Many claimants who prevail within the Social Security Disability/Supplemental Security Income process are surprised to see an award letter come in the mail that says: “The date we found you disabled is different from the date you alleged on your application.” What many don’t realize is that Disability Determination Services (the examiners deciding disability on the Initial Application and Request for Reconsideration levels), Administrative Law Judges and the Appeals Council all have the authority to say that while a claimant is disabled, they became disabled as of a date different than the alleged onset date, or that while a claimant was disabled in the past, they are no longer disabled today. When a claimant receives a letter with an onset date different than what was originally alleged, they have multiple options.
OPTION 1: ACCEPTING THE DECISION AS FINAL
A claimant is allowed to accept the decision as final. In most cases when a claimant receives a partially favorable decision, they find they are entitled to ongoing benefits beginning right then, or sometime in the near future (depending on when they were finally found disabled as of, and the program they qualify for). Many times, the main consequence to a partially favorable decision is a decrease in past due benefits (the payments that track from the date of the award letter, back to the date of entitlement). If the claimant was found eligible for Social Security Disability Insurance benefits, then Medicare entitlement begins approximately 25 months after the date of entitlement. For Supplemental Security Income qualifiers, if they were found disabled on or before the date of their application, then past due benefits track back to the date of the application. If an SSI recipient was found to be disabled as of a date after their application, then past due benefits tracks back to the date their disability was found to begin. For SSI recipients, Medicaid entitlement begins almost immediately. For many claimants, this is an amenable outcome to their situation.
OPTION 2: ONSET APPEAL
A claimant may also pursue an onset appeal. An onset appeal asserts that the claimant agrees with the decision finding the claimant disabled either ongoing, or during the stated period of time (if a closed period), but disagrees with either the finding that the disability began in the recent past, or that the disability is no longer ongoing. A claimant has 60 days from receipt of the first notice that the decision was not fully favorable to the claimant to file an appeal. Social Security will presume a claimant received the decision five days after it was mailed, unless the claimant can provide proof otherwise.
If the partially favorable determination was made at the initial application, the next step is either a Request for Reconsideration, or a Request for Hearing before an Administrative Law Judge, depending on the state. If the partially favorable determination was made by the Administrative Law Judge, then the next step is to appeal the claim to the Appeals Council.
A Request for Reconsideration takes approximately two to five months before a decision is rendered. A Request for Hearing takes 12-15 months from the date of the request before the hearing actually occurs, and possibly another one to three months before a decision is issued. Currently, the Appeals Council is takes approximately 12-15 months to process an appeal and render a decision. A claimant has the right to collect benefits during this process, if he/she was entitled to those benefits under the partially favorable determination.
The respective appealing body has five choices:
- Agree with the claimant and issue a fully favorable decision finding the claimant disabled as of their alleged onset date, and entitled to ongoing benefits. If the claimant is collecting benefits during the appeal, this may cause a retroactive bonus to the claimant’s past due benefits, and, if entitling them to a different program, increase their monthly payment going forward.
- Agree with the lower level determination. If the claimant is collecting benefits during the appeal, there will be no change to those benefits.
- Agree with neither, and modify either the establish onset date of disability, or create/modify the date disability ended. If collecting, depending on the modifications, this can cause a retroactive bonus to the claimant’s benefits, or cause the claimant to have to pay some of those benefits back.
- Agree with neither, and find the claimant “not disabled” during the entire period at issue. If collecting, the claimant will have to pay ALL the benefits back to Social Security. If the claimant is not collecting benefits in this situation, the claimant will owe Social Security nothing.
- A fifth choice is available to the Appeals Council, and that is to remand the case back to the Administrative Law Judge for a new hearing with instructions as to how to proceed.
A partially favorable determination is a substantial crossroad for most claimants. In Part II, we will discuss various situations in which it is ideal to appeal the partially favorable determination, and when it is ideal to leave it where it is at.
