Wednesday, October 26, 2011

Carrillo Yeras v. Astrue

Carrillo-Yeras v. Astrue is an important win for claimants seeking the disability benefits found in the Social Security Act.  Ms. Carrillo applied for benefits and received a denial by Administrative Law Judge decision.  She excercised her rights under the regulations to both file a request for review to the Appeals Council and to file a new claim for benefits with SSA.  As of this year, the agency has withdrawn that dual track process as an option for claimants denied by an ALJ.  Social Security Ruling 11-1p.  The dual track appeal and refile remains a viable option for claimants once they receive a denial of review by the Appeals Council -- they may proceed to the District Court and file a new claim.  This case will have continued ramifications even under current agency policy. 

The case is simple.  Ms. Carrillo re-filed in 2003 after the ALJ denied her first case.  The agency decided that she met the requirements for disability.  The Appeals Council granted the request for reivew of the first case and reopened the second case, sending them both back to the same ALJ for a new consolidated decision.  It is clear that the only reason that the Appeals Council granted the request for review of the first decision was to provide a vehicle to reopen the second case and allow the ALJ to make one decision applicable to both.  SSA calls this a "substitution of judgment."  Any system based on discretion must reject the substitution of judgment of one fact finder by another.  The regulations permit an out for this basic principle in reopening and revision.  20 C.F.R. §§ 404.988 and 416.1488

I assume good faith unless bad faith reaches up and slaps me in the face.  I entertain that the Appeals Council had a legitimate reason for reopening the grant of benefits on the subsequent claim that would permit the substitution of judgment.  The Ninth Circuit decision describes a process that took 23 months from the date that the Appeals Council stated that it would reopen to the date that the ALJ told Ms. Carrillo that he found that she was never entitlted to the benefits paid to her and her family. 

As an exception to the prohibition of a substitution of judgment, the regulations narrowly prescribe the circumstances that SSA can engage in a reopening and revision that constitutes a "take away."  The agency must complete the investigation within 6 months or diligently under the circumstances.  20 C.F.R. §§ 404.991a, 416.1491.  If the agency takes longer than 6 months and has not acted diligently under the circumstances, any change to the reopened decision must find in the claimant's favor, i.e. not a take away. 

This maes sense.  The reopening puts the claimant on the edge of the precipice.  For the next 6 months or during a period of diligent investigation to the point of decision, that person's finances and health insurance hang in the balance.  If the agency does not complete the investigation, it should not have the ability to claw back the properly paid benefits and cease the ongoing benefits.  The agency can always conduct a continuing disability review to remove the person from the disability rolls later by showing improvement or that the first decision rested on error.  SSA has its remedies.  Restricting the reopening and revision process levels the playig field and removes the punitive component of taking away granted benefits to individuals acting in good faith for those claims on the cusp.

But did you notice the name of the lawyer representing Carrillo-Yeras?  I enjoyed working on and arguing that case.  The win is just sweet. 

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