What is Re-Opening?
Generally, an initial determination made on your Social Security Disability claim is subject to your right to appeal- usually within 60 days. In certain instances, however, a decision which would otherwise be final and binding may be reopened or revised.
How is a Claim Re-Opened?
SSA may re-open a decision on its own initiative. Alternatively, a claimant may request that a previous determination be re-opened. Either way, SSA may revise its previous determination so that it is more or less favorable to the claimant. Therefore, certain considerations should be taken into account.
When Can a Claim Be Re-Opened?
SSA regulations set forth the conditions under which a previous determination may be revisited. Although the regulations sound as if a claimant may simply request re-opening and it will be done, it is generally well-established that the decision to re-open a claim remains at the discretion of the Administration.
What is an Initial Determination?
According to 20 C.F.R. §404.900, an initial determination is one made about your entitlement or continuing entitlement to benefits or about any other matter that gives you a right to further review. Regulations differentiate between actions that are deemed “initial determinations” and those actions deemed not to be initial determinations.
Why Does it Matter?
Administrative actions that are not initial determinations may be reviewed by SSA, but are not subject to the administrative review process, and are not subject to judicial review. In other words, there is no right to appeal. Denying a request to re-open a determination or a decision is considered such an action. So, SSA retains discretion.
What are the Three Conditions for Re-Opening?
Regulations cite three conditions for re-opening an otherwise closed case. The most generous provision allows for re-opening a case for any reason within twelve months of the initial determination. Again, the refusal by SSA to re-open a case within twelve months, for any reason, is not subject to appeal.
The second listed condition is within four years (two years for SSI) for good cause. “Good cause” includes new and material evidence, clerical errors in computations of benefits, or evidence that was clearly construed in error. A change in the law is not considered good cause.
Finally, a case may be re-opened at any time if the determination was induced by fraud or similar fault. The regulation goes on to list what it means by similar fault, and includes instances related to death, convictions, and other clerical errors.
When Does Re-Opening Make Sense?
Most often, the request for re-opening a situation arises when a claimant has had a previous claim denied, but files a new claim that is subsequently approved. The question then becomes whether the previously denied claim can be re-opened, effectively granting a claimant more back pay. Because of the huge backlog and the slow pace at which SSA adjudicates claims, it often happens that the request for re-opening cannot be made for any reason under paragraph 1 because a year has already elapsed. Then the good cause provisions of paragraph 2 come into play, ostensibly allowing for re-opening within 4 years if its provisions can be met. As a matter of practice, the most common good cause would have to do with new and material evidence that relates back to the period of the initially denied claim.
Ultimately, a claimant may not demand re-opening under any of these provisions; it may only be requested. And, if denied, the decision may not be appealed.