TN 48 (11-94)

DI 32594.035 Readjudication Notices

A. Policy

The claimant, and his or her representative are notified of any determination. Additionally, class counsel must be notified of all fully or partially adverse determination. Use “Legal Services for the Elderly, 130 W. 42nd St., 17th Floor, New York, NY 10036, ATTN: Mr. David Udell” as the class counsel's address.

B. Procedure - affirmation of prior denial

Follow the instructions below in the affirmation of a prior denial.

1. Title II only

For title II only, send SSA-L951-U2/C2, add third line heading “IMPORTANT INFORMATION,” and include:

  1. Introductory statement that reads:

    “A court order in the State of New York v. Sullivan class action lawsuit (the exercise test court case) requires the Social Security Administration to look at your case again to determine whether we gave appropriate consideration to the results of your treadmill exercise test and to other evidence of your condition.

    We have completed this review and we still find that the determination in your case is proper and in accordance with the law. Therefore, the denial of your application remains unchanged.”

    If Spanish then:

    Send SSA-L951-SP, add third line heading “INFORMACION IMPORTANTE,” and include an introductory statement that reads:

    “Una orden de la corte en el pleito de acción de clase Estado de New York v. Sullivan (caso de corte del examen de ejercicio) pide que la Administración de Seguro Social vea su caso de nuevo para determinar si los resultados de su examen de ejercicios treadmill y otra evidencia de su condición fueron considerados correctamente.”

    “Nosotros hemos terminado la revisión y encontramos que la decisi ón en su caso es apropiada y estáde acuerdo con la ley. Por lo tanto, la denegación de su solicitud continúa siendo la misma.”

  2. An optional paragraph to be used if claimant is in current pay:

    “This notice does not affect the checks that you are getting now based on your later application.”

    If Spanish then:

    “Esta carta no afecta los cheques que usted estárecibiendo basados en sue solicitud posterior.”

  3. Paragraph 4041. (Delete if merged text format is used.)

    If Spanish then:

    “Nosotros hemos incluído una página que le da más detalles de cómo nosotros tomamos la decisión en su caso.”

  4. A discussion of the evidence containing the elements in DI 26530.020. (English only).

  5. Paragraph 140. In the second sentence, substitute “if you still believe” for “if you believe.” After this sentence, insert the following:

    • “You may appeal this determination. You may also file a new claim.”

    If Spanish then:

    “Nosotros esperamos que esto explique satisfactoriamente la razón para la determinación de su caso. Si usted cree que la determinaci ón de reconsideración no es correcta, puede pedir una vista ante un juez administrativo de la Oficina de Vistas y Apelaciones. Si usted quiere una vista, debe pedirla no más tarde de 60 días desde la fecha en que reciba esta notificación. Usted puede llenar la solicitud en cualquier oficina de Seguro Social. Lea el panfleto que le incluimos para una explicación completa de su derecho a apelar.”

    In the second sentence, substitute “si usted todavía cree” for “si usted cree.” After this sentence, insert the following:

    • “Usted puede apelar esta determinación. Usted también puede llenar una solicitud nueva.”

  6. “You have the right to file a new application at any time, but filing a new application is not the same as appealing this decision. If you disagree with this decision and you file a new application instead of appealing:

    • you might lose some benefits, or not qualify for any benefits, and

    • we could deny the new application using this decision, if the facts and issues are the same.

      So, if you disagree with this decision, you should file an appeal within 60 days.”

    If Spanish then:

    “Usted tiene el derecho de llenar una solicitud nueva en cualquier momento, pero llenar una solicitud nueva no es lo mismo que apelar esta decisi ón. Si usted no estáde acuerdo con esta decisión, y llena una solicitud nueva en lugar de apelar:

    • es posible que pierda algunos beneficios, o no cualifique para beneficio alguno, y

    • le podríamos denegar su solicitud nueva usando esta decisi ón si los hechos y los resultados son los mismos.

      Asíes que si usted no estáde acuerdo con esta decisió n, debería llenar una apelación dentro de 60 días.”

  7. “If You Want Help With Your Appeal

    You can have a friend, lawyer or someone else help you. There are groups that can help you find a lawyer or give you free legal services if you qualify. There are also lawyers who do not charge unless you win your appeal. Your local Social Security office has a list of groups that can help you with your appeal.”

    “If you get someone to help you, you should let us know. If you hire someone, we must approve the fee before he or she can collect it. And if you hire a lawyer, we will withhold up to 25 percent of any past due benefits to pay toward the fee.”

    If Spanish then:

    “Si usted quiere ayuda con su apelación

    Un amigo, abogado, o cualquier persona puede ayudarle. Hay agencias que pueden ayudarie a conseguir un abogado o proveerle asistencia legal gratuita, si cualificara. Tambíen, hay abogados que no le cobran nada a menos que usted gane la apelación. Su oficina de Seguro Social, tiene una lista de las agencias que le podrían ayudar con su apelación.”

    “Si usted consigue alguien que le ayude, nos lo debe dejar saber. Si usted contrata a alquien, nosotros debemos aprobar la cuota antes de ser cobrada. Si usted contrata a un abogado, nosotros retendremos hasta un 25 porciento de beneficios pasados adeudados para pagar la cuota.”

  8. Paragraph MG20.

    If Spanish then:

    “Si usted tiene alguna pregunta, puede llamarnos al 1-800-772-1213. Podemos contestar la mayoría de las preguntas por teléfono. Si usted prefiere visitar una de nuestras oficinas, favor de verificar a trav és de la guía telefónica, cual de las oficinas le queda m ás cerca. También puede llamarnos y nosotros le daremos la dirección de la oficina. Favor de tener esta carta a la mano, si llama o visita alguna oficina. Asínos ayudaráa responderle sus preguntas.”

  9. Enclosures:

    • Explanation of Determination (delete if merged text format is used).

    • SSA Pub. No. 70-10281.

2. Title XVI only

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

  1. Follow B.1.a.-e. above.

  2. “You have the right to file a new application at any time, but filing a new application is not the same as appealing this decision. If you disagree with this decision and you file a new application instead of appealing, you might lose some benefits, or not qualify for any benefits. So, if you disagree with this decision, you should file an appeal within 60 days.”

    If Spanish then:

    “Usted tiene el derecho de llenar una solicitud nueva en cualquier momento, pero llenar una solicitud nueva no es lo mismo que apelar esta decisi ón. Si usted no estáde acuerdo con esta decisión, y llena una solicitud nueva en lugar de apelar es posible que pierda algunos beneficios, o no cualificar para beneficio alguno. Si usted no estáde acuerdo con esta decisión, debería llenar una apelación dentro de 60 días.”

  3. “If You Want Help With Your Appeal

    You can have a friend, lawyer or someone else help you. There are groups that can help you find a lawyer or give you free legal services if you qualify. There are also lawyers who do not charge unless you win your appeal. Your local Social Security office has a list of groups that can help you with your appeal.”

    “If you get someone to help you, you should let us know. If you hire someone, we must approve the fee before he or she can collect it.”

    If Spanish then:

    “Si usted quiere ayuda con su apelación

    Un amigo, abogado, o cualquier persona puede ayudarle. Hay agencias que pueden ayudarle a conseguir un abogado o proveerle asistencia legal gratuita, si cualificara. También, hay abogados que no le cobran nada a menos que usted gane la apelación. Su oficina de Seguro Social, tiene una lista de las agencias que le podrían ayudar con su apelación.”

    “Si usted consigue alguien que le ayude, nos lo debe dejar saber. Si usted contrata a alquien, nosotros debemos aprobar la cuota antes de ser cobrada.”

  4. Paragraph 1481.

    If Spanish then:

    “Si en cualquier momento en el futuro, usted cree que cualifica para pagos, favor de comunicarse con nosotros inmediatamente para llenarle una solicitud nueva. Nosotros no podemos pagarle ningún mes antes del mes en el cual solicite.”

  5. Follow B.1.h. and i. above.

3. Concurrent cases

In concurrent cases:

  1. Title II - Follow B.1. above, but add disclaimer paragraph 842.

    If Spanish then:

    “Esta decisión sólo aplica a su caso de Seguro Social por Incapacidad. Si usted no ha recibido una decisión relacionada con su caso del programa de Seguro de Ingreso Suplementario, en breve, usted recibir áuna notificación aparte.”

  2. Title XVI - Follow B.2. above, but add disclaimer paragraph 841.

    If Spanish then:

    “Esta decisión sólo aplica a su caso de Seguro de Ingreso Suplementario. Usted recibiráotra notificación aparte, si usted llenóuna solicitud para beneficios de Seguro Social.”

C. Procedure - revision to partially favorable allowance

Follow the instructions below in a revision to a partially favorable allowance.

1. Title II only

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

  1. Introductory statement, as follows:

    • “A court order in the State of New York v. Sullivan class action lawsuit (the exercise test court case) requires the Social Security Administration to look at your case again to determine whether we gave appropriate consideration to the results of your exercise test and to other evidence of your condition.”

      “We have completed this review and we find that you meet the medical requirements for disability benefits on (onset date) but you do not meet these requirements prior to that date. You must meet certain medical and non-medical requirements to be entitled to disability benefits. Attached to this notice is an explanation of the decision that we made on your claim and how we arrived at it.” (Delete last sentence if merged text format is used.)

      If Spanish then:

      “Una orden de la corte en el pleito de acción de clase Estado de New York v. Sullivan (caso de corte del examen de ejercicio) pide que la Administración de Seguro Social vea su caso de nuevo para determinar si los resultados de su examen de ejercicios treadmill y otra evidencia de su condición fueron considerados correctamente.”

      “Nosotros hemos completado la revisión de su caso, y encontramos que usted llena los requisitos para beneficios de incapacidad al (onset date), pero no llena estos requisitos antes de esa fecha. Usted debe llenar ciertos requisitos médicos y no médicos para ser elegible a beneficios de incapacidad. Adjunto a este aviso, hay una explecación de la decisi ón que hicimos en su caso y cómo llegamos a ella.”

    • Closed period established

      “A court order in the State of New York v. Sullivan class action lawsuit (the exercise test court case) requires the Social Security Administration to look at your case again to determine whether we gave appropriate consideration to the results of your exercise test and to other evidence of your condition.”

      “We have completed this review and we find that you meet the medical requirements for disability benefits from (onset date) to (cessation date).”

      “You must meet certain medical and non-medical requirements to be entitled to disability benefits. Attached to this notice is an explanation of the decision that we made in your claim on how we arrived at it.” (Delete last sentence if merged text format is used.)

  2. Language from B.1.b. and c. above.

  3. Discussion of evidence containing elements in DI 26530.015.

  4. Last three paragraphs from SSA-L1157-U2 DI. (If onset is established as later than alleged, add “as of the date that we have now found that you meet the medical requirements for disability benefits” after “requirements” in first sentence of third paragraph from SSA-L1157-U2 DI - see DI 31515.270.) “We have found that you do not meet the medical requirements for disability from [alleged onset date] through [day before established onset date].”

  5. Route folder to servicing FO (or to DQB if selected for PER or QA).

2. Title XVI only

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

  1. Follow C.1.a., and c. above.

  2. Last three paragraphs from SSA-L1157-U2-SI. (If onset is established later than alleged add “as of the date that we have now found that you meet the medical requirements for disability benefits” after “requirements” in first sentence of third paragraph from SSA-L1157-U2-SI - see DI 31515.275.)

  3. Follow B.2.b. and B.2.c. above.

    If Spanish then:

    Send interim notice on SSA-L8052-U2/C2, add third line heading “INFORMACION IMPORTANTE”

3. Concurrent cases

In concurrent cases:

  1. Title II - Follow C.1. above, but add disclaimer paragraph 842.

  2. Title XVI - Follow C.2. above, but add disclaimer paragraph 841.

D. Procedures - revision to fully favorable allowance

Follow the instructions below for a revision to a fully favorable allowance:

1. Title II only

For title II only:

  1. Enter “ODO/DL-S” in item 29 of SSA-831-C3/U3.

  2. Indicate SSA-L30-C1 as notice on attachment and include following paragraph:

    • “This determination is based on a review of your claim as ordered by the court in the case of State of New York v. Sullivan (the exercise test court case). We have determined that your condition is disabling.”

2. Title XVI only

For title XVI only:

  1. Indicate DO/DL-S as notice on SSA-831-C3/U3.

  2. On attachment, show SSA-8025-U2:

    • Lead-in sentence:

      “This determination is based on a review of your claim as ordered by the court in the case of State of New York v. Sullivan (the exercise test court case).”

    • Paragraph 1029.

    • Paragraph 1414, 1415, 1424, or 1425, as appropriate.

    • Paragraph 1150 or 1151, if appropriate.

3. Concurrent cases

Follow above instructions for each case.

E. Procedure - revision to continuance

Follow the instructions below for a revision to a continuance.

1. Title II only

For title II only:

  1. Enter “ODL/DL-S” in item 29 of SSA 833.

  2. Prepare modified SSA-L1013. Add following to bottom of notice:

    “This determination is based on a review of your claim as ordered by the Court in the case of State of New York v. Sullivan (the exercise test court case). After carefully examining new and old evidence, we find that you are still disabled.”

  3. Indicate SSA Pub. No. 70-10282 as an enclosure.

2. Title XVI only

For title XVI only:

  1. Indicate DO/DL-S as notice on SSA-833.

  2. On attachment, show SSA-L8100-U2, followed by:

    • lead-in sentence:

      “This determination is based on a review of your claim as ordered by the Court in the case of State of New York v. Sullivan (the exercise test court case).”

    • decision paragraph:

      “After carefully examining new and old evidence, we find that you are still disabled.”

    • Numbered (e.g., 1391, 1412, 1413) or dictated paragraphs to give appropriate information contained on front of SSA-L1014.

3. Concurrent cases

Follow above instructions for each case.

F. Procedure - affirmation of cessation

Prepare affirmation of cessation notice as shown below.

1. General

Follow instructions in DI 33015.025 in preparing notice. Do not offer benefit continuation.

2. Specific

  1. Include in notice introductory paragraph from DI 32594.035 B.1.a. Replace last sentence with the following: “Therefore, the decision that your disability ended remains unchanged.”

  2. Include language from DI 32594.035 B.1.f.

  3. Replace last paragraph of notice, which includes sentence “Some can give you a free lawyer” with language in DI 32594.035 B.1.g.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0432594035
DI 32594.035 - Readjudication Notices - 02/21/2013
Batch run: 02/21/2013
Rev:02/21/2013