I-3-9-40.Reopening for Good Cause
Last Update: 5/1/17 (Transmittal I-3-151)
A. Time Limits for Reopening
Other than the 12-month period for reopening for any reason, the Appeals Council (AC) may reopen a determination or decision that is otherwise final for good cause as follows:
Within 4 years from the date of the notice of the initial determination in a claim under title II; or
Within 2 years from the date of the notice of the initial determination in a claim under title XVI.
See generally 20 CFR 404.988(b), 404.989, 416.1488(b), and 416.1489. See also Hearings, Appeals and Litigation Law (HALLEX) manual I-3-9-20 C for Acquiescence Rulings that expand the time period for requesting review.
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.
However, 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),
Then, 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. 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.
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 had no one legally responsible for prosecuting the claim 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 determination or decision;
The evidence relates to the period on or before the date of the determination or decision; and,
The evidence shows facts that would have resulted in a different conclusion as to eligibility, entitlement, or benefit amount than originally reached had the evidence been introduced or available at the time of the determination or decision.
For more information, see the Appeals Council Interpretation at HALLEX II-5-1-9.
New medical evidence shows that the claimant's impairment met the severity requirements of an impairment listed in 20 CFR 404, Subpart P, Appendix 1, 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.
New earnings information, which was not previously on SSA records, indicates that the date last insured identified in the previous determination or decision was incorrect, and the corrected date last insured would result in a different conclusion as to eligibility, entitlement, or benefit amount than originally reached.
2. New and Material Evidence Submitted After Expiration of Time to Reopen
If a 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 based on the current application.
D. Clerical Error
A clerical error is a mathematical error or misapplication of benefit tables, or other similar issue, that 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 reopen a determination or decision that 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-3-9-60 A.
E. Error on the Face of the Evidence on Which the Determination or Decision Is Based
An error on the face of the evidence is an obvious error that clearly causes an incorrect determination or decision. The following are examples of errors 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.
A Supreme Court decision found a law that we applied to be unconstitutional. See Social Security Ruling 17-1p.
While a claim was being processed, the claimant submitted a medical report to the field office that 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 reopen a determination or decision that 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-3-9-60 A.
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 Federal court order in a class action case, or the issuance of an SSR or an Acquiescence Ruling.
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 notice of the initial determination, reopening is appropriate only if the result would be more 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.