TN 6 (08-90)

DI 27515.035 Resolution of Conflict in Title II/Title XVI Claims

A. Policy

1. General

In most concurrent title II/title XVI claims, the disability determinations under both titles should agree.

2. When Determinations May Differ

In some concurrent claims, different determinations may be appropriate because the rules for determining disability differ or because eligibility factors are not satisfied.

Examples :

  • For DWB benefits payable prior to January 1991 for which was filed prior to 01/01/1991, a DWB denial and title XVI medical-vocational allowance (See DI 11015.001B.).

  • DIB denial after DLI and a title XVI allowance. (See DI 27515.035B.4).

B. Procedure

1. Conflicting Determinations

When there are conflicting determination/decisions:

  1. a. 

    Resolve conflicting disability determination/decisions for the same period in concurrent title II/title XVI claims under the adoption policy in DI 27515.015 A.2.

  2. b. 

    Follow DI 27520.030 for jurisdiction when resolving conflicting determinations.

  3. c. 

    Consider reopening and revision of the earlier determination (see reopening procedures in DI 27505.001ff) to resolve conflicting determinations.

2. Different Appeal Levels

Adjudicate the claim at the higher appeal level if the decisions are at different appeal levels.

3. Reopening not Possible

Perform a CDR on the conflicting decision on a post basis (see DI 27520.030ff if conflict in decisions occur).

4. Differing Determinations

If Then...

unable to show medical onset before title II eligibility ends

  • Continue title XVI disability.

  • Deny title II disability, e.g., not insured.

the requirements for disability differ, e.g., title II DWB vs title XVI medical /vocational decision (this example involving title II DWB is applicable only for DWB benefits payable prior to January 1991 for which applications were filed prior to 01/01/1991. (See DI 11015.001B.)

  • Continue title XVI disability.

  • Determine title II DWB independently of title XVI decision.

title II duration requirement is not met, but SSI conversion claim State Plan continues to be met, and disability does not exist under Federal criteria.

  • Continue title XVI, i.e., title XVI blindness claim allowed without considering duration.

  • Deny title II per DI 27515.001A.2.

the requirement for duration is not met for title II, and title XVI is protected by 1619 provisions

  • Continue title XVI disability.

  • Deny title II for engaging in SGA or duration requirement not met.

the requirements for title II differ, e.g., title II DWB, and statutory requirements never existed for DWB, and title XVI now ceased

  • Deny title II.

the title XVI disability ceased before title II duration requirement met

  • Deny title II.

the title XVI disability ceased more than 14 months before the title II claim is filed, and claimant is not insured for title II benefits when the title XVI claim filed

  • Deny title II if title XVI filing does not protect title II filing.

work at SGA levels is protected by TWP provisions; and the duration  requirement for title XVI is not met

  • Continue title II.

  • Determine title XVI based on evidence in file.

the prior title XVI denial is not subject to reopening due to time limits, but a reason to question prior denial exists, per DI 27515.015A.2.

  • Continue title II established under prior application.

  • Solicit a new title XVI application and develop entitlement on new and material facts. See DI 27510.005B.

the title XVI claim is not subject to reopening because there is no new and material evidence , i.e., title II allowance is made on the basis of a “change in position”

  • Solicit a new title XVI application and develop entitlement, based on the facts. See DI 27510.005B.

  • Continue title II

title II ceased in a concurrent title II/XVI case and title XVI is continued because of failure to realize the concurrent situation and no notice was released

  • Perform current CDR on title XVI.

  • Cease title XVI currently, if applicable, and retain the prior title II cessation.

  • Consider reopening the prior title II if unable to cease the title XVI.

  • Solicit a new title II application if unable to reopen title II cessation.

  • Adjudicate the new title II application without consideration of the title XVI continuance.

To Link to this section - Use this URL:
DI 27515.035 - Resolution of Conflict in Title II/Title XVI Claims - 03/22/2005
Batch run: 04/14/2014