PURPOSE: To state the policy and describe the relevant evidence to be considered when establishing the onset date of disability under the provisions of titles II and XVI of the Social Security Act (the Act) and implementing regulations.
CITATIONS (AUTHORITY): Sections 216(i), 223(a), 223(d), 1614(a) and 1621 of the Social Security Act, as amended; Regulations No. 4, Subpart P, sections 404.1505, 404.1509, 404.1577, 404.1581, and 404.1582; and Regulations No. 16, Subpart I, sections 416.905, 416.906, 416.907, 416.909, 416.981 and 416.982.
INTRODUCTION: In addition to determining that an individual is disabled, the decisionmaker must also establish the onset date of disability. In many claims, the onset date is critical; it may affect the period for which the individual can be paid and may even be determinative of whether the individual is entitled to or eligible for any benefits. In title II worker claims, the among of the benefit may be affected; in title XVI claims, the amount of benefit payable for the first month of eligibility may be prorated. Consequently, it is essential that the onset date be correctly established and supported by the evidence, as explained in the policy statement.
In title II cases, disability insurance benefits (DIB) may be paid for as many as 12 months before the month an application is filed. Therefore, the earlier the onset date is set, the longer is the period of disability and the greater the protection received.
Under title XVI, there is no retroactivity of payment. Supplemental security income (SSI) payments are prorated for the first month for which eligibility is established after application and after a period of ineligibility. Therefore, except for certain cases of aliens where an exact onset date of disability must be determined for eligibility purposes, the only instances when the specific date of onset must be separately determined for a title XVI case is when the onset is subsequent to the date of filing or when it is necessary to determine whether the duration requirement is met.
POLICY STATEMENT: The onset date of disability is the first day an individual is disabled as defined in the Act and the regulations. Factors relevant to the determination of disability onset include the individual's allegation, the work history, and the medical evidence. These factors are often evaluated together to arrive at the onset date. However, the individual's allegation or the date of work stoppage is significant in determining onset only if it is consistent with the severity of the condition(s) shown by the medical evidence.
A title II worker cannot be found disabled under the Act unless insured status is also met at a time when the evidence establishes the presence of a disabling condition(s). Although important to the establishment of a period of disability and to the payment of benefits, the expiration of insured status is not itself a consideration in determining when disability first began.
Onset in Disabilities of Traumatic Origin
For disabilities of traumatic origin, onset is the day of the injury if the individual is thereafter expected to die as a result or is expected to be unable to engage in substantial gainful activity (SGA) (or gainful activity) for a continuous period of at least 12 months (see SSR 82-52, PPS-89, Titles II and XVI: Duration of the Impairment). The fact that the claimant worked on the day of onset is not relevant, irrespective of the hours worked and money earned.
Onset in Disabilities of Nontraumatic Origin
In disabilities of nontraumatic origin, the determination of onset involves consideration of the applicant's allegations, work history, if any, and the medical and other evidence concerning impairment severity. The weight to be given any of the relevant evidence depends on the individual case.
In determining the date of onset of disability, the date alleged by the individual should be used if it is consistent with all the evidence available. When the medical or work evidence is not consistent with the allegation, additional development may be needed to reconcile the discrepancy. However, the established onset date must be fixed based on the facts and can never be inconsistent with the medical evidence of record.
Precise Evidence Not Available -- Need for Inferences
In some cases, it may be possible, based on the medical evidence to reasonably infer that the onset of a disabling impairment(s) occurred some time prior to the date of the first recorded medical examination, e.g., the date the claimant stopped working. How long the disease may be determined to have existed at a disabling level of severity depends on an informed judgment of the facts in the particular case. This judgment, however, must have a legitimate medical basis. At the hearing, the administrative law judge (ALJ) should call on the services of a medical advisor when onset must be inferred. If there is information in the file indicating that additional medical evidence concerning onset is available, such evidence should be secured before inferences are made.
If reasonable inferences about the progression of the impairment cannot be made on the basis of the evidence in file and additional relevant medical evidence is not available, it may be necessary to explore other sources of documentation. Information may be obtained from family members, friends, and former employers to ascertain why medical evidence is not available for the pertinent period and to furnish additional evidence regarding the course of the individual's condition. However, before contacting these people the claimant's permission must be obtained. The impact of lay evidence on the decision of onset will be limited to the degree it is not contrary to the medical evidence of record. (In mental impairment cases, see SSR 83-15, PPS-96, Titles II and XVI, Evaluation of Chronic Mental Impairments.)
The available medical evidence should be considered in view of the nature of the impairment (i.e., what medical presumptions can reasonably be made about the course of the condition). The onset date should be set on the date when it is most reasonable to conclude from the evidence that the impairment was sufficiently severe to prevent the individual from engaging in SGA (or gainful activity) for a continuous period of at least 12 months or result in death. Convincing rationale must be given for the date selected.
Malignant Neoplastic Disease
To establish onset of disability prior to the time a malignancy is first demonstrated to be inoperable or beyond control by other modes of therapy (and where prior evidence is nonexistent) requires a medical judgment by a physician. (At the hearing level, the ALJ should obtain an expert opinion from a medical source.) this judgment is based on medically reported symptoms, the type and location of the specific malignancy, and extent of involvement when first demonstrated.
Hospitalized Mental Patients
In cases currently or previously hospitalized claimants alleging disability on the basis of a psychiatric impairment, the allegation of the beginning date of disability may be made in the disability application, the Form SSA-824 (Report on Individual With Mental Impairment), or in a statement by the hospital staff. In determining the correct onset in these cases the following should be considered:
Because mentally ill persons may not be capable of protecting themselves from possible loss of benefits by furnishing necessary evidence concerning onset, development should be undertaken in such cases to ascertain the onset date of the incapacitating impairment. Contact with the individual's family, former employers, and other associates may lead to information about previous hospitalizations, medical treatment, or manifestations of symptoms prior to the current hospitalization. However, such contacts should not be made unless authorized by the individual or his or her representative shown in the disability application or elsewhere in the file. DO assistance should be requested whenever needed.
Technical Requirements and Onset of Disability
Title II: Childhood Disability Cases
In most title II childhood disability cases, a precise onset date need not be established as long as disability is found to have begun prior to attainment of age 22. A precise onset date will be necessary to determine the first month of entitlement when all the following conditions are met: (a) the application is filed before attainment of age 23, (b) disability began within 12 months of the date the application is filed, and (c) disability is established after attainment of age 18.
In reentitlement cases, a precise onset date will not always be necessary. When an exact date cannot be readily ascertained but the evidence does establish that the individual was disabled prior to the expiration of the reentitlement period and a precise date is not material, onset should be the earliest date which can be established based upon all the evidence of record. The entitlement period begins with the month following the last month of previous entitlement to childhood disability benefits and ends with the close of the 84th months (7 years) following the month this recent entitlement to childhood disability benefits terminated because the individual ceased to be under a disability.
Under P.L. 97-35 (the Omnibus Budget Reconciliation Act of 1981), effective September 1, 1981, a disability decision is needed solely to: (1) entitle a spouse, mother, or father caring for a child age 16-18 who receives child's benefits and (2) pay the lump-sum death payment (LSDP) to a disabled widow(er) or a childhood disability beneficiary (CDB) when the spouse was not living with the deceased worker at the time of death. In these situations, if a child-in-care provision is at issue, a disability determination for a child may be needed as early as age 15«.
Title II: Disabled Widow(er) Cases
To qualify for disability insurance benefits, a widow(er) must have become disabled before the end of a certain period described by law. The disability must begin at least 5 full calendar months before the month the widow(er) attains sage 60 (before age 63 if disability is being established for "Medicare only" purposes) and no later than 84 months after the latest of the following months:
A disability which began before the worker died or while the claimant was entitled to mother's/father's insurance benefits meets this requirement.
Many disabled widow(er) cases will involve onset dates long past. However, establishing a precise date of onset will not be necessary in all cases. For example, if the evidence establishes that the individual was disabled more than 5 full months prior to the beginning of the prescribed period, a determination containing this conclusion would be sufficient without establishing the precise month, day, or year of onset.
When a case is received solely because a disabled widow(er)'s benefit (DWB) determination is required to determine entitlement to payment of LSDP under the provisions of P.L. 97-35, the case will be evaluated under the same criteria used for other DWB claims. To pay LSDP to a disabled widow(er), the established onset date must be on or before the first day of the fifth month preceding the month of death of the worker. such an onset date is necessary because a disabled widow(er) would be entitled to, or eligible for, benefits for the month of the worker's death only if the 5-month waiting period has ended prior to the month of death.
For a "Medicare only" claimant to be entitled to Medicare benefits, onset must fall within the prescribed period. Thus, the latest controlling date (i.e., the latest date onset could be established without affecting the first month of entitlement) to be used is the last day of the prescribed period. The latest of the dates obtained in the following three situations should be used as a "trial" control date. If it falls within the prescribed period, it becomes the correct controlling date. If it falls after the end of the prescribed period, then the last day of the prescribed period is the correct controlling date.
It is not necessary to extend the period of consideration for onset beyond age 62 years and 6 months. An onset at age 62 years and 7 months or later becomes a denial because the claimant will automatically become entitled to Medicare on the basis of age at 65.
Title II: Blindness Cases
Statutory blindness is the only impairment specifically defined as a disability in title II of the Act. A disability freeze must be established for every qualified worker who is statutorily blind, regardless of the ability to engage in SGA. For disability freeze purposes, therefore, the beginning date of disability due to statutory blindness is the date the medical evidence shows (or where reasonable medical inferences can be made) that the individual's visual impairment first met the statutory definition of blindness. However, since no disability freeze can begin before the earnings requirement is met, it is unnecessary to develop evidence to establish an onset date earlier than the date the earnings requirement is first met.
Under the 1972 amendments to the Act, a statutorily blind worker is not required to meet the requirement of substantial recent work (the "20/40 test or alternative earnings test for young workers) to be insured for DIB or a disability freeze. The statutorily blind claimant is insured for DIB or a disability freeze if fully insured while meeting the definition of statutory blindness. However, this provision does not apply to those visually impaired workers who do not meet the statutory definition of blindness in section 216(i) of the Act.
In some cases (except those in which entitlement is based solely on the liberalized insured status requirement of the 1972 amendments), before becoming statutorily blind, the individual may have met the earnings requirement and have been unable to engage in SGA (or gainful activity) because of another impairment. If statutory blindness is superimposed on a preexisting impairment (which by itself met the duration requirement), the disability freeze onset date should be fixed as the date the individual first became unable to engage in SGA (or gainful activity).
Two onset dates must be established in the case of a worker who engaged in SGA despite statutory blindness but who subsequently, before applying for DIB, because unable to continue doing so. The first date marks the medical onset of statutory blindness, when the freeze must being whether or not the individual was engaging in SGA. The second date marks the onset of inability to engage in SGA (or gainful activity).
Title XVI Cases -- Specific Onset Ordinarily Not Necessary
Onset will be established as of the date of filing provided the individual was disabled on that date. Therefore, specific medical evidence of the exact onset date need not generally be obtained prior to the application date since there is no retroactivity of payment because title XVI payments are made beginning with the date of application provided that all conditions of eligibility are met. However, see the following discussion regarding the need to determine whether an earlier onset is necessary for certain aliens or where duration is at issue.
Title XVI -- Specific Onset Is Necessary
There may be instances where it is necessary to establish that disability has existed for several consecutive months (possibly up to 12 months) immediately prior to the date of filing in order to assure that the severity/blindness requirements of the law are met. (There is no duration requirement for a finding of statutory blindness in title XVI cases.) This situation may occur where: (1) the duration requirement is not met as of the application date, even though the requisite level of severity is established as of the date of filing, e.g., disability ceases shortly after application date but prior to adjudication; (2) medical recovery is expected within 12 months of filing but onset occurred within the 12 months prior to application; (3) the claimant begins work at an SGA level on or after the date of filing but met the severity/duration requirement prior to returning to work (in which case the claimant may be afforded the protection of a trial work period); or (4) medical documentation prior to application date is relevant to an assessment of severity/duration in the impairment category involved, e.g., myocardial infarction, cirrhosis, certain mental conditions, or for some dual title II-XVI claims where an earlier onset must be established for the title II claim.
Title XVI -- Alien Cases
For certain aliens who apply for SSI payments after September 30, 1980, it must be determined whether the individual became blind or disabled after entry into the United States. Under P.L. 96-265 (the Social Security Disability Amendments of 1980), in considering eligibility for SSI payments based on income and resources (I&R), aliens generally will be deemed to have, in addition to their own I&R, the I&R of their sponsor for a period of 3 years after entry into the United States. However, deeming will not apply after onset if an alien becomes blind or disabled after entry into the United States. Deeming when it applies will disqualify some aliens from receiving SSI payments and will reduce the amount received by others. Consequently, an onset after entry into the United States, which would preclude deeming is to the claimant's advantage. Therefore, when current evidence suggests that the condition started earlier than alleged, and onset would require the application of the deeming provision, all possible evidence must be obtained and reasonable presumptions made to arrive at the correct onset date which may be different from the claimant's allegation.
EFFECTIVE DATE: Except for the provisions implemented under P.L. 96-265 effective October 1, 1980, and P.L. 97-35 effective September 1, 1981, and P.L. 97-248 effective October 1, 1982, the policy explained herein was effective on August 20, 1980, the date the regulations covering the basic policy in the subject area were effective (45 FR 55566).
CROSS-REFERENCES: Program Operations Manual System, sections DI 2481-2486.3.
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