TN 2 (04-05)
DI 26530.015 Personalized Disability Explanation in Initial Closed Period and Unfavorable Onset Date Allowances
A. Policy -- General
The DDS will prepare a personalized disability explanation with an interim notice (SSA-L1157) for initial title II and title XVI closed period and unfavorable onset date allowances. (See DI 26530.005D.3. for when the explanation is not required in these situations.
In initial concurrent title II/title XVI and DIB/DWB, DIB/CDB closed period and unfavorable onset date allowances, the DDS will prepare a separate notice and personalized disability explanation for each claim. However, when the basis for the decision is the same for both claims (e.g., DIB/CDB medical/vocational allowance) and the contents of the personalized disability explanation are the same, the personalized disability explanation may be photocopied and attached to each interim notice. The correct SSN must be shown on each copy.
B. Policy -- Elements of personalized disability explanation in closed period and unfavorable onset allowances
The personalized disability explanation must contain the following elements:
List all medical (not necessary when work activity is the only reason for the unfavorable onset) and nonmedical sources evaluated (do not mention unresponsive sources). Identify medical sources by name and date of receipt of the evidence. Nonmedical sources (e.g., school guidance counselors, welfare departments, vocational rehabilitation agencies, day treatment facilities, sheltered workshops, social workers, and third party lay evidence) will be listed as evidence sources but will not be identified by name. Excluding third party lay evidence, nonmedical sources should be identified by position and organization (e.g., Vocational Rehabilitation Counselor, Department of Rehabilitation Services, report received XX/XX/XX). Third party lay evidence (e.g., family members, neighbors, coworkers, etc.) will be identified under the list of reports using the following statement: “Information from other people who know about your health.” If the lay evidence is the only evidence, omit the word “other.” Reports may be listed in paragraph form if saving space becomes a consideration or more than three reports are used;
When the medical sources were unresponsive, the disclaimer statement in DI 26530.055 provides an optional fill-in to say that additional reports were not obtainable; however, we had enough information to evaluate the claimant's condition;
(Optional) A statement that “The determination on your claim was made by an agency of the State. It was not made by your own doctor or by other people or agencies writing reports about you. However, any evidence they gave us was used in making this determination. Doctors and other people in the State agency who are trained in disability evaluation reviewed the evidence and made the determination according to Social Security law and regulations;”
A list of the impairments evaluated. Do not use technical terms unless the claimant uses and appears to understand them. When information in file suggests that the claimant has a terminal illness, mental impairment or is unaware of the exact nature of his/her condition, the examiner will use his/her judgment as to what, if anything, will be listed in the explanation concerning the impairments. If the claimant is unaware of an impairment, use general terms such as “The reports do not show any other conditions which would significantly limit your ability to work;”
A brief description of medical severity as of the month of cessation in closed period allowances or a brief description of the medical or medical/vocational basis for this established onset date in unfavorable onset date allowances. However, care must be taken in discussing medical evidence (address unconfirmed allegations by stating that evidence does not reveal any other disabling conditions). A later onset may be established because a prior ALJ or AC decision is binding. In this case explain that the later onset is established because of an administrative law judge or Appeals Council decision which found him/her not disabled through the date of the decision;
For claims filed before March 27, 2017, explain how you considered a treating source’s medical opinion(s) and any opinion(s) that you gave more weight than a treating source’s medical opinion. For additional information, see DI 24503.035, for claims filed on or after March 27, 2017, see DI 24503.030.
When vocational factors were considered in a closed period allowance; provide a brief description of the job the claimant can do or a statement that although the person cannot do past relevant work, he or she can adjust to other work which is less demanding (refers to nonexertional limitations or restrictions including mental) or requires less physical effort (specify in general terms, e.g., lighter work). Do not cite other jobs;
When vocational factors were considered in an unfavorable onset date allowance; provide a brief description of the job the claimant could do or a statement that although the person could not do past relevant work, he or she could adjust to other work that was less demanding; (refers to nonexertional limitations or restrictions including mental) or requires less physical effort) (specify in general terms, e.g., lighter work). Do not cite other jobs;
When the claimant's work activity is the reason for the closed period or unfavorable onset determination, the information provided in the attachment must cover this issue.
1. Personalized disability explanation for closed period allowance (all medical reports were obtained)
The following reports were considered in deciding your claim:
Dr. John Jones' report, received August 1, 1979.
Dr. Bob Smith's report, received January 30, 1980.
The Holy Cross Hospital's report, received December 12, 1979.
You said that you became unable to work on January 1, 1979, due to multiple fractures of the right leg. The medical evidence shows that your condition prevented you from working from January 1, 1979, through January 29, 1980, when your right leg had healed to the point where you could do your job as a truck driver.
2. Personalized disability explanation for unfavorable onset allowance (all medical reports were obtained)
The following reports were considered in deciding your claim.
Dr. Bob Smith's report, received December 1, 1979.
Dr. John Jones' report, received January 5, 1980.
You said that you became unable to work on October 1, 1977, because of emphysema. While you stopped work because of your condition, the medical evidence needed to evaluate your condition did not show your condition was severe enough to meet our requirements until your examination in December 1979. Because of the severity of your condition at that time and medical experience with your type of condition, your impairment(s) met our requirements as early as June 1, 1979.
D. Policy -- Special situations
1. Unfavorable allowance -- Freeze claimant
When the DDS prepares an unfavorable allowance for a freeze claimant, the DDS will prepare only the personalized disability explanation. The component that will maintain the folder will be responsible for the notice. (See DI 32005.000 to determine the component to be shown in the remarks of SSA-408.)
2. Unfavorable onset date allowance -- DWB for Medicare only
When the DDS prepares an unfavorable allowance for a DWB claim filed for Medicare coverage only, the DDS will prepare only the personalized disability explanation and will forward the case to the PSC for release of the personalized disability explanation with the PSC notice.
3. Unfavorable onset date allowance -- EOD within 5 months of full retirement age (FRA) (DIB)
When the DDS establishes DIB onset later than alleged (for medical reasons) but within 5 months of full retirement age (FRA), the DDS will prepare only the personalized disability explanation and will forward it to the PSC through the DO. Annotate SSA-408 that personalized disability explanation should be released with RIB notice.