TN 2 (08-04)

DI 42548.095 List of Exhibits

Exhibit 1 – Class Notice

Exhibit 2 – Reply Form

Exhibit 3 – Application for Class Membership

Exhibit 4 – SSN Verification Notice

Exhibit 5 – Screening Sheet Worksheet and Worksheet Instructions - Deleted

Exhibit 6 – Notice of Non-Entitlement to Relief – Revised (Previously Notice of Class Membership Denial)

Exhibit 7 – Prior Default Notice - Deleted

Exhibit 8 – Priority Flag for Pending Hyatt Class Claims

Exhibit 9 – Good Cause Denial Notice - Revised

Exhibit 10 – Notice of Denial of Class Membership After Further Review - Deleted

Exhibit 11 – Alternate Class Membership Denial Notice - Deleted

Exhibit 12 – Folder Flag At Lease One Claim Screened In and One Screened Out - Deleted

Exhibit 13 – No benefits payable notice -New

Exhibit 14 – Favorable Determination/Decision Worksheet & Transmittal - New

Exhibit 15 – Hyatt (H3) Class Action – Reopening Reviews for Settlement Subclass Cases

Exhibit 1 – Class Notice

SOCIAL SECURITY NOTICE

Important Information

Name                                 H3                   DATE:            
Address                                                        CLAIM NUMBER:         
City, State, Zip                    DOC:

NOTICE: YOU COULD GET SOCIAL SECURITY BENEFITS!
READ CAREFULLY! YOU ONLY HAVE 120 DAYS TO RESPOND

  • We may have good news for you. We may owe you disability money. This is because of a court case called Hyatt v. Shalala .

We denied your old disability claim. You can ask us to look at your old claim again if you had complaints of pain.

IF YOU NOW GET MONEY FROM SOCIAL SECURITY

Even if you now get Social Security, we may still owe you more disability money. You cannot lose benefits for which you are eligible by asking us for a Hyatt review.

IF YOU ASKED FOR HYATT RELIEF BEFORE

Even if we denied your Hyatt claim before, you may get disability money now.

WHAT YOU NEED TO DO

IF YOU WANT US TO LOOK AGAIN AT YOUR OLD CLAIM:

FILL OUT THE ENCLOSED REPLY FORM AND SEND IT TO US NOW.

YOU HAVE ONLY 120 DAYS TO DO THIS. DO NOT WAIT OR YOU MAY LOSE YOUR RIGHTS!

SEE NEXT PAGE

WHAT WE WILL DO

If you ask us to look again at your old claim, we will review your case. If we find you qualify for a Hyatt review, we will give you a new decision on your case.

IF YOU HAVE ANY QUESTIONS

If you have any questions, you may call your local Social Security office at              . We can answer most questions over the telephone. You can write or visit any Social Security office. The office that serves your area is located at:    

If you have a lawyer or representative, you may show this notice to him or her.
You can also call any of the following phone numbers. If you call, you can ask questions about this notice or get help in finding a lawyer. The help you get when you call is free.

Exhibit 1 – Class Notice (Cont'd)

The North Carolina Disability Hotline:

 

1-800-638-6810

 

The lawyers for the Hyatt lawsuit:

 

1-800-299-8619

 

  • If you cannot get through, please wait a few days and call again.

 

DON'T WAIT. ACT NOW!

  • Enclosures:

Reply form and envelope

Exhibit 2 - Reply Form

SOCIAL SECURITY ADMINISTRATION

_____________________________________________________________________________________

HYATT REPLY FORM

_____________________________________________________________________________________

IMPORTANT

RETURN THIS FORM WITHIN 120 DAYS TO REQUEST REVIEW OF YOUR CLAIM

____________________________________________________________________________________

DATE:

                    CLAIM NUMBER:

IF YOU WANT YOUR CLAIM REVIEWED, PLEASE SIGN AND DATE THIS FORM. YOU MUST ALSO FILL IN THIS FORM AND MAIL IT IN THE ENCLOSED ENVELOPE. YOU DO NOT NEED A STAMP.

Write the area code and the telephone number where we can call you.

(AREA CODE) ___________ TELEPHONE NUMBER ______________________

[   ] Check this box only if your address is different than
         shown above, and enter your correct address.

_________________________________________________________________

ADDRESS (NUMBER AND STREET, APT. NO., P.O. BOX, or RURAL ROUTE)

____________________________________________ _________________

CITY and STATE                                                        ZIP CODE

Exhibit 2 Reply Form (Cont'd)

[  ] Check this box only if the Claim Number shown above is different from your Social Security Number, and write your Social Security Number below.

     

__________________________________________

SOCIAL SECURITY NUMBER

____________________________________________ _________________

SIGNATURE                                                                    DATE

Privacy Act Notice

The Social Security Act (Sections 205(a) of title II, 702 of title VII, 1631(e)(1)(A) and (B) of title XVI, and 1869(B)(1) and (c) of title XVIII) allows us to collect the information on this form. We will use the information to process your claim. You do not have to give us this information, but without it we may not be able to process your claim. Information may be disclosed to another person or to another governmental agency for the administration of the Social Security program or for the administration of programs requiring coordination with the Social Security Administration. Explanations about these and other reasons why information you provide us may be used or given out are available in Social Security Offices. If you want to learn more about this, contact any Social Security Office.

Exhibit 3 – Application for Class Membership

 

  • H3

APPLICATION FOR HYATT CLASS MEMBERSHIP

  • Social Security may owe you disability benefits. This is because of a recent court case called Hyatt v. Shalala. If we denied your old disability claim, and you had complaints of pain, you can ask us to look at your old claim again.

Even if you now get money from Social Security, we may still owe you more disability money. Even if we denied your Hyatt claim before, you may get disability money now. You cannot lose benefits for which you are eligible by asking us for a Hyatt review.

If you want us to look again at your old denied claim, fill out this form and return it to your local Social Security field office as soon as possible.

___ ___ ___ - ___ ___ - ___ ___ ___ ___       __ __ /__ __/ __ __

SOCIAL SECURITY NUMBER               DATE OF BIRTH (mm/dd/yy)

________________________________________________________for

REPRESENTATIVE PAYEE (If Applicable) __________________________        ­­­­­­­­­­­­­___________________        ____

 NAME (LAST)                          (FIRST)                           (MI) _______________________________________________________________

 ADDRESS ___________________________________    _______    _____________

__________________________________   _______        __________

CITY                                                      STATE         ZIP CODE

 (    )    -                                                                            
TELEPHONE NUMBER

_________________________________________    ___/___/______

SIGNATURE                                                      DATE

If you have any questions, or need help, call the North Carolina Disability Hotline (toll-free) at 1-800-638-6810.

     ----------------------------------------------------------------------------------------------------------------

     For Field Office Use Only

  • FO: Verify SSN, CLAIM NUMBER                       BIC/MFT

___ ___ -  ___ -      ___ ___ ___                            ­­   ______
CLAIM NUMBER                                                  BIC/MFT

and mail to:

OCO, Class Action Section
ATTN: HYATT Coordinator
P.O. Box 32909
Baltimore, MD 21241-2909

Exhibit 4 – SSN Verification Notice

 

SOCIAL SECURITY ADMINISTRATION

                    Date:

Social Security Number:

                                                                ___ ___ ___-___ __-___ ___ ___             

You asked us to review your past claim for disability benefits under the Hyatt, et al. v. Shalala settlement agreement. We could not do so because we have no record that you ever filed an application for those benefits on the Social Security number you gave us.

You might have given us the wrong Social Security number. Our records show you requested review under Social Security number ___ ___ ___ -___ ___-___ ___ ___.  Please check this Social Security number carefully.

If you find that the number you gave us is wrong, please write the correct Social Security number on the line above, under “Social Security Number”. Return this letter in the enclosed envelope.

If the number you gave us is correct, please provide us with evidence that you filed a claim under this Social Security number. You can submit this evidence, along with this letter, in the enclosed envelope.

If we do not hear from you within 30 days from the date of this notice, we will take no further action on your request for review under the Hyatt, et al. v. Shalala lawsuit.

If you have any questions, you may call us toll-free at 1-800-772-1213, or call your local Social Security office at XXX-XXXX. We can answer most questions over the phone. You can also write or visit any Social Security office. The office that serves your area is located at:

Address
City, ST ZIP

If you do call or visit an office, please have this letter with you. It will help us answer your questions. Also, if you plan to visit an office, you may call ahead to make an appointment. This will help us serve you more quickly.

Enclosure: Envelope

Exhibit 6 – Notice of Non-Entitlement to Relief - REVISED

SOCIAL SECURITY ADMINISTRATION

IMPORTANT INFORMATION

Date:

Claim Number:

Dear               :

We looked at your case as the result of a class action court case in North Carolina called Hyatt. We looked at your case even if we looked at it earlier and sent you a letter saying you were not entitled to a Hyatt review.

As a result of reviewing your case, we found that you are not entitled to a Hyatt review. This means we will not review your old disability case again. The reason you are not entitled to this review is explained below.

IF YOU DISAGREE

You, or your representative, have 120 days from the date you receive this notice to write to Social Security to request review of this decision.

If you want Social Security to review this decision, please write to:

Social Security Administration
Office of the General Counsel
Room 617 Altmeyer
6401 Security Blvd
Baltimore, MD 21235-6401,

THE REASON YOU ARE NOT ENTITLED TO HYATT REVIEW IS BECAUSE:

We have no evidence that you ever filed an application for social security disability insurance benefits under either title II or title XVI of the Social Security Act. Your application was for ­_________________________________________________________________________________________________________________________________________________________________________.

You did not receive a less than fully favorable determination/decision (choose one) by a North Carolina adjudicator on or after July 7, 1981 and before November 14, 1991. The final determination/decision (choose one) on your claim was

(fill in the reason the claimant does not qualify for Hyatt review)

­____________________________________________________________________________________

____________________________________________________________________________________

Exhibit 6 – Notice of Non-Entitlement to Relief - REVISED (Cont'd)

You did not receive a medical denial/determination. The final determination decision was based on _______________________________________________________________.

Remember that you only have 120 days to ask us to review this decision. If you do not contact us within 120 days this decision will become final.

IF YOU NEED HELP

If you have questions or want help, you should contact:

Your lawyer or representative; or

The lawyers for the Hyatt class:

Hyatt Attorney
North Carolina Justice and Community Development Center
P.O. Box 28068
224 South Dawson Street
Raleigh, NC 27611-8068
1 (800) 299-8619

INFORMATION ABOUT FILING A NEW APPLICATION

If you think you are disabled now, you may file a new application. A new application is not the same as asking us to review your claim under Hyatt. In the new application, you may not be able to receive disability benefits for the period of time you asked for in your prior claim. If you decide to file a new application, contact any Social Security office.

cc: Claimant's Representative
   Hyatt Attorney

Exhibit 8 – Priority Flag for Pending Hyatt Class Claims

 

Claim No: _________         

PENDING HYATT CLASS CLAIM

PROCESS ON A PRIORITY BASIS

Exhibit 9 Good Cause Denial Notice

SOCIAL SECURITY ADMINISTRATION

IMPORTANT INFORMATION

(Field Office Return Address)
(Field Office Phone Number)

Date:

Claim Number:

  • On __________ we sent you a letter about a court case called Hyatt v. Shalala. In our letter we told you that you could ask us to review your old disability claim. Our letter told you that you had to ask for a review within 120 days from your receipt of the letter. However, our records show you did not ask for review until____________.

  • If you had a good reason for being late, we could still review our claim. However, based on the facts that you gave us, we find that you did not have a good reason. This means that we cannot review your claim.

  • If You Disagree

  • You or your representative, have 120 days from the date you receive this notice to write to Social Security to request review of this decision.

  • If you want Social Security to review this decision, please write to:

    Social Security Administration
    Office of Central Operations
    Attn: HYATT Coordinator
    P.O. BOX 32909
    Baltimore, Maryland 21241-2909

If You Need Help

If you have questions or want help, you should contact:

  1. Your lawyer or representative; or

  2. The lawyers for the Hyatt class:

Hyatt Attorney
North Carolina Justice and Community Development Center
P.O. Box 28068
224 South Dawson Street
Raleigh, NC 27611-8068
1 (800) 299-8619

Exhibit 9 – Good Cause Denial Notice (Cont.)

Information About Filing A New Application

If you think you are disabled now, you may file a new application. A new application is not the same as asking us to review your claim under Hyatt. In the new application, you may not be able to receive disability benefits for the period of time you asked for in your prior claim. If you decide to file a new application, contact any Social Security office.

If You Have Any Question

If you have any questions, you may call or visit any Social Security office. If you do call or visit an office please have this notice with you. It will help us answer your questions.

cc:

Hyatt Attorney
Claimant's Representative
Litigation Staff

Exhibit 13 - Hyatt III – Notice of No Benefits Due

SOCIAL SECURITY ADMINISTRATION

Claimant's Name                             H3                  SSN

Address                                                                 DOC

We have reviewed your prior claim(s) because of the class action court case called Hyatt. Your case was reviewed even if we looked at it earlier and sent you a letter saying you were not entitled to a review.

We found that you were disabled beginning (fill in established onset date). This means that the earliest your benefits can start is

  1. (fill in MM/YY for Social Security disability) (and/or)

  2. (fill in MM/YY for Supplemental Security Income).

[For title II only claims select 1, for title XVI only claims select 2, for concurrent claims complete both].

Since you already received these benefits, we do not owe you any more money because of this review.

If you believe that this determination is not correct, you may request that your case be reexamined. If you want this reconsideration, you must request it not later than 60 days from the date you receive this notice. You should make your request through any Social Security office. If additional evidence is available, you should submit it with your request.

If you have any questions about your claim, you may get in touch with any Social Security office. Most questions can be handled by telephone or mail. If you do visit an office, please take this notice with you.

cc:

Hyatt Attorney
North Carolina Justice and Community Development Center
224 South Dawson Street
P.O. Box 28068
Raleigh, NC 27611
Telephone: 1-800-299-8619
Claimant's Representative
Litigation Staff

Exhibit 14Hyatt III Favorable Determination/Decision Worksheet and Transmittal

Graphic: G-DI_42548.095

NOTE: Please do not forward completed folders to The Class Action Section (CAS) located in Baltimore, Maryland. Upon completion of a case, the folder should be forwarded to the appropriate storage facility (PSC, WBDOC, ODO). CAS does not house completed folders.

Exhibit 15 Hyatt (H3) Class Action – Reopening Reviews for Settlement Subclass Cases

A. BACKGROUND

There are two separate subclasses of claimants that are entitled to relief under the March 1994 Hyatt Settlement Order, i.e., they are the primary and settlement subclasses.

1. Primary Subclass

The primary subclass, subject to certain very limited exclusions, consists of all individuals whose disability claims, which included allegations of pain, were finally denied or terminated on or after July 7, 1981 and before August 6, 1990. Primary subclass members have their claims reopened and receive full appeal rights. See DI 12548.001B.1., DI 32548.001B.1., DI 42548.001B.1., HALLEX I-5-404IV.B.1.

2. Settlement Subclass

The settlement subclass, subject to certain very limited exclusions, consists of all individuals whose disability claims, which included allegations of pain, were finally denied or terminated by the North Carolina DDS on or after August 6, 1990 and before November 14, 1991. Settlement subclass members receive a disability redetermination with limited appeal rights. See DI 12548.001B.2., DI 32548.001B.2., DI 42548.001B.2., HALLEX I-5-404-IV.B.2-3.

B. NEW PROCESS

Effective immediately all settlement subclass members will prospectively have their claims reopened and will receive full appeal rights. The settlement subclass members' claims will have the same appeal rights as the primary subclass members.

C. REFERENCES

Follow POMS DI 12548.020B., DI 32548.020, and DI 42548.009B. to process all HYATT H3 class member claims. The POMS and HALLEX are currently being revised and will be issued upon completion.

D. CONTACTS

Questions regarding the content of this message or about the HYATT case should be directed as follows:

  • SSA Offices, other than OHA, should contact the HYATT coordinator in their Regional Office.

  • Regional Coordinators should contact the Office of Acquiescence and Litigation Coordination (OALC).

  • OHA offices contact: The appropriate OHA Regional Office.

  • OHA Regional Office should contact the Chief Judge’s Office.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0442548095
DI 42548.095 - List of Exhibits - 08/05/2004
Batch run: 01/27/2009
Rev:08/05/2004