SSR 69-6a: Sections 216(i) and 223.—Disability—Onset of Disability Must Be Firmly Established Prior to Expiration of Disability Insured Status
The claimant filed an application for a period of disability and disability insurance benefits in December 1965, alleging inability to work since 1949 because of a nervous disorder. The claimant's earnings record showed her insured status for disability purposes expired on December 31, 1953. The evidence established that she had been gainfully employed for a number of years and that she stopped working in 1948 when her husband became reemployed and it was no longer necessary for her to work. There was no evidence of a severe mental condition or of the claimant having received medical treatment from 1948 to March 1956 when she was committed to a mental hospital. Admission history showed severe mental disturbance during the month preceding hospitalization. Held, claimant was not under a disability within the meaning of the Act on or prior to December 31, 1953, since (1) there was no definite evidence as to the severity of claimant's mental impairment prior to such date, (2) the claimant's employment prior to 1949 demonstrated an ability to engage in substantial gainful activity, and (3) there was no evidence indicating her unemployment between 1949 and 1956 was due to a physical or mental impairment. The fact that her impairment may at any time after December 31, 1953, have reached such severity as to preclude her from engaging in substantial gainful activity is academic since she could not meet the insured status requirement after such date. Accordingly, the claimant is not entitled to a period of disability or disability benefits.
This case is before the Appeals Council on its own motion for review of the hearing examiner's decision dated March 27, 1967. The hearing examiner held that the claimant was entitled to a period of disability commencing January 1, 1949, and to disability insurance benefits under applicable provisions of the Social Security Act.
The claimant filed an application for a period of disability and for disability insurance benefits on December 2, 1965, alleging inability to work from 1949 because of a nervous disorder. She stated that she had been nervous most of her life and that as early as 1947 she had to stop working for about 3 months. In 1949 she stopped working completely because of her nervousness, but indicated she had no medical treatment from 1949 until 1956, when a psychiatrist had her committed to [X] Hospital because of auditory hallucinations. She indicated that since 1956, when she was first committed, she had been hospitalized at least 50 percent of the time.
STATEMENT OF THE LAW AND ISSUES
Section 216(i) of the Social Security Act provides for the establishment of a period of disability, and section 223 provides for the payments of disability insurance benefits under conditions therein specified. As herein pertinent, both sections prior to the enactment of the Social Security Amendments of 1965 on July 30, 1965, defined "disability" as an inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or to be of long-continued and indefinite duration.
In pertinent part, sections 216(i) and 223 of the Act, as amended, now define "disability" as an inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months.
When a claimant's entitlement is dependent on the amended definition of "disability," disability insurance benefits are not payable for any month prior to September 1965 [section 303(f)(1) of Public Law 89-97]. Entitlement to a period of disability may not be established under an application, if the period would have ended more than 12 months before the date such application was filed [section 216(i)(2)(E) of the Act as amended in 1965].
The Amendments of 1965 eliminated the provision of the Act which specifically limited the prospective life of disability applications. The Act now provides that if a claimant meets all the requirements for entitlement at any time before the Secretary issues a final decision on an application, such application shall be deemed to have been filed in the first month in which all requirements were met.
The general issues before the Appeals Council are whether the claimant is entitled to a period of disability and to disability insurance benefits under sections 216(i) and 223, respectively, of the Social Security Act, as amended. The specific issues are whether the claimant was under a "disability," as defined in the Act either prior to or after the Amendments of 1965, and if so, when such disability commenced and the duration thereof; and whether the special earnings requirements of the Act are met for the purpose of entitlement.
The claimant's earnings record shows that the special earnings requirements of the Act were met from a time prior to 1949, when the claimant allegedly became unable to work, and that these requirements continued to be met through December 31, 1953. Therefore, in order to be entitled to a period of disability or to disability insurance benefits, it is necessary for the claimant to establish that she was under a "disability" from a time on or prior to December 1, 1953.
SUMMARY OF MEDICAL EVIDENCE
The medical evidence before the hearing examiner consisted of the following:
A report from [X] Hospital disclosed that the claimant was admitted to the hospital on February 28, 1956, and was committed on March 15, 1956. She remained hospitalized until April 12, 1957, on which date she was transferred to the [Y] Hospital. According to the admission history from [X] Hospital, as obtained from the claimant's husband, the claimant seemed to become withdrawn about a week before her hospitalization. A precipitating factor was the information acquired about November 1955, that an operation was to be performed on her youngest son in January 1956. She became quite anxious and concerned about this. Also, toward the latter part of 1955, the claimant became quite involved with the [Z] Association. On February 27, 1956, upon returning home about 10:00 p.m., the husband found a police car in front of the house. The claimant had become disturbed and had telephoned the police department telling them that an officer of the [Z] Association was roaming outside the house; that he had hypnotized her and she was in a "spell"; and that he was able to communicate with her and was doing her thinking. When the police arrived at the home they asked a Dr. [H] to attend to the claimant, who was at that time telling people that she was going to write a book on child care the next day; that she knew the answers to all the people's problems; that her husband would be killed on the way home; and that she thought her son was the Jewish Messiah. The claimant was given a sedative by Dr. [H], who subsequently recommended that she go to a hospital, which she did without too much objection. Her condition was diagnosed as a schizophrenic reaction, paranoid type. She was given an indefinite leave in June 1956, but returned to the hospital in November 1956 at which time she was complaining of auditory hallucinations. She began receiving electroshock therapy in November 1956. In January 1957, she was considered to be in good remission and was permitted a one week visit to her husband on January 26, 1957. She returned to the hospital on February 8, 1957, fearful of her husband, and believing that he was using marijuana. She remained in the hospital until her transfer to the [Y] Hospital.
The evidence from the [Y] Hospital consisted of approximately 26 separate narrative summaries relating to the claimant's condition from April 12, 1957 to October 22, 1959, and from October 28, 1959 through July 30, 1965. According to a report dated May 23, 1957, the claimant's illness began over a period of a few months in late 1955 and early 1956. In a report dated May 27, 1957, her condition was diagnosed as: "Schizophrenic reaction, paranoid type, chronic, severe, manifested by hostility, evasiveness, ideas of reference, ideas of influence, inappropriate affect, poor judgment, and lack of insight."
The claimant showed significant improvement from time to time throughout her hospitalization, but would become acutely and seriously disturbed at other times, often during a period of trial visit. Nevertheless, she was able to remain outside the hospital on trial visits for extended periods, as, for example, from December 1957 to June 1958, and from January 1959 to October 1959. In this latter month, the claimant, being pregnant, was temporarily transferred to [C] Hospital for delivery. She was readmitted to [Y] Hospital on October 28, 1959, being 4 days post partum, her child having died within a day or two of birth. She had become increasingly disturbed while at [C] Hospital. Following readmission to [Y] Hospital she became progressively more disturbed, with her delusions becoming more bizarre and more openly expressed. She became so disturbed, hostile and threatening, that it was necessary for her to be placed in seclusion for short periods of time at her own request. By January 1960, the claimant showed marked improvement, and she was again released on a trial visit beginning February 1960, and remained out of the hospital continuously until August 1960 (except for 2 days' hospitalization in May 1960). At the time of her return to the hospital she had reportedly been upset at home for several weeks prior thereto, and had been "deluging" the staff with psychotic letters. Nevertheless, toward the end of September 1960, she had a sudden clearing of her psychotic symptoms and was able to go on unaccompanied passes and reportedly did well. She was placed on leave of absence once more for a 15-day period in order to look for work. She was successful in finding employment and made a good adjustment. Her leave was then changed to trial visit status. While out of the hospital on trial visit she apparently remarried. Prior to her return in February 1961, she once more began "flooding" the hospital with psychotic letters. Thereafter, she had two subsequent trial visits, the second of which ended in February 1962, at which time she returned to the hospital in a coma following a suicide attempt with an overdose of benadryl. The claimant improved with hospitalization and was placed on trial visit 5 months later. This was followed by rehospitalization and further trial visits, the last ending in December 1964. The claimant then remained hospitalized for the next 7 months. The last report from the [Y] Hospital indicated that it was believed she was ready to resume her prehospital activities on July 30, 1965 and she was then placed on a 90-day trial visit. It was believed doubtful that she would ever be able to work full time again consistently in the foreseeable future.
In a letter dated July 18, 1966, from [H], M.D. who is a specialist in psychiatry and neurology, and to whom previous reference was made in the admission history taken at the time of the claimant's commitment to [X] Hospital, Dr. [H] indicated that in 1956 the claimant and her family were his neighbors and that her husband had sought his advice because the claimant had become so mentally disturbed. He stated: "In retrospect there were, before the frank breakdown, earlier signs and symptoms of psychological ill health."
Other evidence in file included a statement dated December 154, 1965, from the claimant's ex-husband, [N] to whom the claimant was married from November 1947 until March 1961. He indicated in his statement that prior to the claimant's hospitalization for mental illness in 1956, he was almost totally ignorant of this type of illness, its symptoms and its effects. He stated that having become aware of this illness as a result of his wife's hospitalization, and the fact that the public in general has been alerted to observe, consider and treat mental illness, he realizes, in retrospect, that his wife had mental symptoms almost as long as he had known her. He stated that intermittently throughout their married life, his wife suffered emotional upsets which he neither understood nor knew how to combat or be considerate of. He indicated that many instances of emotional disturbances and periods of deep depression, though puzzling to him then, are now recognizable as mental illness. He also stated that there were numerous times when he was told by others that peculiarities in his wife's behavior had been observed. He concluded that his wife had suffered from mental illness for many more years than she was known to be ill.
In a letter dated May 26, 1966, the claimant stated that her illness has never been obvious to anyone but professional people, even currently, despite the fact that she has been under commitment to a mental hospital for 10 years. She further stated that she was as ill in 1949 as in 1956, when first hospitalized.
In a second letter received in June 1966, the claimant indicated that once when she was absent without leave from the maximum security ward of the [Y] Hospital, she was refused admittance to the [D] Hospital on the grounds that she was not in need of psychiatric care.
At the hearing on March 10, 1967, the claimant testified that she was born on February 8, 1922, and was a high school graduate. She was living at the [Y] Hospital at the time of the hearing, but was to be released on a trial visit that same day. She stated that she still hears voices and has heard voices since she was 9 or 10 years old. She testified that she first began working at age 17 as a secretary, but became nervous after 3 weeks and quit. She next worked as a bookkeeper about 1 year, again became nervous and quit, following which she obtained a job with the [M] Railroad as a clerk-typist and personal stenographer. She stated she had no difficulty applying herself to her work, but whenever she became nervous on a job she would quit and take another. She indicated that here was little gap between jobs because she didn't have much money to support herself. Upon quitting her railroad job she went into military service in 1943. While in service she was an athletic instructor and did office work. Other later work included that of cashier, waitress and babysitter. She married in 1947 but soon returned to work when her husband became unemployed. Following unemployment of her husband, she stopped work in 1948. The claimant agreed that when compelled to work, she has done do, but when there was no necessity to work, she has not. She did not again resume employment until 1957. She stated that all of her work in the last 10 years has been followed by hospitalization. She believes that at the time of the episode in 1956 when she was committed to [X] Hospital, her condition was the same as in the previous 10 years, but that this was the first time that she had ever spoken her thoughts. For example, she stated that she thought that her son was the Messiah ever since his birth in September 1949 but she had never told anyone until 1956. She stated that she had lost a brother when he was 10 years old, and she was told by a doctor at [X] Hospital that when her son had to undergo surgery, she had become confused because her son looked like her deceased brother, and she thought that her son was also going to die. She stated: "This is actually what made me go completely insane."
At the hearing the claimant's psychiatrist from the [Y] Hospital, Dr. [A] also testified. She stated that with the claimant's type of illness the longer a person stays on the job, the more severe it often becomes because such a person becomes more involved with interpersonal relationships. The doctor stated the opinion that the claimant is capable of handling her work when she starts out, but because she is so competent, employers want her to take higher type positions which she cannot handle. Dr. [A] stated that at the time the claimant was committed in 1956, it seemed as though she had been psychotic for a couple of years, but as more was learned about the claimant's background, for example, that she had heard voices when she was about 9 or 10 years old, it became clear that she had had severe problems over a long period of time. The doctor indicated that she did not believe the claimant's working was detrimental to her condition when she was able to do it for short periods. She stated, however, that if the claimant does not stop working when she begins to become disturbed, she will become very disturbed. In answer to the further question of whether the claimant was severely impaired on or prior to December 31, 1953, Dr. [A] stated that she did not honestly know; that she wasn't as familiar with the claimant's work record before the hearing, being unaware that it had been so irregular. She did not believe that the claimant could have supported herself over a long period of time.
Dr. [A] stated that the claimant has constantly hallucinated since she has known her; that she is mildly depressed most of the time, and sometimes severely depressed.
EVALUATION OF EVIDENCE
The medical evidence as summarized in this decision clearly establishes that the claimant has been seriously impaired because of her mental condition at least since February 1956. Conceding severity at that point, the questions to be resolved are whether her condition was such as to prevent her from engaging in substantial gainful activity on or prior to December 31, 1953, that is, the date on which she was last insured for disability purposes; and if so, whether the work in which she engaged subsequent to 1956, demonstrated her ability to engage in substantial gainful work, notwithstanding the severity of her impairment.
Regarding the first question, the claimant has stated that she has been hearing voices since age 9 or 10. Such auditory hallucinations do, of course, indicate that she had not been perfectly normal from a mental standpoint throughout most of her life. The claimant has, however, (at least until about February 1956), apparently always been able to recognize that the voices she heard were imaginary and to accept them as a fantasy. That these symptoms did not socially or occupationally inhibit her is obvious from the fact that she was able to be employed regularly, although changing jobs frequently. No evidence of serious personality disintegration is indicated prior to her hospitalization in 1956. While it is not known whether symptoms of mental illness posed any problems with employers or coworkers, considering that she was accepted into the Women's Army Corps in December 1943, was on active duty for 24 months, obtained the rank of Sergeant and was honorably discharged, it seems clear that whatever her symptoms were through that period, they did not interfere with her day-to-day functioning, her ability to handle her work assignments, to get along with others, etc. In view of the regimentation and discipline demanded in the Army, she might be expected to have functioned at least as well following her return to a more relaxed civilian life and work in 1946. Her earnings record shows 12 consecutive quarters of coverage beginning with the first quarter of 1946, with annual earnings averaging over $2,400.00 per year for the 3 years from 1946 through 1948, at which point she terminated her employment because of her marriage. Thereafter, until 1957, her earnings record is of no help in evaluating her condition since she held no employment of any kind.
The fact that the claimant did not work after 1948 warrants no presumption that she was mentally unable to work since she indicated in her testimony that she did not work when there was no economic necessity to do so, and as noted, she stopped working when she became supported by her husband.
The record contains no medical evidence contemporary with the period at issue in this case, which would show exactly what her condition was at that time, and in fact, no medical reports whatever have been furnished which describe treatment of any physical or mental condition prior to the claimant's hospitalization at [X] Hospital in 1956.
We are faced then with the situation where the evidence clearly establishes that the claimant was able, and in fact, did engage in substantial gainful activity through 1948, but where it is not affirmatively shown that she was able to so engage thereafter through December 31, 1953. However, in the absence of any contemporary evidence of a definite mental impairment on or prior to December 31, 1953, the Appeals Council is unable to arbitrarily conclude that one was present but undetected on or before that date. Certainly, where the record is devoid of any conclusive evidence that the claimant's condition significantly changed between 1948 and the latter part of 1955, it is more reasonable to conclude that the status quo was maintained, than to suppose that the claimant became totally incapacitated at some point between those dates. Furthermore, the evidence definitely indicates that more pronounced mental symptoms occurred as a result of what the claimant interpreted as a personal crisis, that is, the impending surgery which her son was to undergo in January 1956, and that these mental changes took place on or shortly before her hospitalization in February 1956. While she alleges hallucinations prior to her hospitalization, it is obvious from a reading of the medical reports that her condition became quite different from what it had been, with manifestations of disorientation, arrogance, hostility, inappropriate affect, ides of reference and influence, lack of insight, lack of judgment, and periods of tremulousness, withdrawal and paranoid tendencies.
The claimant's ex-husband and her former neighbor, who was a psychiatrist, have stated that, in retrospect, they believe the claimant was not mentally well prior to the episode in February 1956. However, the facts do not indicate, inferentially or otherwise, that the claimant's mental status was disabling on or prior to December 31, 1953, or that it was any worse than it had been prior to December 1948, during which time she demonstrated her ability to earn a living.
The claimant's treating psychiatrist also indicated that the claimant has had severe problems for a long period before 1956. In response to a specific question as to whether she believed the claimant was severely impaired on or before December 31, 1953, the psychiatrist stated that she did not honestly know, but that from what she knew of the claimant's work history, it appeared that she was not ever able to work steadily at any given job because of hearing voices. The Appeals Council, however, does not agree that such conclusion is warranted in the face of the evidence of record. For example, a review of the claimant's work history, including her earnings record, reveals that she worked regularly in every quarter from the third quarter of 1939 through the fourth quarter of 1948. Secondly, the claimant testified to the fact that although she changed employers when she became nervous, there was little interval between periods of employment and she had no difficulty applying herself to her work.
Therefore, after considering all the evidence relating to the claimant's condition throughout the period in which she was employed, ending in 1948, and her condition as it has existed before and after February 1956, the Appeals Council is of the opinion, and so finds, that the evidence does not establish that the claimant was precluded from engaging in substantial gainful activity on or prior to December 31, 1953, and that she was not disabled within the meaning of the Social Security Act on or before that date.
Having reached the above conclusion, the question of whether the claimant demonstrated ability to engage in substantial gainful activity by her work after 1956, becomes academic. The claimant may not have demonstrated ability to engage in substantial gainful activity with reasonable regularity subsequent to the time she was committed to the hospital, inasmuch as every work effort was followed by a return to the hospital, sometimes for extended periods. However, it is noted that even during this period subsequent to February 1956, when her overall condition was obviously more serious than before, she reportedly was able to function very well in competitive work situations for periods of 6 months or longer. Thus, such evidence gives further support to the previous conclusions reached in this decision, that during the period when her symptoms were less severe, that is, through December 1948, when she was regularly employed, and thereafter until her hospitalization in 1956, her condition did not prevent her from engaging in substantial gainful activity.
After careful consideration of the entire record, the Appeals Council makes the following findings:
The claimant's application for a period of disability and disability insurance benefits was filed on December 2, 1965.
The claimant last met the special earnings requirements of the Act on December 31, 1953.
The evidence does not establish that the claimant had a physical or mental impairment sufficiently severe to prevent her from engaging in substantial gainful activity on or before December 31, 1953.
The evidence establishes that the claimant's mental conditions began deteriorating shortly before February 1956.
The evidence fails to establish that the claimant's impairments were of such severity as to preclude her from engaging in substantial gainful activity for any continuous periods commencing at a time on or prior to December 31, 1953, which would permit entitlement to a period of disability or to disability insurance benefits.
The claimant was not under a "disability," as defined in the Act either prior to or after the Social Security Amendments of 1965, commencing at a time on or before December 31, 1953.
It is the decision of the Appeals Council that the claimant, based on her application filed on December 2, 1965, is not entitled to a period of disability or to disability insurance benefits under the provisions of sections 216(i) and 223, respectively, of the Social Security Act, in effect prior to the Social Security Amendments of 1965, or as amended thereby. The decision of the hearing examiner is reversed.
 During this and other periods of trial work, the claimant obtained employment, usually as a secretary. Her earnings record discloses postings of $2,285.80 in 1959, $1,934.60 in 2960, and $1,227.32 in 1964. Lesser amounts are shown for the years 1958, 1961, and 1962.
 The claimant indicated she divorced her husband in 1959 and hospital reports indicate that she instituted divorce proceedings in or about October 1959.