TN 1 (11-00)

DI 12548.015 Adjudication and Appeal Rights

A. Policy

1. General

Members of the Primary Subclass whose final denials/terminations were at the initial or reconsideration level will have their disability claims reopened at the reconsideration level. Primary Subclass members whose final denials/terminations were at the Administrative Law Judge (ALJ) or Appeals Judge (AAJ) level will have their claims reopened at the ALJ hearing level.

Members of the Settlement Subclass will have disability redetermined (redetermination) at the reconsideration level. The redetermination consists of a review of the evidence in the class member's file relevant to the period adjudicated in the claim being reviewed. If the disability redetermination shows that the class member was disabled during the period covered by the determination being reviewed, the class member's claim will be reopened and disability evaluated up to the present. Members who have both a Primary Subclass and a Settlement Subclass claim will be adjudicated as Primary Subclass members. Copies of all Hyatt III determinations/decisions released must be forwarded to claimant, claimant's representative, if any, and class counsel. If there is no systems input because of the Hyatt III determination/decision, a copy must also be sent to Litigation Staff to assure closure of the claim on CATS.

2. Review Standard

In adjudicating class claims, the disabling effects of hypertension and diabetes will be fully considered without requiring the presence of end-organ damage for a finding of disability. In addition, instructions on the evaluation of pain during the relevant period of Hyatt readjudications will be applied in a manner consistent with the following:

  • 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 deteriorating nerve 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.

3. Appeal Rights

Class members whose claims are reopened may appeal their reconsideration level determination to an ALJ. However, members of the Settlement Subclass whose claims are not reopened must provide new and material evidence in order to receive an ALJ hearing. The ALJ will decide whether the evidence is new and material.

Evidence will be considered “new and material” if:

  • It was not considered by the adjudicator who made the prior final determination on the Hyatt claim; AND

  • The new 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 in the ultimate decision.

4. Jurisdiction and Consolidation - Readjudication Claims

A readjudication claim is a class claim of an individual determined to be a Primary Subclass member or Settlement Subclass member entitled to a reopening (see DI 12548.015A.1.). See DI 12548.045 for special priority instructions, which apply when the class claim is a pending claim.

Consolidate readjudication claims as follows when a subsequent non-class claim is pending and at least one class claim is screened in.

If the pending claim is:

  1. Before the AC or is one for which an ALJ hearing has been held or an ALJ decision rendered, do not consolidate the Class Claim and the pending claim for adjudication.

  2. One for which an ALJ hearing has been scheduled but has not yet been held, consolidate the Class Claim and the pending claim for disability adjudication by an ALJ.

  3. One for which an ALJ hearing has been requested by the claimant but has not yet been scheduled, the Class Claim and the pending claim shall be consolidated for adjudication by the North Carolina DDS. If the DDS renders an adverse determination, it will forward the class member's consolidated claims to OHA to schedule a hearing by an ALJ.

  4. At the init