessary to constitute a readjudication of the merits of the entire
period.
SSA's position is that such a readjudication occurred if (1) a subsequent
application alleged the same (or earlier) onset date of disability as the
prior Hyatt III claim, and (2) medical evidence describing the claimant's
condition as of the alleged onset date was “available” to the
post-Hyatt adjudicator, and (3) the post Hyatt decision, “including
supporting documentation,” indicates that disability was
“considered” back to the alleged onset date. Pla. App. E4.
For example, because Ms. Pressley alleged the same disability onset date,
December 1996, in each of her applications, and because the ALJ in 1993
“evaluated” her condition during the entire alleged period,
she was denied Hyatt III class membership. Pla. App. A26.
The court agrees with plaintiffs that SSA's interpretation of subparagraph
1(b)(I) conflicts with the language of the 1994 Settlement Order, the
parties' agreed-upon class membership determination instructions, the
Social Security Act and regulations, and due process. Indeed, plaintiffs
have identified independent grounds that call for this court to grant the
first motion.
Under Social Security regulations, the claim asserted by a disability
application is a claim for benefits.
20 CFR Sections
404.610,
416.310. The
period of time covered by that claim is the period of benefits which may
be awarded on that application.
20 CFR Section
404.316(a). Under the statute, Social Security disability benefits
can be awarded for no more than twelve months prior to the date of the
application. SSI benefits cannot be awarded for any month earlier that the
date of the application being adjudicted. 42 U.S.C. Sections 416(I)(2),
1382(c)(6). Linda Pressley's December 1987 claim for SSI thus sought
benefits from the date of application forward. When she reapplied in
January 1991 it was again for SSI benefits, so the period of benefits
covered by her second claim began with the date of her second application,
January 1991, even though she again alleged she had been disabled since
December 1986. Pla. App. M.
An application for Social Security or SSI disability benefits need not
prove permanent disability to be eligible for benefits. The claimant only
needs to prove a disability that has lasted or is expected to last twelve
months. 20 CFR
Sections 404.1505(a),
416.905(a).
Linda Pressley's December 1987 claim alleged she had been disabled for
twelve months, since her December1996 accident. Pla. App. A26. But by
1993, when her 1991 and 1992 claims were denied, her fractures had healed,
and her doctor opined that she could perform sedentary work. Pla. App.
M2-3. When the ALJ denied Ms. Pressley's 1991 and 1992 claims in 1993, the
issue before him was not whether she had been disabled for any twelve
month period since December 1996, but rather whether she was disabled
during the period from January 1991 through the date of his decision. That
was the period covered and the period adjudicated by the post-Hyatt
decision. Pla. App. M. Because the ALJ did not adjudicate the period
covered by Pressley's 1987 claim in his 1993 decision, that claim remains
eligible for Hyatt III relief.
SSA's position is that if the post-Hyatt adjudicator
“considered” the entire alleged period of disability and had
“available” to him medical evidence from the entire period,
this is sufficient to constitute an adjudication of the entire period.
Pla. App. E4. This court disagrees that consideration or discussion of the
prior period is equivalent to an actual decision on the period of benefits
sought in the first claim. Judges may discuss a past period as background
or context for a decision about the claimant's current condition. In the
Pressley case, the judge discussed the past period to support his
conclusion that she had improved and was not currently disabled. Pla. App.
M. Consideration or discussion of a prior period of alleged disability is
not sufficient to be a reopening and readjudication of a prior claim.
McGowen v. Harris, 666 F.2d 60, 67-68 (4th Cir.
1981); Hall v. Chater, 52 F.3d 518,521 (4th Cir.
1995).
SSA's published regulations governing administrative finality prohibit a
readjudication of a period of benefits which already has been finally
denied in a previous claim unless that prior claim is first reopened.
20 CFR Sections
404.905,
404.987,
416.1405,
416.1487. Thus, a
post-Hyatt decision could not have been a “determination on the
merits” of the period of benefits that was previously finally
denied by SSA when it denied the Hyatt III claim unless the Hyatt III
claim was reopened in the post-Hyatt decision. Both the 1994 Settlement
Order (note 5) and the parties' agreed upon class membership instructions
(Pla. App. F4), specify that if the post-Hyatt adjudicator decided not to
reopen the Hyatt III claim, this was not a “determination on the
merits” or “readjudication” of the period of benefits
sought in the Hyatt III claim. Yet SSA contends a post-Hyatt decision
could readjudicate the entire period of disability benefits without
reopening the Hyatt III claim. Pla. App. A14, B7.
In the Pressley case, the first claim was denied in December 1987. Because
Ms. Pressley did not appeal, that decision became final sixty days later,
in February 1988. In the 1993 decision the ALJ did not reopen the December
1987 denial, so under SSA's administrative finality regulations and note 5
of the 1994 Settlement Order, the 1993 decision could not have
readjudicated the period of disability denied in December 1987. Pla. App.
A26, M.
SSA's regulations state that there is no right to appeal SSA's failure to
reopen a previously finally denied claim.
20 CFR Sections
404.903(I),
416.1403(a)(5).
Absent a reopening, there is no right to judicial review of a previous
period of disability benefits that was finally denied in a prior claim.
Califano v. Sanders, 430 U.S. 99 (1977). Without
the right to administrative appeal or to judicial review as to the prior
period of disability benefits, there cannot have been a readjudication of
the period of benefits sought by the Hyatt III claim.
Finally, under principles of due process, a post-Hyatt decision could not
have readjudicated the period of benefits previously finally denied by SSA
in the Hyatt III claim unless SSA clearly communicated to the claimant in
its post-Hyatt decision that it was doing so. SSA's own regulations
require clear notice to the claimant of what is being adjudicated in the
agency's decision. 20 CFR
Section 404.904. The court cannot locate in SSA's post-Hyatt
decisions, in the Pressley case or in the other case examples in evidence,
any language informing the claimant that the period of benefits sought by
her previous claim was being readjudicated. Indeed, SSA's position is that
“SSA does not have to state that the decision is an
adjudication” for it to be one. Def. Response at 25. As evidence
that SSA readjudicated a prior claim, SSA relies on “supporting
documentation” which is not part of the decision communicated to
the claimant. Pla. App. E4, Def. Exh. G. Without clear notice to claimant
of SSA's new adjudication of the prior period, there cannot have been a
“determination on the merits” “covering the same period
of time as the Hyatt III claim,” as required by subparagraph
1(b)(I).
Subparagraph 1(b)(I) is plainly limited to decisions issued after November
14, 1991. SSA nonetheless applies its interpretation of subparagraph
1(b)(I) to ALJ and Appeals Council decisions issued between August 6, 1990
and November 14, 1991. Pla. App. A11. SSA states that this practice is
permitted by paragraph 10(k) of the 1994 Settlement Order. This court
disagrees. Paragraph 10(k) excludes from Hyatt III relief only claims that
were “finally denied” by an ALJ or the Appeals Council after
August 6, 1990. For the same reasons discussed above, SSA may not use this
provision to deny Hyatt III relief for previously denied claims which were
not reopened and readjudicated after August 6, 1990.
SSA also extend its interpretation of subparagraph 1(b)(I) to case in
which the claimant amended his alleged onset date in a post-Hyatt claim,
if the original alleged onset date in the post-Hyatt claim was the same as
in the earlier Hyatt claim. Pla. App. B12. Once again, SSA is claiming
that the decision on the second claim “would cover the entire period
of the first claim,” without reopening the Hyatt III claim in the
post-Hyatt decision, and even though the Hyatt III claim was not being
adjudicated at the time of the amendment of the onset date.
Id. For the same reasons explained
above, this practice is not permissible.
Plaintiffs' Second Motion
Plaintiffs' October 31, 1996 motion challenges SSA's position, first
announced to class counsel in a letter dated July 15, 1996, that SSA would
deny Hyatt III class membership to individuals who responded to a Hyatt II
notice but who subsequently withdrew that request for Hyatt II relief or
otherwise declined to pursue fully their rights under Hyatt II. Pla. App.
B9. Hyatt III rights were created by the Fourth Circuit Court in 1986, 807
F.2d 376, and implemented by the district court's December 1987 order, 118
F.R.D. 572. Because SSA continued to use an illegal pain standard in
performing Hyatt II reviews, individuals who were eligible for Hyatt
reviews are not excluded from receiving Hyatt III relief. 1994 Settlement
Order, paragraph 1, Exhibit A.
Subparagraph 1(b)(iii) of the 1994 Settlement Order requires individuals
who received Hyatt II notices to “timely...respond” to the
Hyatt II notice, but does not require any action beyond that initial
response. This provision must be construed as written. The court therefore
agrees with plaintiffs that SSA's class membership denials based on
failure to pursue fully Hyatt II relief is not authorized by the 1994
Settlement Order. Indeed, SSA's practice conflicts with language in the
Settlement Order providing that Hyatt III claimants need not have
exhausted administrative remedies available to them prior to November 14,
1991. 1994 Settlement Order, note 3.
For the above reasons, the court hereby grants plaintiffs' motions and
enters the following ORDER:
1.
In making Hyatt III class membership decisions, SSA shall interpret
paragraph 1 of the 1994 Settlement Order as follows:
A.
Subparagraph 1(b)(I) of the 1994 Settlement Order does not permit Hyatt
III class membership denial for a Hyatt III claim (an application for
disability benefits denied by SSA between July 7, 1981 and November 14,
1991 and otherwise eligible for Hyatt III relief) unless, in a post-Hyatt
decision (a decision issued on or after November 14, 1991 by the N.C.
Disability Determination Service or a decision issued by an administrative
law judge or the Appeals Council on or after August 6, 1990), SSA reopened
(pursuant to 20 C.F.R.
404.987 or
414.1487) the
Hyatt III claim (as defined in paragraph 1(a) of the 1994 Settlement
Order), and made a new decision on the merits of the Hyatt III claim, and
clearly communicated to the claimant in its post-Hyatt decision that the
Hyatt III claim had been readjudicated. In addition, SSA may not deny
Hyatt III class membership on the ground that a post-Hyatt decision
adjudicated a post-Hyatt claim (favorably or unfavorably) based upon an
amended alleged onset date of disability, unless the Hyatt III claim was
reopened and was in the process of being adjudicated at the time of the
claimant's amendment of the alleged onset date.
B.
SSA may not deny Hyatt III class membership on the ground that an
individual who timely (or untimely with good cause) responded to a Hyatt
II notice subsequently withdrew that request for Hyatt II relief or
otherwise failed to pursue administrative remedies available under Hyatt
II.
2.
SSA shall identify all individuals who were denied Hyatt III class
membership prior to the implementation of this Order for whom the class
denial may have been affected by one of the agency's interpretations of
the 1994 Settlement Order enjoined in paragraph 1 above. SSA's prior class
membership denial shall be void in all of the identified cases. SSA shall
identify, in its reports to class counsel under paragraph 11(a) of the
1994 Settlement Order, the individuals whose prior class membership
denials are void pursuant to this paragraph. A new class membership
determination will be made by SSA in all such cases. All identified
individuals, their appointed representatives, and class counsel shall
receive written notice of any class membership denials made by SSA under
this procedure. Those class membership denials shall be subject to review
by class counsel and appeal pursuant to paragraph 8(d) of the 1994
Settlement Order. SSA shall identity, in its reports to class counsel
under paragraph 11(a) of the 1994 Settlement Order, the new class
membership decisions issued pursuant to this paragraph. Such reports shall
be provided every sixty days until this paragraph has been fully
implemented.
3.
Immediately upon entry of this Order, SSA shall cease class membership
denials based on the interpretations enjoined in this Order. SSA shall
provide to class counsel within ninety days of the date of this Order
detailed proposed instructions for the implementation of this Order. Class
counsel shall have thirty days from receipt of the proposed instructions
to object to SSA concerning any of the instructions. The court's approval
is not needed if the parties reach agreement on the instructions. If the
parties cannot in good faith resolve any dispute concerning the
instructions, each party shall submit within 150 days of the date of this
Order its proposed instructions to the court, along with a brief
explanation of why the proposed instructions should be approved by the
court.
4.
To the extent practicable, at each stage of class membership review and
merits adjudication, SSA shall accord priority to the cases entitled to
relief under this Order over other Hyatt III implementation.
5.
To the extent practicable, SSA shall promptly provide to class counsel
other information reasonably requested for the purpose of monitoring SSA's
compliance with this Order.
6.
This court will retain jurisdiction to enforce this Order and the 1994
Hyatt III Settlement Order.
This the 21st day of October, 1999
|
|
/s/
Graham C. Mullen
Chief
Judge
United States District Court
|