PURPOSE: To enunciate the policy regarding the applicability of the supplemental security income (SSI) presumptive disability (PD) and presumptive blindness (PB) provision in cases where a prior disability or blindness decision has been made and the applicant appeals the decision or files a subsequent application.
CITATIONS (AUTHORITY): Social Security Act, as amended, Section 1631(a)(4)(B), Regulations No. 16, Subpart I, Sections 416.951, 416.952 and 416.953.
PERTINENT HISTORY: Both the act and congressional reports contain language relating to the intended purpose of the PD provision.
Section 1631(a)(4)(B) of the act states that benefits may be paid "to an individual applying for such benefits on the basis of disability or blindness for a period not exceeding 3 months prior to the determination of such individual's disability or blindness . . ." (Emphasis added).
The congressional committee reports (Senate Report No. 92-1230, page 391; House Report No. 92-231, page 155) pertaining to the provision are substantively identical; the House Report states: "Under this provision, applicants for disability benefits could be paid up to 3 months benefits when a prima facie case for determining that a disability existed had been presented. In order to avoid any interruption of benefits to an eligible disabled person, your committee expects that the Secretary will make the initial determination of disability before the end of the 3-month period."
POLICY DIRECTIVE STATEMENT: The PD and PB provision may be implemented only when an individual is applying for SSI disability benefits; i.e., filing an initial or subsequent SSI application based on disability or blindness.
The history and language of the statute -- with the wording "prior to the determination" -- clearly indicate that the provision is not to be extended to the situation where the individual is filing a request for an administrative appeal. The language of the committee reports discusses the benefits to be paid strictly in terms of bridging the period from filing to the initial determination of disability. Implementation of the provision is, therefore, precluded in any case at the appellate level, including cases where there is evidence that the applicant's condition is more severe, evidence of an additional impairment that was not previously considered, or cases where the denial was on the basis that the income and resources requirements were not met.
Where an individual has previously applied for benefits and been denied, the provision may be implemented upon reapplication if the individual meets the criteria for PD payments and there has been a change in the disability or blindness factor incident to the prior denial which would justify the strong likelihood of an allowance of the subsequent claim. Under these circumstances, a PD or PB benefit is payable even though the individual previously received a PD or PB benefit, and may have a concurrent administrative appeal pending on the prior denial. The provision may also be implemented in cases where the prior denial was on a basis other than disability or blindness and there has been a change in the factor that resulted in the denial. For example, a severely impaired applicant may be denied initially on the grounds that his or her work activity constituted substantial gainful activity. At the time of the request for reconsideration, he or she is no longer working and files a subsequent application. In such a situation, a PD or PB decision can be made on the new application.
This reapplication policy recognizes the language and basic thrust of the statute for providing benefits of PD or PB on application for SSI disability or blindness benefits where there is a strong likelihood of eligibility. To permit implementation of the provision on subsequent application without acknowledgement and consideration of the reason or cause of a prior disallowance, would be contrary to the language and intent of the statute; i.e., that the provision should only be implemented where there is strong evidence of the likelihood of eligibility. Obviously, in an unchanged circumstances which had previously been determined not to meet the SSI disability or blindness requirements, the likelihood is that eligibility based on disability or blindness would not be found on subsequent application.
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