I-2-10-14.Writing a Decision When Fraud or Similar Fault Is at Issue
Last Update: 6/7/22 (Transmittal I-2-244)
In addition to the standard issues addressed in an administrative law judge (ALJ) decision under Hearings, Appeals, and Litigation Law (HALLEX) manual I-2-8-0, an ALJ must specifically address an issue of fraud or similar fault.
If the ALJ is asked to adjudicate a claim under HALLEX I-1-3-25 or I-1-3-26, the ALJ will be provided specific instructions, which will describe the facts or case characteristics common to the patterns of known or suspected fraudulent activity. This information will permit the ALJ to decide based on the totality of the circumstances if there is reason to believe fraud or similar fault was involved in the provision of evidence in an individual case. The instructions will also include any special decision writing requirements.
When the ALJ determines that the issue of fraud or similar fault is not material to the decision, the ALJ will not make a finding on the issue of fraud or similar fault but will explain the reasons for not finding it material in the decision's rationale.
The ALJ will limit the decision to the issues set forth in the notice of hearing and not include any reference to suspected criminal violations.
B. Disregarding Evidence
1. Finding Reason to Believe Fraud or Similar Fault Was Involved in the Providing of Evidence
If there is reason to believe that fraud or similar fault was involved in the providing of evidence in the claim, the ALJ's findings will clearly identify any document(s) or evidence that is disregarded because of a finding of fraud or similar fault and explain the basis for the finding in the decision rationale.
However, in addressing false testimony or evidence in the decision, an ALJ should be careful not to draw conclusions about possible violations of the law.
If evidence is not being disregarded, the decision rationale must include a statement that the ultimate decision regarding the benefit claim is based on evaluation of all the evidence, including the evidence that was questioned. Unsubstantiated suspicions about the evidence's authenticity or legitimacy should not impact consideration of the evidence.
2. The Authority
The ALJ will cite the authority for determining whether evidence is disregarded. The authority for these findings are sections 205(u)(1)(B) and 1631(e)(7)(A)(ii) of the Social Security Act, and Social Security Ruling (SSR) 22-2p: Titles II and XVI: Evaluation of Claims Involving Similar Fault in the Providing of Evidence.
3. The Standard of Proof
The ALJ decision will state the standard of proof used when adjudicating issues of fraud or similar fault. When considering whether evidence should be disregarded, the adjudicator will use the “reason to believe” standard. “Reason to believe” means reasonable grounds to suspect that fraud or similar fault was involved in the provision of evidence. The reason to believe standard requires more than mere suspicion, speculation, or a hunch, but it does not require a preponderance of evidence. See SSR 22-2p.
In the decisional paragraph, the ALJ will address only the disposition of the claim.
C. Reopening Due to Fraud or Similar Fault
When considering whether the conditions for reopening exist under HALLEX I-2-9-65, the adjudicator will use the “preponderance of the evidence” standard to determine whether a determination or decision was obtained by fraud or similar fault. “Preponderance of the evidence” means that after considering the evidence as whole, the existence of the fact to be proven is more likely than not. See 20 CFR 404.901 and 416.1401.
For further instructions regarding reopening a determination or decision for fraud or similar fault see HALLEX I-2-9-65.