TN 1 (11-00)
DI 32548.025 Disability Redetermination and Appeal Rights for Settlement Subclass Members
The disability redetermination period is the period of time covered by the determination under review. Any period of time after the date of the determination under review would not fall within the redetermination period.
NOTE: Class claims in which disability is redetermined are referred to as “reassessment claims” in the Hyatt III court order.
1. Disability redetermination
Claims of Hyatt III Settlement Subclass members (DI 32548.001B.2.) are redetermined, not reopened. The Hyatt III disability redetermination consists of an assessment of the class member’s claim based on the evidence that was in file when the claim was previously adjudicated and any new evidence submitted by the individual pertaining to that period. Upon receipt of the class claim, the DDS will send the class member notice of his/her right to submit additional evidence, DI 32548.095, Exhibit 6.
The class member’s claim must be redetermined in accordance with DI 32548.001B.4. and current instructions for evaluating disability. If it is determined that the class member is disabled during the redetermination period, the DDS will then reopen the claim and assess disability from that time to the present.
2. Securing additional evidence
The redetermination is based on the evidence that was in file when the claim was previously adjudicated and any additional evidence submitted by the class member pertaining to that period. However, if in making the redetermination, the DDS determines that the evidence in file is insufficient to assess disability, the DDS must develop for any necessary additional evidence relating to the redetermination period, i.e., through the date of the determination under review. (See DI 32548.010D.3.)
3. Appeal rights
Settlement Subclass members may appeal their reconsideration level determination to an administrative law judge (ALJ). To receive an ALJ hearing, Settlement Subclass members must provide “new and material evidence” within 105 days after receiving the DDS determination. 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 III claim; AND
The new evidence, by itself or with the other evidence then before the ALJ, would warrant a change in any finding pertinent to any matter at issue or in the ultimate decision.
4. Redetermination shows claimant is disabled
When redetermination shows that the class member was disabled, the claim becomes a readjudication class claim and is reopened in accordance with DI 32548.020. The DDS must develop evidence covering the period from the date of the prior determination to the present. Do not develop periods for which disability has been established based on a subsequent claim.
Recognizing that it may be difficult to obtain evidence for the entire development period, the DDS should use judgment and make reasonable inferences in establishing the onset and in determining that the impairment(s) persisted at a disabling level of severity from the onset date until adjudication.
5. Redetermination shows claimant is not disabled
When the redetermination shows that the claimant was not disabled during the redetermination period, the claim will not be reopened. No further development relating to disability is necessary. A reconsideration level determination affirming the prior denial will be prepared based on the information in file, including any additional evidence submitted by the claimant. REMEMBER THAT THE HYATT III DETERMINATION/DECISION CANNOT RESULT IN A LESS FAVORABLE DISABILITY ONSET THAN THE SUBSEQUENT CLAIM.
Take the following steps in reviewing Settlement Subclass member claims:
Upon receipt of a settlement subclass claim, send DI 32548.095, Exhibit 6, to the class member. Hold claim for 10 days to allow class member the opportunity to notify the DDS about whether he or she will submit evidence. If the claimant has not contacted the DDS within the 10-day period, or has already submitted the evidence, conduct redetermination. If the class member has contacted SSA within the 10-day period, but has not provided the additional evidence, give the claimant an additional 2 weeks to do so.
After affording the class member the opportunity to submit additional evidence, conduct the redetermination by reviewing the evidence in the class member’s file and any new evidence submitted, including any written or oral statement, relating to the period in question, and establish whether the determination in the claim under review should be changed. Only assess disability for the redetermination period.
If the current disability assessment does not establish disability during the redetermination period, prepare a denial according to DI 32548.025C.3. If the current disability assessment establishes disability for the redetermination period, see DI 32548.025C.4.
If disability cannot be established during the redetermination period, prepare an SSA-831-U3 affirming the prior determination. Follow the instructions in DI 27015.001 in completing the SSA-831-U3. Enter the date of the determination under review in Item 19B. Write “ Hyatt III Settlement Subclass Redetermination - Denial Affirmed” in Item 34.
If the redetermination shows that the claimant was disabled, assess disability from the date of the prior determination to the present. The DDS will obtain an SSA-3441-F6 and SSA-827s from the claimant and develop medical evidence through the current date of adjudication. Do not develop periods for which disability has been established based on a subsequent claim. See DI 22505.001 for general medical development procedures. If the DDS encounters any difficulty in obtaining needed information, the DDS may request FO assistance via an SSA-883-U3. In assessing disability, consider DI 32548.025B.4.
Complete SSA-831-U3 according to DI 27015.001. Write “ Hyatt III Settlement Subclass Redetermination - Reversal” in Item 34.
Prepare and release any notices in all cases, as appropriate.
Forward all folders to FO (or DQB if folder selected for PER or QA).