TN 1 (11-00)

DI 32548.050 Notice Instructions - Revision of Denial to Partially Favorable Allowance

Citations:

Regulations No. 4 - Secs. 404.904, 404.1715, 416.1404, 416.1515

A. Policy - primary and settlement subclass claims

In Primary and Settlement Subclass claims, the claimant, his/her representative, if any, and class counsel must be notified of any determinations, which is wholly or partially unfavorable. (See NL 00601.003 for signature requirement).

Class counsel"s copy of the notice is sent to:

North Carolina Justice and Community Development Center

P.O. Box 28068

224 South Dawson St.

Raleigh, North Carolina 27611-8068

Telephone 1 (800) 299-8619

B. Procedure

1. Title II only

For title II only cases, send an interim notice on an SSA-L951-U2/C2; add the third line heading “IMPORTANT INFORMATION”; and include:

  1. An introductory statement which reads:

    (Onset Established as Later Than Alleged)

    “We have completed the review you requested as a result of the Hyatt III court order. Based on our review, we find that you meet the medical requirements for disability benefits on  (onset date). You must also meet certain non-medical requirements to be entitled to disability benefits.”

    NOTE: For cases involving a consolidated determination (i.e., a Hyatt III claim and a pending claim) add: “This notice includes our decision on both the Hyatt III case review and the new application filed on  (date of new application).”

    Attached to this notice is an explanation of the decision we made on your claim and how we arrived at it.” (Delete last sentence if merged text format is used.)

    (Closed Period Established)

    “We have completed the review you requested as a result of the Hyatt III court order. Based on our review, we find that you meet the medical requirements for disability benefits from  (onset date) to   (cessation date). You must also meet certain non-medical requirements to be entitled to disability benefits. Attached to this notice is an explanation of the decision we made in your claim and how we arrived at it.” (Delete last sentence if merged text format is used.)

  2. The optional paragraph in DI 32548.045B.1.b. if the earliest claim within the Hyatt III period is not a Hyatt III eligible claim(s).

  3. A discussion of the evidence containing the elements in DI 26530.015.

  4. The last three paragraphs from the SSA-L1157-U2-DI. (If onset is established as later than alleged add “...as of the date we have now found that you meet the medical requirements for disability benefits...” after “rules” in the first sentence of the third paragraph from the SSA-L1157-U2-DI).

    On cases returned from OHA for consolidation (or one of several Hyatt III claims that were appealed to the ALJ hearing level (DI 32548.015B.1.)), make the following changes to the SSA-L1157-U2-DI:

    • delete the last sentence of the third paragraph.

    • add a new paragraph: “Since you previously had requested a hearing on your case, we are sending your case to the Office of Hearings and Appeals for a hearing before an administrative law judge with respect to

    (Examiner choose the appropriate one)

    • the date we found you disabled.” or

    • our finding that your disability ended on  (enter the date of cessation) .”

  5. Route folder to servicing FO.

2. Title XVI only

For title XVI only cases, send an interim notice on an SSA-L8052-U2/SSA-L8052-C2, add the third line heading “IMPORTANT INFORMATION” and include the following elements:

  1. Follow DI 32548.050B.1.a.

  2. Follow DI 32548.050B.1.b.

  3. Follow DI 32548.050B.1.c.

  4. The last three paragraphs from the SSA-L1157-U2-SI. (If onset is established later than alleged, add “. . . as of the date we have now found that you meet the medical requirements for disability benefits . . .” after “rules” in the first sentence of the third paragraph from the SSA-L1157-U2-SI.)

    On cases returned from