I-3-9-4.Reopening for Good Cause
Last Update: 3/08/13 (Transmittal I-3-46)
A. Time Limitations for Reopening
The Appeals Council (AC) may reopen a determination or decision, which is otherwise final, 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 the 12-month period for reopening for any reason, but within 2 years from the date of the notice of the initial determination in a claim under title XVI.
B. Good Cause Defined
Good cause for reopening a determination or decision exists 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
The evidence that was considered in making the determination or decision clearly shows on its face that an error was made.
The good cause for reopening rules generally do not apply if the circumstances in Social Security Ruling (SSR) 91-5p: Mental Incapacity and Good Cause for Missing the Deadline to Request Review exist. Under SSR 91-5p, if a claimant presents evidence that mental incapacity prevented him or her from timely requesting review of an adverse determination, decision, dismissal, or review by a Federal district court, and the claimant had no one legally responsible for prosecuting the claim at the time of the prior administrative action (e.g., a parent of a claimant who is a minor, legal guardian, attorney, or other legal representative), the Social Security Administration (SSA) will determine whether or not good cause exists for extending the time to request review. If the claimant satisfies the substantive criteria, the time limits in the reopening regulations do not apply. In that case, regardless of how much time has passed since the prior administrative action, the claimant can establish good cause for extending the deadline to request review of that action.
However, in the Fourth Circuit, cases must be handled in accordance with Acquiescence Ruling (AR) 90-4(4). In these cases, SSA must reopen an otherwise final administrative determination at any time when a claimant was unrepresented at the time of the prior adjudication and establishes he or she lacked the mental capacity to understand the procedures for requesting review, unless SSA holds an evidentiary hearing and determines that mental incompetence did not prevent the claimant from filing a timely appeal.
C. New and Material Evidence
To satisfy the regulatory standard for reopening, evidence is “new and material” when the evidence:
is not part of the claim(s) record as of the date of the ALJ decision or determination;
is relevant, i.e., involves or is directly related to issues adjudicated in the prior decision or determination;
relates to the period on or before the date of the decision or determination; and
shows that the decision or determination is contrary to the weight of the evidence.
The weight of the evidence is defined as the balance or preponderance of evidence. See HALLEX I-3-3-4.B.
In other words, the weight of the evidence means it is “more likely than not” that the totality of evidence, including the additional evidence, would change the ALJ"s action, findings, or conclusion.
For discussion relating to when the AC will consider additional evidence in association with a request for review, see HALLEX I-3-3-6.
New medical evidence shows that the claimant"s impairment met an impairment listed in Appendix 1, Subpart P, during the previously adjudicated period and that an allowance based on the prior application is warranted.
New medical evidence shows that the original medical prognosis did not prove to be accurate 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"s return to substantial gainful activity.
2. Effect of New and Material Evidence
It may not always warrant a different conclusion.
It may produce a significant change in a factor of entitlement that warrants a revision of a prior unfavorable determination or decision, but does not change the ultimate unfavorable determination or decision.
The AC 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 AC issued a decision finding that the claimant was not disabled under Rule 202.16. The AC"s decision became final and binding when the claimant did not file a civil action in federal court. Two years later, the claimant requests that the AC reopen its decision and submits evidence that establishes he was limited to sedentary work during the period at issue. Even though the claim will still be denied under Rule 201.23, if the reopening time limit criteria are met, the AC may reopen its prior decision, issue a revised decision, and provide the claimant with court appeal rights.
3. New and Material Evidence Submitted after Expiration of Time to Reopen
If the claimant submits new and material evidence after the prescribed time for reopening has expired and the evidence warrants an allowance during the previously adjudicated period, the AC may establish the onset date as shown by the evidence. However, the claimant is only entitled to benefits or a period of disability on the current application.
D. Clerical Error
A clerical error is a mathematical error or 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.
Under title II, the AC may generally only reopen a determination or decision which is otherwise final within 4 years from the date of the notice of the initial determination. However, if a determination or decision was fully or partially unfavorable to the claimant due to a clerical error, the title II determination or decision may be reopened at any time. See 20 CFR 404.988(c)(8) and HALLEX I-3-9-6.A.8.
E. Error on the Face of the Evidence on Which the Determination or Decision Is Based
Error on the face of the evidence is an obvious error which clearly causes an incorrect determination or decision. The following are examples of error on the face of the evidence:
The adjudicator relied on the wrong person"s medical report or earnings record.
In a title II only claim, onset of disability was established after the claimant last met the special earnings requirements.
Benefits in a cessation case were terminated as of the month disability ceased, rather than being terminated as of the close of the second month following the month in which disability ceased.
Evidence in the possession of SSA at the time the determination or decision was made clearly shows that the determination or decision was incorrect.
While a claim was being processed, the claimant submitted a medical report to the Social Security field office which would have resulted in a different conclusion. However, the medical report was not associated with the claim file until after the determination or decision became final.
Under title II, the AC may generally only reopen a determination or decision which is otherwise final within 4 years from the date of the notice of the initial determination. However, if a determination or decision was fully or partially unfavorable to the claimant, due to an error that appears on the face of the evidence that was considered when the determination or decision was made, the AC can reopen at any time. See 20 CFR 404.988(c)(8) and HALLEX I-3-9-6.A.8.
F. Change in Legal Interpretation or Administrative Ruling
A change of legal interpretation or administrative ruling may be the result of 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 an SSR or an AR.
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. Although a change of legal interpretation or administrative ruling may be a basis for reopening within 12 months of the date of the initial determination, such reopening is appropriate only if the result would be favorable to the claimant.
G. Effect of Change in Statutory Provision
If a statute has been amended, any reopening depends on the provisions of the amendment itself. The amendment will provide the effective date of the change and indicate its effect on any prior determinations or decisions.