Last Update: 9/28/05 (Transmittal I-2-65)
Citations:
An Administrative Law Judge (ALJ) has the authority to reopen a determination or hearing decision, which is otherwise final and binding, for good cause as follows:
after the 12-month period for reopening for any reason but within 4 years from the date of the notice of the initial determination in a claim under Title II; or
after 12 months but within 2 years from the date of the notice of the initial determination in a claim under Title XVI.
NOTE:
Under the regulations there are other grounds for reopening. See I-2-9-60, Reopening at Any Time.
An ALJ must find that good cause exists for reopening a determination or hearing decision under the following circumstances:
new and material evidence is furnished;
a clerical error in the computation or recomputation of benefits was made for a claim under Title II, or a clerical error was made for a claim under Title XVI; or
there is an error on the face of the evidence on which the determination or hearing decision is based.
NOTE:
The circumstance described in SSR 91-5p is not a basis for finding good cause to reopen under section 404.989(a) or 416.1489(a). Except for claimants residing in the Fourth Circuit whose cases must be handled in accordance with the procedures in Acquiescence Ruling (AR) 90-4(4), the appropriate action for an adjudicator in a case in which a claimant requests reopening in the circumstance described in SSR 91-5p is to treat the request as a request for an extension of time to file a request for reconsideration (see sections 404.909(b) and 416.1409(b)), a hearing before an ALJ (see sections 404.933(c) and 416.1433(c)), or Appeals Council review of an ALJ's dismissal of a hearing request (see sections 404.968(b) and 416.1468(b)), and consider whether the claimant had good cause for missing the deadline to request review under section 404.911 or 416.1411 for purposes of determining whether to grant the request for an extension of time. See SSR 91-5p. Final rules published January 12, 1994 (59 Fed. Reg. 1629) amended sections 404.911 and 416.1411 to add a new paragraph (a)(4) to each of these sections to state explicitly that, in determining whether a claimant had good cause for missing the deadline to request review, the Agency will consider, among other things, "whether you had any physical, mental, educational, or linguistic limitations (including any lack of facility with the English language) which prevented you from filing a timely request or from understanding or knowing about the need to file a timely request for review." There is no time limit within which a claimant must make a request for an extension of time to file a request for review. By contrast, as explained in HALLEX I-2-9-40 A. above, a determination or decision may be reopened based on good cause only within the four-year period (Title II) or two-year period (Title XVI) specified in section 404.988(b) or 416.1488(b).
Definition
Generally, evidence is “new” when the adjudicator who made the prior determination or decision did not consider it. It is “material” when the new evidence, either by itself or when considered with the other evidence then before the adjudicator, would warrant a change in any finding pertinent to any matter at issue or in the ultimate decision (either favorable or unfavorable). If the new evidence does not warrant a change in any finding pertinent to any matter at issue or in the ultimate decision, the evidence is not both “new” and “material” and thus would not satisfy the regulatory standard for reopening.
Examples:
New medical evidence shows that an originally favorable prognosis proved to be inaccurate, and that an allowance based on a prior application is warranted; e.g., the prior adjudicator believed that the claimant's broken hip would be healed within 12 months but later medical evidence shows that the broken hip had not healed sufficiently within 12 months to permit the claimant to return to substantial gainful activity.
An ALJ found that the 30 year old claimant for disability insurance benefits was illiterate, unskilled, could no longer perform his heavy labor job due to his back impairment but had the residual functional capacity to perform light work. The ALJ issued a decision finding that pursuant to Rule 202.16, the claimant was not disabled. The ALJ's decision became final and binding upon the claimant's failure to appeal the hearing decision to the Appeals Council level. Two years later, the claimant requests the ALJ to reopen the hearing decision and submits new and material evidence which establishes that in fact the claimant was limited to sedentary work. Even though the claim will still be denied under Rule 201.23, if the time limit criteria are met, the ALJ must reopen the prior hearing decision, issue a revised hearing decision and provide the claimant with full appeal rights.
If a claimant requests reopening after the specified time for reopening has expired, the regulations require the ALJ to deny the request for reopening. The ALJ must notify the claimant in writing of the denial and the rationale for it.
A change of legal interpretation or administrative ruling on which a determination or decision was made may result from such events as a change in a regulation, a decision of the United States Supreme Court, a court order in a class action case, or the issuance of a Social Security Ruling or a Social Security Acquiescence Ruling.
When there is a change of legal interpretation or administrative ruling, an ALJ may reopen and revise a determination or ALJ decision under the 12-month rule only if the result will be favorable to the claimant. However, a change of legal interpretation or administrative ruling is not “good cause” to reopen a determination or decision under the 2- or 4-year rules. (See also I-2-4-40 F., Effect of a Subsequent Change in Statute, Regulation, or Policy Interpretation on Applicability of Res Judicata.)
If a statutory provision has changed, whether reopening is possible depends on the provisions of the amendment and its effective date.
A clerical error is a mathematical error, misapplication of benefit tables, etc., which resulted in an incorrect payment of a monthly benefit or an incorrect lump-sum death payment. It ordinarily occurs in the computation or recomputation of benefits. (See I-2-9-60 A.8., Reopening at Any Time.)
Error on the face of the evidence is an obvious error which reasonable minds would agree “directly caused” an incorrect determination or ALJ decision. (See I-2-9-60 A.8., Reopening at Any Time.) The following are examples of error on the face of the evidence:
Relying on the wrong person's medical report or earnings record caused the adjudicator to reach an incorrect determination or decision.
In a Title II case, onset of disability was found as of a date after the claimant last met the special earnings requirements.
Benefits in a cessation case were terminated as of the month disability ceased, rather than as of the close of the second month following the month in which disability ceased.
Evidence in the possession of the Social Security Administration at the time the determination or hearing decision was made clearly shows that the determination or hearing decision was incorrect.
Example:
While a claim was being processed, the claimant submitted to a Social Security field office (FO) a medical report which would have resulted in a different conclusion. However, the medical report was not associated with the claim file until after the determination or hearing decision became final.