TN 59 (07-99)

DI 11011.001 Collateral Estoppel -- General

Citations:

Regulations 20 CFR 404.950 (f) and 416.1450 (f)

A. Policy - Rules of Collateral Estoppel

Based on the rules of Collateral Estoppel, a prior favorable determination or decision made by SSA or the court must be adopted for the same period on the new claim unless the prior favorable determination can be reopened under the rules of administrative finality.

EXCEPTION: For disability claims, the prior favorable medical determination cannot be adopted if:

  • the claimant is currently engaging in SGA,

  • the claimant has engaged in SGA since the established onset (see DI 11011.001B.1.d. and EM-01204 SEN)

  • different rules for determining disability apply (e.g., blindness or childhood disability, see DI 11055.001 Title XVI Disability Claims, expedited reinstatement determinations (EXR), see DI 13050.055B.2. Medical Determination for Expedited Reinstatement),

  • there is reason to believe the prior determination was wrong, or

  • the title XVI record is currently in terminated status; or

  • title XVI entitlement was based on a State welfare conversion and a federal disability decision is needed. (See DI 11011.001B.1.g.).

NOTE: Nonrollback conversion claimants were those receiving aid under a state plan due to disability or blindness as of 12/73 and received aid for at least 1 month prior to 07/73. Effective 01/74 these individuals were converted to the SSI rolls.

IMPORTANT: See EM-01204 SEN for additional instructions on potential adoption.

B. Policy - Jurisdiction of Collateral Estoppel Cases

1. SSA Jurisdiction

  1. SSA has jurisdiction for most adoptions in which a medical determination is not required.

    IMPORTANT: These claims will be processed as District Office Final Authorization (DOFA), unless a DOFA exclusion applies.

  2. If a subsequent application for disability is filed by an individual with a current medically established disability and the collateral estoppel rules apply, the Field Office (FO) must adopt the favorable medical disability determination or decision per the chart in DI 11011.005. The FO must also prepare the SSA-831-U3.

    NOTE: If the previous folder is a Certified Electronic Folder (CEF), follow instructions per (DI 81010.142).

  3. If a title XVI (DI) determination is adopted to a title II claim and the date first insured, on the title II claim, is later than the title XVI onset date, use the date first insured on the title II claim, as the title II onset date.

  4. If the claimant has SGA after the title XVI onset date or if medical improvement is indicated on the new claim, do not adopt the determination. Request the prior file and forward the case to the DDS for possible adoption.

  5. A prior approved claim in suspense status may be adopted provided there is no current SGA, no indication of medical improvement, the claimant is in suspense for a nondisability reason and, if the prior claim is a title XVI claim, it has not been in suspense status over 12 consecutive calendar months.

  6. The SSA-3368-BK need not be prepared if the full disability determination is being adopted (e.g. partial award not involved) and a DDS determination is not needed.

  7. If the FO representative is unable to determine from the SSID whether the claim is a rollback or nonrollback, and the original folder is not available for review, do not adopt the existing determination, forward the claim to the DDS. See DI 28075.010, Nonrollback Conversion Cases and DI 28075.015, Rollback Conversion Cases.

  8. The FO may only adopt a prior medical determination or decision to a new filing under the rules of collateral estoppel. They may not adopt a prior collateral estoppel determination or decision to a new filing.

2. DDS Jurisdiction

  1. The DDS has jurisdiction for the disability determination in cases excluded from SSA jurisdiction.

  2. If the adopted disability determination is not fully favorable on the new claim, the FO prepares a partial award and processes the case to pay before the case is routed to the DDS. (See the chart in DI 1101