TN 1 (01-11)
DI 40105.055 Disability Insurance Benefits (DIB) Insured Status Not Met – Office of Disability Operations (ODO) Only
A. Claimant does not meet insured status requirements
When the claimant does not meet the insured status requirements at or after the alleged onset date (AOD), in the case of traumatic onset, or more than 1 year before the AOD, in the case of non-traumatic impairments with gradual onset, a disallowance for lack of insured status is proper.
Review the information in file to determine whether an earlier onset is possible at a point when the claimant meets the earnings requirements.
Assume that the field office (FO) gave the claimant the explanation and opportunity to submit additional evidence unless the file contains an unresolved earnings discrepancy or coverage issue.
B. Unresolved earnings discrepancy or coverage issues
When there is an unresolved earnings discrepancy or coverage issue
Develop gaps in work only when it is material to establishing an earlier onset date;
Do not develop for a specific explanation by the claimant if information in file indicates a reasonable basis for the lack of posted earnings during such periods;
Explain gaps in the earnings record if a year or more of continuous, substantial postings follow them.
C. Possibility of an earlier onset date
Obtain additional earnings information from the Detailed Earnings Query (DEQY) if an earlier onset date is possible and additional earnings information is necessary to determine whether the claimant meets the insured status at that point.
When an earlier onset is possible, at a point when the claimant meets the earnings requirements, or within 1 year of the onset of a non-traumatic impairment, route the case to the Disability Determination Services (DDS) for a medical determination. If the case is electronic, the DE/DPS must route the EF to the FO who will then route it to the DDS, since there is no electronic communication between the PCs and DDS.
In situations where an earlier onset is not possible, or an earlier date is possible, but not at a point when the disability insured status requirements is met, in traumatic impairment cases, or within 1 year of the date the insured status requirement was last met, the claim must be denied.
D. Processing the claim
Preparation of Form SSA-831 (Disability Determination and Transmittal) is not required for processing.
When it is determined that a denial is necessary,
route the claim to the Claims Authorizer (CA)/Claims Technical Examiner (CTE) via Form SSA-559 (Claims Folder/Material Transmittal), and
request that the CA use the Modernized Claims System (MCS) to process the disallowance using code 090.
The CA/CTE is also responsible for providing the notice to the claimant.
E. See also