TN 11 (11-12)

DI 25501.450 Inferring Onset for the Established Onset Date (EOD)

This section explains our policy regarding inferring onset dates.

REMINDER:

  • The onset date is the first day the claimant meets the definition of disability or statutory blindness as defined in the Act and regulations.

  • The established onset date (EOD) is the date that a claimant meets the definition of disability and all the relevant entitlement or eligibility factors.

A. Inferring onset

1. General policy for inferring onset

In some cases, based on the evidence in file, we may infer the onset date of a disabling impairment(s) to a date sometime before the date of the first recorded medical examination or the earliest available medical records. Determining when an impairment reached disabling severity requires informed judgment of the particular case facts. An inferred onset date must have a supportable medical basis and be consistent with the nature of the condition. If there is information in the file indicating additional medical evidence concerning the onset date is available, we must make reasonable effort to obtain the evidence before making inferences.

2. Using the available medical evidence to infer onset for the EOD

The adjudicator should consider all available evidence, bearing in mind the nature of the impairment. Specifically, the adjudicator should consider what medical presumptions he or she can reasonably make about the course of the condition. The inferred onset should be established on the date when it is most reasonable to conclude from the evidence that the impairment was sufficiently severe to prevent the claimant from engaging in substantial gainful activity (SGA) for a continuous period of at least 12 months or that the condition will result in death.

       

CAUTION: Onset dates set at the date of a consultative examination or the date of first treatment may not capture a period of disability prior to the examination or the date of first treatment.

3. Using collateral sources to infer onset for the EOD

If the adjudicator cannot make a reasonable inference about the progression of the impairment based on the evidence in file, and additional relevant medical evidence is not available or does not exist, it may be necessary to explore other sources of documentation. You may find it useful to gather information from family members, friends, and employers to determine why medical evidence is not available for the pertinent period and may provide insight into the progression of the claimant’s impairment(s). Do not give weight to third party evidence when it clearly contradicts the other evidence of record.

B. Component roles for inferring onset

1. Field office (FO)

The FO does not have a role in inferring onset.

2. Disability Determination Services (DDS)

If additional information is not available, but the evidence in the file supports an allowance determination, the adjudicator will consider inferring onset.

C. Instructions for inferring onset

Disability Determination Services (DDS)

If you are unable to make reasonable inferences about the severity of the impairment based on the evidence in file, and additional relevant medical evidence is not available, explore other sources of documentation. Do not routinely consider the first day the claimant was seen by a medical provider as the onset date for a non-traumatic impairment. Obtain information from family members, friends, and employers to determine why medical evidence is not available for the pertinent period and to furnish additional evidence regarding the course of the claimant’s condition. This additional third-party evidence can provide insight that would help in pinpointing the exact onset. For more information on contacting collateral sources, see DI 22511.011D.2. If you can make a reasonable inference about onset, after making reasonable efforts to obtain additional evidence, infer onset using the available medical and other evidence that describes the history, signs, and symptoms of the claimant’s disease process.

EXPEDIENT: We may infer onset within three years of the filing date if:

  • the severity of the current impairment is fully documented

    and

  • the only missing evidence relates to earlier treatment.

We will not use this expedient to infer onset when:

  • there is contrary evidence in the case record;

  • medical judgment determines the impairment(s) was not disabling at the alleged onset date (AOD); or

  • the onset date clearly occurred after AOD.

To apply this expedient to infer an EOD, the evidence must show all of the following requirements:

  • Evidence at the time of AOD appears to exist and was requested, but was not received.

  • A minimum of 10 calendar days elapsed since the initial evidence request (see DI 22505.035), even if the adjudicator did not learn of the existence of this evidence until after he or she requested other evidence.

  • Evidence in the case record is complete enough to determine the impairment(s) is disabling and satisfies the duration requirement.

and

  • The adjudicator has documented that in his or her judgment that the unavailable evidence would likely support the AOD documented in the case record.

EXAMPLE: Rhonda filed a Disability Insurance Benefit (DIB) claim on 05/01/2011 alleging disability due to rheumatoid arthritis. Her alleged (and potential) onset date is 06/01/2009. Two rheumatologists treated Rhonda from 2005 through the current period. Dr. Original treated Rhonda from 2005 through 02/20/2010, and Dr. Present treated her from 03/15/2010 through the present. DDS requested medical evidence of record (MER) from both physicians upon receipt of the case. Dr. Present provided medical records within five days of the Medical Evidence of Record (MER) request. However, after 14 days, Dr. Original had not responded to the request for MER. DDS sent a follow-up letter to Dr. Original, again requesting the MER. After 10 days, DDS documented that Dr. Original still had not responded to their MER request. DDS prepared a residual functional capacity (RFC) that currently allows Rhonda on a medical-vocational basis. The medical evidence from Dr. Present dated 03/15/2010 indicates that at the time of her first visit, she had bilateral deformities in multiple joints in her hands. The first time she saw Dr. Present, she was unable to use her fingers to tie her shoes and had very limited range of motion in her fingers and wrists. DDS noted their RFC evaluation is effective retroactive to the claimant’s AOD of 06/01/2009.

DDS correctly inferred onset using the expedient because:

  • They requested all relevant medical evidence,

  • 10 days elapsed since the initial request (in the example the DDS chose to follow up with Dr. Original, but the expedient does not require that.)

  • the evidence was complete enough to satisfy the duration requirement,

  • there was no contrary evidence in the case file, and

  • the missing evidence would likely support the AOD based on the severity of the claimant’s condition on 03/15/2010.

REMINDER: If inferring onset, explain your determination in the Findings of Facts and Analysis of Evidence block in eCat or on an SSA-416 (Case Analysis Form) and download the rationale into section F of the electronic folder. For more information about onset rationales, see DI 25501.200.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0425501450
DI 25501.450 - Inferring Onset for the Established Onset Date (EOD) - 03/26/2015
Batch run: 03/26/2015
Rev:03/26/2015