BASIC (03-86)

DI 42001.015 Material Which May Result in a Reopening

A. Report of death during waiting period and after award processing

Notice of a claimant's death during the waiting period may raise a question of whether the prior determination should be changed. The DE should examine the death certificate to determine the cause of death. If death was traumatic (i.e., auto accident, etc.) and not related to the impairment on which an allowance was made, the determination should be reopened to a denial. (See DI 40105.000 for processing instructions.)

B. Report of death within one year after denial or cessation

When the claimant dies after the waiting period and within a year of denial or cessation, the servicing PSC will process the survivor's claim in the usual manner. The PSC will also verify the time elapsed between the date of denial and death. If the date of death was within 1 year of the date of initial notice of disability denial or termination, the PSC will determine whether a favorable disability decision (based on the alleged onset date) is likely to result in benefits to the survivor.

The PSC will ascertain whether (based on the alleged onset data) a favorable disability decision will:

  • Increase the survivor's monthly or potential monthly benefit; or

  • Result in a DIB for at least 1 month

A statement showing the effect of a favorable decision including the amounts involved will be noted on a sheet of paper and placed on prongs on the right side of the claims folder. If either of the above criteria is met, the PSC will attach an SSA-567 (Notice for Subsequent Handling) to the folder, advising that after the completion of all PSC actions, the case should be forwarded to DRS for reexamination. After all PSC actions, including certification for payments of survivors benefits and/or the lump sum death payment (LSDP), the case folder will be sent under an SSA-559 to the Disability Review Section noting, “Disability Claim to be Reexamined Under DI 42001.015B.” If neither of the above criterion is met, the PSC will take no further action on the disability claim.

DRS will reexamine cases referred by the PSC and decide whether the evidence warrants reopening of the prior determination. If DRS finds that reopening is not justified, no further action will be taken and the case will be returned to the servicing PSC module annotated “Reopening Not Warranted” on the SSA-567. If it appears that death resulted from an impairment which may have been more severe than shown by the evidence developed during the claimant's lifetime, forward the file to the DDS for further review and possible reopening.

C. Report of work at the SGA level less than one year from onset

When a beneficiary returns to work less than one year after onset, several questions are raised, one being whether the 12 month duration requirement for disability is met. Another is whether the disability should be ceased immediately or continued subject to a TWP. A third being whether the prior favorable determination, which has become final (GN 04001.040A.1.) should be reopened and revised to a denial or a later onset date, and if an SSA-831-U5 denial determination should be prepared.

NOTE: When a prior determination has not become final, i.e., final notice has not been released, any revisions should be made by preparing another determination. Reopening a determination which was never final is inappropriate (see GN 04001.040A.). The prior allowance determination should be placed in the folder with the notation, “Do not process” entered in Remarks section.

1. Factors to be considered in return to work situations

The following factors must be considered in order to arrive at the proper decision in these cases:

  1. Work which is SGA performed less than 12 months from onset, and prior to the date of the final determination, cannot be protected by the trial work provisions (see DI 13010.035) and would constitute the basis for reopening and revision to a denial or the establishment of the later onset (if SGA stopped).

  2. Work performed in or after the month of entitlement and more than 12 months from onset, is protected by the trial work provisions, regardless of whether such work occurs before or after the final determination.

  3. Work performed after the waiting period and after the date of the final determination is protected by the trial work provisions, regardless of whether such work occurs less than, or more than, 12 months after onset.

  4. Work activity which is otherwise protected by the trial work provisions will still raise an issue of possible medical recovery in cases which are diaried for medical recovery (see DI 13005.055).

NOTE: If a person returns to work less than 12 months from onset and before the date of the final determination, the issue to be resolved is whether the work performed is SGA. If so, an SSA-831-U5 denial determination must be prepared. (Any previously prepared SSA-831-U5 determination should be processed as in the “NOTE” above.) If the work is not SGA and it continues after the date of the final determination, other action must be taken, e.g., the granting of a TWP or a continuance of disability.

2. Date of final determination defined

The date of the final determination is the date of the notice of the determination (see GN 04001.040A.2.a for a definition of final determination). In cases processed via CAPS, if a copy of the notice is not in file, use the “run date” on the CAPS output Form SSA-2417-C1 to obtain the date of notice. If a copy of the notice or an SSA-2417-C1 is not in file, use the date of approval on award input forms; for example, the SSA-3687-U2 (prepared by the DO), the SSA-4648-U3 (prepared by the DDS, if dated after the DO input form), or an SSA-3687-U2 (prepared by the reviewing office, ODO or the PSC). The input forms are usually on the left side of the folder, but may be on the right side as well.

Use the date of the form that “finally authorized” benefits. When several input forms are in file, do not use input forms that change systems data, correct systems edits or correct erroneous inputs.

3. Date of onset defined

The onset date is the first day on which the beneficiary was under a disability. It is not the first month in which benefits were payable. The onset date can be identified from the SSA-831-U5 on the left side of the claims folder, the MBR or the Microfiche.

4. Return to work in the waiting period

When a claimant returns to work at the SGA level during the waiting period and before the final determination, and this work continues, the claim must be denied. When a claimant returns to work at the SGA level during the waiting period and after the final determination, and this work continues, the determination of allowance on the claim must be reopened and revised to a denial. When a claimant returns to work at the SGA level during the waiting period, but this work activity later stops (and the unsuccessful work attempt criteria in DI 11010.145 are not met), the claim must be forwarded to the DDS for their consideration of a later onset date. An unsuccessful work attempt (UWA) during the waiting period will not preclude a finding of disability.

NOTE: When the claimant returns to work in the last month of the waiting period and the claimant's earnings in that month do not exceed the amount shown in DI 10501.015, the work does not represent SGA in the waiting period; however, it should be evaluated in considering a return to work less than 12 months after onset.

See DI 13010.105 for specific processing instructions in cases involving work at the SGA level less than one year from onset.

D. Material received after appeal effectuation

1. General

The RECONE (ODO) or DEC (DRS) will receive claims files from the DE and, occasionally, from Records Maintenance, containing evidence considered to be new and material and relating to the period decided by the ALJ on an earlier application. Evidence of this nature may also be received in connection with the processing of a request for reconsideration.

If the ALJ's decision is subject to reopening, i.e., the new and material evidence is received within the 4 year period following the notice of the initial denial of the prior claim, send the file to the ALJ by SSA-559 with a copy for the file. This should be done after processing to payment any determination favorable to the claimant on the basis of the new application. On this SSA-559, tell the ALJ that evidence considered to be new and material has been submitted for whatever action he/she deems appropriate. Also, if an initial or reconsidered determination is being deferred pending his/her consideration of the evidence (see DI 40105.050A.), advise the ALJ of that fact.

Our subsequent processing will depend, of course, on whether the ALJ has reopened and revised his/her decision. Our action would either be one of effectuation of a revised decision or the completion of our initial or reconsidered action on the new claim.

In any case where the ALJ has declined to reopen his/her decision and you feel that reopening is still indicated, refer the case to OD, by SSA-559 giving the reasons for the referral.

2. Material received without new application in file

The RECONE (ODO) or DEC (DRS)may receive additional evidence or information relating to the matter that was an issue before the ALJ. If this material is not a repetition of material already considered by the ALJ, send it to the ALJ by an OF-41 with sufficient identifying information in the remarks. Do not send the claims folder. If the ALJ needs the claims folder, he/she will call for it. (See GN 03104.200.)

E. Inquiries

If a reopening is possible based on information contained in the correspondence (see DI 27501.000 for criteria for reopening), send the applicant the model letter in NL 00705.500. If no additional evidence was submitted, adapt the letter to the situation.

Any submitted correspondence that contains sufficient evidence to support a reopening of a prior decision should be associated with the file and forwarded to the DDS using SSA-847-U3 (SSA Request for Case Action). If additional information is needed return the case to the DO using SSA-5526-U3 (Request for Additional Evidence of Disability). Request the DO to arrange a personal interview following the guides in DI 12026.015. Request updating of the file, point up any gaps in the original evidence, and request fuller documentation of any pertinent issues. Tell the DO to forward the file to the DDS after they complete their development.

All controlled inquiries, including examiner development, will be monitored by the inquiries specialist in the module. When the development and/or the claims file is returned by the DO or DDS, it will be referred directly to the RECONE (ODO) or DE (DRS) for any further action necessary. The RECONE/DEC has sole adjudicative responsibility for these cases.

F. Additional medical evidence

If additional medical evidence is received in the PC after the DDS has made the disability/blindness determination and returned the folder, associate the evidence with the folder and determine whether it could affect the decision. Check the folder to see if the evidence is duplicate material. If the evidence is a duplicate of another document already in file, annotate “Duplicate Evidence” and initial and date the document and prong file it on the right hand side of the folder. If the claimant submitted the evidence or could reasonably be expected to have known that it was being submitted and the evidence was received after the date the determination notice was released to the claimant, prepare a letter and release it to the claimant. Otherwise, it is unnecessary to acknowledge receipt of the material. If the material is not duplicate evidence, the RECONE (ODO) or DE (DRS) will review to determine if the facts contained will change the decision. If not the material should be annotated “NAN” and prong filed on the right side of the folder. If it appears the medical evidence could change the prior decision the folder should be forwarded to the DDS via the SSA-L847 with remarks, “New medical evidence in fil