TN 46 (01-17)

GN 00502.030 Lay Evidence of Capability

A. Policy for lay evidence of capability

Lay evidence (nonmedical and nonlegal evidence) of capability helps you understand how the beneficiary has been managing any benefits and other funds that have been available to them to meet daily needs (food, shelter, clothing, and medical care).

Absent evidence of legal incompetence, lay evidence must be developed and considered in every capability determination.

Lay evidence may support or disprove the medical evidence in a case. As the decision maker, you must carefully evaluate all lay and medical evidence when making a determination of the beneficiary's capability. For component responsibilities, see DI 23001.005.

1. What are some examples of lay evidence?

Lay evidence is nonmedical and nonlegal evidence, which gives insight into a beneficiary's ability to manage or direct the management of his or her benefits. Some common examples of lay evidence include:

  • your observations (during a face-to-face interview) of the beneficiary's behavior, reasoning ability, how he or she functions with others, and how effectively he or she pursues the claim;

  • a statement made by the beneficiary that he or she is capable or incapable of managing his or her benefits;

  • documentation or reports that the beneficiary has been unable to meet his or her basic needs in the past, despite available income;

  • signed statements from, or contacts with, third-party sources with direct knowledge of facts or circumstances regarding the beneficiary’s daily living (e.g. beneficiary's relatives, custodian, close friends, neighbors, landlord, representatives of community groups, social workers, therapists, clergy, and adult protective services workers) that describe the beneficiary's ability to manage benefits and meet daily needs;

  • the payee applicant's answer to question 2 on the Form SSA-11-BK (Request to be Selected as Payee) (see GN 00502.115) or the similar question on the electronic Representative Payee System (eRPS) Capability screen (MS INTRANETERPS 009.017)); and

  • in disability cases, the beneficiary’s answer to question 17 on the Form SSA-3373-BK (Function Report-Adult) – Ability to handle money.

REMEMBER: The beneficiary is probably capable if he or she can tell you the amount of money received monthly, the source of the money, the amount of rent/mortgage, or the amount spent on groceries. The beneficiary is also capable if he or she can direct someone else to manage his or her benefits.

2. How do lay evidence and medical evidence work together?

Lay and medical evidence will both lead you to a clear understanding of a beneficiary's ability to manage or direct the management of benefits.

Sometimes, they may conflict. Nevertheless, you must evaluate both lay and medical evidence and make a capability determination based on the most convincing evidence.

3. How much lay evidence do I need to make a determination?

You need as much evidence as necessary to have a clear understanding of the beneficiary's abilities. This will vary from case to case.

B. Examples of capability determinations

Here are some examples using lay evidence and medical evidence:

1. Example 1 - Significant medical evidence available

Mr. Green's doctor submitted a Form SSA-787 (Physician’s/Medical Officer’s Statement of Patient’s Capability to Manage Benefits) describing Mr. Green's condition and stating that Mr. Green is incapable.

Mr. Green's brother, who is also his custodian, files a payee application. In answer to question #2 on the SSA-11-BK, Mr. Green's brother states that Mr. Green does not know the value of money and frequently gives it away to strangers.

At the interview, Mr. Green does not seem to understand your questions and answers them incoherently.

In this case, lay evidence of capability would be your observations of Mr. Green's incoherent speech and his brother's statement in answer to question #2 on the SSA-11-BK. Both the medical and lay evidence seem to agree that Mr. Green needs a payee.

2. Example 2 - Medical evidence is not convincing or not available

Mr. Brown's doctor submitted a Form SSA-787 stating that Mr. Brown is incapable.

However, Mr. Brown filed his own application for benefits and, to your observations, seemed able to handle his own affairs.

Therefore, the medical evidence is not consistent with the lay evidence (your observations).

To clarify:

  • discuss the need for a payee with Mr. Brown and obtain his statement about how he is handling his own affairs;

  • obtain statements from friends, relatives or other knowledgeable sources about how he is functioning in society and how he handles money; and

  • obtain a statement from the caseworker at the neighborhood mental health clinic (which Mr. Brown says he visits twice a week) about how Mr. Brown is functioning in the community and how he handles his money.

3. Example 3 - Lay evidence outweighs medical evidence

Mr. Black's doctor submitted a Form SSA-787 stating that Mr. Black is incapable.

At the interview, Mr. Black understands your questions and answers them coherently.

In response to questions about how Mr. Black has been managing his finances, he tells you that he belongs to a center in his community that helps him. He is directly involved in setting up a budget, choosing the services he needs and handling his money. He says the center is a place where he exercises control and authority over how his money is spent and how his bills are paid. You obtain a statement from the caseworker at the center that confirms Mr. Black's statements.

Since the medical evidence is not consistent with the lay evidence (your observations), and because Mr. Black is directing the management of his benefits, you find Mr. Black capable.

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GN 00502.030 - Lay Evidence of Capability - 04/10/2017
Batch run: 04/10/2017