TN 11 (11-12)

DI 25501.280 Notifying Claimants of Partially Favorable Allowances

Citations:

20 CFR 404.1618 and 416.1018

A. Policy for notifying claimants of partially favorable allowances

The Disability Determination Services (DDS) prepares a personalized disability explanation (PDE) for the claimant whenever it makes a disability determination that is not fully favorable (i.e., partially favorable) to the claimant. The DDS sends the PDE with an SSA-L1157-DI or SSA-L1157-SI.

1. General definition of partially favorable allowance

A partially favorable allowance means we found the claimant disabled or blind, but the established onset date (EOD) is unfavorable because it is after the alleged onset date (AOD), unless the allowance is for a title XVI claim and the EOD is on or before the application date or it meets the criteria of one of the exceptions found in DI 25501.280A.2. in this section.

2. Definition of partially favorable allowance for title II claims

In title II claims, a partially favorable allowance is when the EOD is after the AOD because of medical, medical-vocational, or technical reasons.

EXAMPLE: The adjudicator might change the EOD to the date the claimant first met a favorable vocational rule. The adjudicator may also establish a later EOD based on technical factors, such as performance of substantial gainful activity (SGA) or a previously adjudicated period that we cannot reopen (see DI 25501.250).

EXCEPTIONS: An EOD after the AOD is fully favorable if the following criteria apply.

  • For Medicare claims, if the EOD allows monthly benefits or entitlement on the earliest possible date based on the filing date of the application, the period of retroactivity, the number holder's date of death, or the first possible month of entitlement (see DI 26530.005D.2.).

  • The EOD is the date first insured for Disability Insurance Benefits (see DI 26530.005D.3.).

  • The EOD is established on or before the control date for Disabled Widow(er) Benefit (DWB) or Disabled Minor Child (DMC) claims.

  • The EOD is fully favorable for Child Disability Benefit (CDB) claim purposes as described in DI 25501.330A.6.

  • The EOD is fully favorable on any date within a given month, if we can determine the claimant did not become disabled on the first day of that month (see DI 25501.300A.2.).

3. Definition of partially favorable allowance for title XVI claims

In title XVI claims, a partially favorable allowance is when the EOD is in the month after the month of filing, or in the month after the protective filing month, if there is one.

4. Notice requirements for partially favorable allowances

We must send the claimant and any appointed representative a PDE for all partially favorable allowances including changes of onset due to SGA and prior determinations and decisions, except as noted previously in DI 25501.280A.2. in this section. The PDE explains why we changed the EOD to be partially favorable. The personalized explanation must:

  • be legally sufficient (notices must convey enough information to allow the claimant to act in an informed matter);

  • not be offensive in any way;

  • be brief, informal, and not technical;

  • be written in plain, simple language; and

  • specifically explain the medical, vocational, work activity, or other reasons for establishing an onset date after the AOD and only partially favorable for the claimant.

B. Component roles for notifying claimants of partially favorable allowances

1. Field office (FO)

The FO does not have a role in administering this policy, except in cases where the claimant is not capable or if capability is unresolved; see DI 26535.036E. Also, see DI 11010.345K for FO procedures for preparing interim disability notices in capability issue cases.

2. Disability Determination Services (DDS)

The DDS prepares a PDE to the claimant whenever it makes a decision that is onl