Generally, a determination or decision that is made is final and binding if a timely request for review or appeal is not filed. However, there are certain circumstances that allow for reopening and revising prior determinations and decisions. The rules governing the circumstances for reopening are different for SSDI and SSI claims. 20 C.F.R. 404.988 sets forth the conditions for reopening SSDI claims. A determination or decision may be reopened:
- Within 12 months of the date of the notice of the initial determination, for any reason;
- Within four years of the date of the notice of the initial determination if good cause is found
20 C.F.R. 404.989 notes good cause will be found if: new and material evidence is furnished; a clerical error in the computation or recomputation of benefits was made; or the evidence that was considered in making the determination or decision clearly shows on its face that an error was made. Further, there are additional less common circumstances that allow for reopening at any time in the following situations: claims involving fraud or similar fault; a person previously determined to be dead, and on whose earnings record your entitlement is based, is later found to be alive; or in circumstances when your claim was denied because you did not prove that a person died, and the death is later established.
The regulations provide reopening may occur in the aforementioned scenarios. For practical purposes, the most common reopening conditions are within 12 months for any reason and within four years if good cause is found. As a practitioner it is important to request re-opening of prior determinations when filing an Appointment of Representative form for all new clients. Further, prior applications more than 12 months old are most likely to be reopened during a hearing with an ALJ based on the condition of new and material evidence. If a Medical Expert (ME) testifies during a hearing that the claimant’s condition meets or equals any of the Listing of Impairments, representatives should always inquire with the ME as to the onset. Further, the existence of new and material evidence that further corroborates prior evidence may serve a basis for reopening.
The rules governing the circumstances for reopening for SSI claims are set forth in 20 C.F.R. 416.1487 and 416.1488. Again, reopening may occur within 12 months for any reason; however, reopening may only occur within 2 years if good cause is found. The good cause provisions are set forth in 20 C.F.R. 416.1489 and are the same as the good cause provisions for SSDI claims.
A similar mechanism to reach back and reopen prior claims is set forth in Social Security Ruling 91-5p. However, the ruling technically does not reopen a prior application; rather it extends the time to request review. Social Security Ruling 91-5p pertains if the claimant had good cause for missing the deadline to request review. This Ruling provides that if a claimant presents evidence that mental incapacity prevented her from requesting timely review of an administrative action, and the claimant had no one legally responsible for prosecuting the claim on her behalf at the time of the prior adverse action, SSA “will determine whether or not good cause exists for extending the time to request review.” SSR 91-5p. “The claimant will have established mental incapacity for the purpose of establishing good cause when the evidence establishes that he or she lacked the mental capacity to understand the procedures for requesting review.” In making the 91-5p determination, the following four factors must be considered: (1) inability to read or write; (2) lack of facility with the English language; (3) limited education; and (4) any mental or physical condition which limits the claimant’s ability to do things for him/herself. In all cases, “[t]he adjudicator will resolve any reasonable doubt in favor of the claimant.” If it is determined, applying the proper criteria, that the claimant lacked the mental capacity to understand the procedures for requesting review, time limits are tolled “regardless of how much time has passed since the prior administrative action.” In such cases, the adjudicator must “take the action which would have been appropriate had the claimant filed a timely request for review.”
