DI 125: Court Cases
TN 43 (11-94)
List of Exhibits
Exhibit 1 - State of New York Class Membership Notice
Exhibit 2 - Reply Form
Exhibit 3 - Good Cause Denial Notice
Exhibit 4 - Undeliverables Checklist
Exhibit 5 - Screening Sheet
Exhibit 6 - SSN Verification Notice
Exhibit 7 - State of New York Non-Membership Notice
Exhibit 1 State of New York Class Membership Notice
THE STATE OF NEW YORK v. SULLIVAN
(THE EXERCISE TEST CASE) CLASS MEMBER NOTICE
Date:
Claim Number:
We are writing to let you know that we have decided you are entitled to a new decision because of the State of New York v. Sullivan case (the exercise test case).
-
We will contact you when we start reviewing your claim and ask you if you have additional evidence.
You will be told where to send any additional evidence at that time.
-
If you have a legal representative you should show this notice to that person. If you would like to obtain a legal representative, you may call:
-
Legal Services, which will refer you for free assistance if you are financially eligible.
In the New York city area: Legal Services for New York City at (212) 431-7200 OR The Legal Aid Society at (212) 577-3300.
In the rest of New York state: Greater Upstate Law Project, at 1-800-724-0490.
The National Organization of Social Security Claimant's Representatives will refer you to an attorney who will charge a fee for representation, call 1-800-431-2804.
-
-
If you have other questions, you may also contact the Social Security Administration at 1-800-772-1213. If you visit a Social Security office, please bring this letter with you. It will help us answer your questions.
Si usted no entiende esta carta, llavela a la oficina de Seguro Social arriba mencionada para que se la expliquen.
Exhibit 2 Reply Form
Exhibit 3 Good Cause Denial Notice
Claim Number:
On , we sent you a letter about a court case called State of New York et al. v. Sullivan, the exercise test case. In that letter we said that you could ask us to review your previous Social Security or Supplemental Security Income disability claim and that this could result in benefit payments to you. We notified you that you had to reply to that letter within 120 days if you wanted us to review your claim. Our records show that you did not ask for that review until .
Under certain limited conditions, we can extend the time limit for requesting review. However, based on the facts that you gave us, we are unable to extend the time limit in your case. Accordingly, we cannot review your claim under the State of New York et al. v. Sullivan, the exercise test case, court case.
WHAT YOU MAY DO IF YOU DISAGREE WITH THIS DETERMINATION
-
You may write Legal Services for the Elderly, one of the offices that represented the plaintiff class in this action. Their address is:
Legal Services for the Elderly
Attention: Good Cause
130 W. 42nd St., 17th Fl.
New York, NY 10036
If it is difficult for you to write, you may call Legal Services For The Elderly at: (212) 391-0120.
-
If you prefer, you may send your written disagreement directly to:
The Office of the General Counsel
Department of Health and Human Services
Rm. 639 Altmeyer Bldg.
6401 Security Blvd.
Baltimore, MD 21235
ATTN: The Exercise Test Case
IF YOU HAVE A LEGAL REPRESENTATIVE OR WOULD LIKE TO OBTAIN ONE
If you have a legal representative you should show this notice to that person. If you would like to obtain a legal representative, you may call:
-
Legal Services, which will refer you for free assistance if you are financially eligible.
In the New York city area call: Legal Services for New York City at (212) 431-7200 OR The Legal Aid Society at (212)577-3300.
In the rest of New York State call: Greater Upstate Law Project, at 1-800-724-0490 or 1-800-635-0355.
The National Organization of Social Security Claimant's Representatives will refer you to an attorney who will charge a fee for representation, call 1-800-431-2804.
IF YOU HAVE OTHER QUESTIONS
You may also contact the Social Security Administration at 1-800-772-1213. If you visit a Social Security office, please bring this letter with you. It will help us answer your questions.
Si usted no etiende esta carta, llavela a la oficina de Seguro socil arriba mencionada para que se la expliquen.
Exhibit 4 Undeliverables Checklist
State of New York Undeliverable Checklist
Week Ending FO code
New Address Located - Notice Remailed
Name SSN New Address
Efforts Completed - No New Address Located
Name SSN New Address
Exhibit 5 Screening Sheet
SN
STATE OF NEW YORK
(THE EXERCISE TEST CASE) SCREENING SHEET
PLEASE BE AWARE THAT YOU MUST CONSIDER ALL CLAIMS DECIDED DURING THE PERIOD COVERED BY THE COURT ORDER (i.e., June 1, 1980 through February 2, 1994) WHEN MAKING THE CLASS MEMBERSHIP DETERMINATION.
1. SSN - -
[ ] TITLE II [ ] TITLE XVI [ ] CONCURRENT
2. CLAIMANT'S NAME
3. BIC or ID
DATE OF SCREENING - -
MEMBER (J) [ ] NON-MEMBER (F) [ ]
SCREEN-OUT CODE (04, 05, 06, 07, 08, 11, 12, or 13--enter as appropriate on lines above)
I. CLASS MEMBERSHIP DETERMINATION
4. |
Did the claimant file an application for disability benefits under Title II or Title XVI of the Social Security Act? (NOTE: Regardless of the absence of any documentation on the computer, DO NOT screen the claimant out if they have provided evidence of a denial or cessation decision issued between June 1, 1980 and February 2, 1994). |
Yes No |
5. |
Did the claimant live in New York State at the time of any final denial or cessation decision of the Secretary made between June 1, 1980 and February 2, 1994? |
Yes No |
6. |
Did the claimant receive a subsequent fully favorable decision for the earliest alleged onset date for Title II or the earliest application date for Title XVI? |
Yes No |
7. |
Was the claim(s) finally decided after the date the Agency implementation instructions were issued? |
Yes No |
8. |
Was the claim(s) decided by a judgment of a district court that became final and unappealable before December 4, 1989? |
Yes No |
9. |
Is any case a “170” case? |
Yes No |
10. |
Was any claim(s) finally denied or ceased at step 3, (title II widow/widower, or title XVI disabled children) 4 or 5 of the sequential evaluation process (or the equivalent steps of the CDR process) by the New York DDS, by a hearing office servicing the State of New York or by the Appeals Council between 6/1/80 and 12/3/89 inclusive? |
Yes No |
11. |
Was any claim(s) finally denied or ceased at step 2, 3, (title II widow/widower, or title XVI disabled children) 4 or 5 of the sequential evaluation process (or the equivalent steps of the CDR process) by the New York DDS, by a hearing office servicing the State of New York or by the Appeals Council between 12/4/89 and 2/2/94? |
Yes No |
12. |
On any claim(s) did the claimant allege, or is there evidence in file of ischemic heart disease, hypertensive vascular disease, myocardiopathies, rheumatic or syphilitic heart disease? |
Yes No |
13. |
On any claim(s) does the medical evidence in file include the results of an exercise test (e.g., treadmill, bicycle, arm ergometry)? |
Yes No |
II. Non-members or members who have already received relief
If you checked block 04, 05, 06, 07, 08, 11, 12 or 13 the claimant is not entitled to relief as a class member. Check “non-member” (F) in item 3 and fill in the screen-out code (04, 05, 06, 07, 08, 11, 12 or 13). Proceed to IV.
III. Class Members
If you have no blocks checked, the claimant is entitled to relief as a class member. Check “member” (J) in Item 3. Proceed to IV.
IV. Dates
On the lines below, please enter the date(s) of all final decisions considered in the screening process, and indicate the administrative level at which the final decision was made (i.e., DDS, ALJ, AC). Also record the dates of any determinations after the date Agency implementation instructions were issued that you considered in the screening process, and indicate the administrative level at which the determination was made (i.e., DDS, ALJ, or AC).
|
|
|
|
|
|
V. SCREENER IDENTIFICATION
(NOTE: BEFORE SIGNING, PLEASE COMPLETE ITEM 3.)
| |
Print name, phone number and component | |
|
|
Signature |
State of New York (SONY) Screening Sheet Instructions (DI 42594.015B.2.)
-
Consider all Title II and XVI claims (denials/cessations) finally decided during the period June 1, 1980 to February 2, 1994, inclusive.
NOTE: If ALJ, AC or Federal court made last decision in SONY time period, send the case to OHA for screening.
-
Review the SONY alert, related queries (FACT, SSIRD, etc.) and claim file(s).
When the claim file has been destroyed or declared lost, determine if the case may be screened out solely on the basis of information shown on the queries. EXAMPLE 1. SSIRD shows Title XVI claim(s) denied for excess income and resources; FACT shows Title II claim(s) denied because insured status not met at any point, or alleged onset date occurred more than one year after insured status last met (disallowance code 90). Check block 11. EXAMPLE 2. SSIRD shows a Title XVI claim that was denied initially but subsequently allowed at the reconsideration or ALJ level with no change in date of eligibility: Check block 6. Any case which cannot be conclusively screened out on the basis of the queries must be sent to the FO for reconstruction.
Complete Questions 1 - 3 and Part I of the screening sheet as follows:
Question 1. |
Enter the SSN under which the claim was filed and check Title II, Title XVI or Concurrent. |
Question 2. |
Enter claimant's name. |
Question 3. |
|
Question 4. |
|
Question 5. |
|
Question 6. |
|
Question 7. |
|
Question 8. |
|
Question 9. |
|
Question 10. |
|
Question 11. |
|
Question 12. |
|
Question 13. |
|
Complete Part IV of the screening sheet by entering the dates and administrative review level (initial, recon, ALJ or AC) of all final determinations/decisions issued during the period June 1, 1980 to February 2, 1994, inclusive, that were considered during the screening process; as well as the dates and administrative review level of all final determinations/decisions issued after February 2, 1994.
-
Complete Part V, “Screener Identification”.
Place a copy of the completed screening sheet in the claim folder and send a copy to:
ODIO
Attn: State of New York Coordinator
P.O. Box 17369
Baltimore MD 21298-0050
Exhibit 6 SSN Verification Notice
Claim Number:
You have asked us to review your claim for Social Security and/or Supplemental Security Income disability benefits under the State of New York et al. v. Sullivan, (the exercise test case). We have been unable to do so because we have no record that you ever filed an application for Social Security or SSI.
You might have given us the wrong Social Security number when you told us that you wanted to have your claim reviewed under State of New York et al. v. Sullivan, the exercise test case. If you gave us the wrong number, that would explain why we have not been able to find a record of your claim. Please check your Social Security number carefully, and compare it to the following number. The number you gave us is . If this number is wrong, please write your correct Social Security number on the line above, marked “Claim Number.”
If you asked for Social Security on someone else's record, please write that person's Social Security number on that line above, marked “Claim Number.”
Return this letter in the enclosed envelope.
If you do not give us a new Social Security number but you have evidence which shows that you filed a claim, please take the evidence, along with this letter, to your local Social Security office.
Please respond to this notice promptly. We can take no further action on your request for review under State of New York, et al. v. Sullivan, the exercise test case, until you respond.
IF YOU HAVE A LEGAL REPRESENTATIVE OR WOULD LIKE TO OBTAIN ONE
If you have a legal representative you should show this notice to that person. If you would like to obtain a legal representative, you may call:
-
Legal Services, which will refer you for free assistance if you are financially eligible.
In the New York city area call:
Legal Services for New York City at (212) 431-7200 OR The Legal Aid Society at (212) 577-3300.In the rest of New York state call:
Greater Upstate Law Project, at 1-800-431-2804.
IF YOU HAVE OTHER QUESTIONS
You may also contact the Social Security Administration at 1-800-772-1213. If you visit a Social Security office, please bring this letter with you. It will help us answer your questions.
Enclosure: Envelope
Si usted no entiende esta carta, llavela a la oficina de Seguro Social arriba mencionada para que se la expliquen.
Exhibit 7 State of New York Non-Membership Notice
STATE OF NEW YORK V. SULLIVAN (The Exercise Test Case)
Date:
Claim Number:
THIS NOTICE IS ABOUT YOUR SOCIAL SECURITY/SSI BENEFITS.
PLEASE READ IT CAREFULLY!
-
WE HAVE DETERMINED THAT YOU ARE NOT ENTITLED TO RECEIVE A NEW DECISION IN THE STATE OF NEW YORK V. SULLIVAN COURT CASE (THE EXERCISE TEST CASE).
You asked us to review your case under the terms of the exercise test case, or under another of the New York court cases (i.e., Stieberger, Dixon, and/or Hill), or we identified you as a potential State of New York class member through some other means. We have looked at your case and decided that you are not entitled to relief as a State of New York class member. The reason you are not entitled to relief is checked below. (If we are also looking at your claim in connection with other New York court cases, (Stieberger, Dixon, and/or Hill), you will be getting separate notice(s) regarding class membership in those cases).
-
WHY YOU WILL NOT RECEIVE A NEW DECISION
YOU ARE NOT ENTITLED TO RELIEF AS A STATE OF NEW YORK CLASS MEMBER BECAUSE:
1. |
[ ] |
You were not issued a decision by the New York Disability Determination Service (DDS) or the Office of Hearings and Appeals, for New York state, denying or ceasing disability benefits on or after June 1, 1980 and February 2, 1994. |
2. |
[ ] |
You did not live in the state of New York at the time your claim for disability benefits was finally denied or ceased. |
3. |
[ ] |
Your claim did not involve in any way the problems of heart disease or a heart condition. |
4. |
[ ] |
There were no exercise test results in your file. |
5. |
[ ] |
Your benefits were denied or ceased for some reason other than your medical condition. That reason was
|
6. |
[ ] |
You have received a subsequent fully favorable decision awarding you either Title II benefits based on the earliest date that you said you were disabled, or Title XVI disability benefits based on the earliest date on which you applied. We will be in touch with you if you are owed any additional retroactive benefits. |
7. |
[ ] |
Other
|
We looked at the decision(s) dated:
-
WE ARE NOT DECIDING WHETHER YOU ARE DISABLED
It is important for you to know that we are not deciding whether you are or were disabled. We are deciding only that we will not make a new decision, based on the exercise test case, on your past claim(s) for disability benefits.
-
WHAT YOU MAY DO IF YOU DISAGREE WITH THIS DETERMINATION
-
You may write Legal Services for the Elderly, one of the offices that represented the plaintiff class in this action. Their address is:
Legal Services for the Elderly
130 W. 42nd St., 17th Fl.
New York, NY 10036
ATTN: The Exercise Test CaseIf it is difficult for you to write, you may call Legal Services For The Elderly at: (212) 391-0120.
-
If you prefer, you may send your written disagreement directly to:
OFFICE OF THE GENERAL COUNSEL
DEPARTMENT OF HEALTH AND HUMAN SERVICES
RM. 639 ALTMEYER BLDG.
6401 SECURITY BLVD.
BALTIMORE, MD 21235
ATTN: THE EXERCISE TEST CASE You may also contact the Social Security Administration. To locate your local Social Security office, call 1-800-772-1213. If you visit a Social Security office, please bring this letter with you. It will help us answer your questions.
-
-
IF YOU HAVE A LEGAL REPRESENTATIVE OR WOULD LIKE TO OBTAIN ONE
If you have a legal representative, you should show this notice to that person. If you would like to obtain a legal representative, you may call:
-
Legal Services, which will refer you for free assistance if you are financially eligible.
In the New York city area call:
Legal Services for New York City at (212) 431-7200 OR The Legal Aid Society at (212) 577-3300.In the rest of New York state call: Greater Upstate Law Project, at 1-800-724-0490.
The National Organization of Social Security Claimant's Representatives will refer you to an attorney who will charge a fee for representation, call 1-800-431-2804.
-
YOU ALSO HAVE THE RIGHT TO FILE A NEW APPLICATION FOR BENEFITS. FILING A NEW APPLICATION IS NOT THE SAME AS CHALLENGING OUR CLASS MEMBERSHIP DECISION, AND OBTAINING A NEW DECISION ON A PAST APPLICATION.
-
IF YOU HAVE OTHER QUESTIONS
You may also contact the Social Security Administration at 1-800-772-1213. If you visit a Social Security office, please bring this letter with you. It will help us answer your questions.
Si usted habla español y no entiende esta carta, favor de llevarla a la oficina de Seguro Social arriba mencionada para que se la expliquen.
DI 120: Appeals Processing