Last Update: 9/08/05 (Transmittal I-3-36)
This section discusses the application of the doctrine of administrative res judicata to decisions under the Social Security Act (the Act). When a prior determination or decision with respect to the same party, facts, and issue or issues has become administratively final, the doctrine of administrative res judicata may be used either to dismiss a request for hearing entirely or to refuse to consider any one or more such issues, when a subsequent application arises out of the same title of the Act. The purpose of administrative res judicata is to prevent claimants from “relitigating” their claims before Administrative Law Judges (ALJs) and the Appeals Council (AC) after the matters raised have already been finally decided.
The regulations at 20 CFR 404.957(c)(1) and 416.1457(c)(1) provide that administrative res judicata is present when all three of the conditions listed below exist:
There has been a previous determination or decision under the same subpart with respect to the same party.
The previous determination or decision was based on the same facts and on the same issue(s).
The previous determination or decision has become final by either administrative or judicial action.
The regulations state that the ALJ may dismiss a request for hearing on the basis of administrative res judicata. Although this indicates that such dismissal is discretionary, when the requisite conditions are met administrative res judicata should be applied. Therefore, if the ALJ issued a decision on the merits but should have dismissed on the basis of administrative res judicata, the Appeals Council will assume jurisdiction, vacate the hearing decision, and dismiss the request for hearing. It is possible to dismiss one or more issues on the basis of administrative res judicata, and still render a decision on other issues.
There are situations in which it is inappropriate to apply administrative res judicata. These situations arise when either there has been a change in issues (e.g., specific section in listing of impairments changed) or the prior determination is not administratively final (e.g., claimant lacked mental competency to appeal prior determination or incorrect, incomplete, or misleading information was provided to the claimant).
The following situations represent changes in issues, and administrative res judicata would not be applicable:
The prior adjudicator found that the claimant had multiple not-severe impairments, and the prior determination or decision was issued on or before November 30, 1984.
The prior adjudicator found that the claimant had a non-severe impairment, and the prior determination or decision was issued before December 24, 1985.
No prior determination or decision was ever made under the medical-vocational guidelines (grid regulations) that became effective February 26, 1979, and the prior denial was based on the ability to perform other than past relevant work.
Evaluation of claims for widow's insurance benefits based on disability where the prior final decision or determination was made prior to May 22, 1991.
Additional examples of situations that represent changes in issues and in which administrative res judicata would not be applicable are contained in POMS DI 27516.010.
The following policy applies when an unrepresented claimant lacked the mental competence to pursue further administrative appeal:
Whenever an ALJ or the AC considers the application of administrative finality or administrative res judicata to a determination or decision that was made on a prior application, and there is evidence that a claimant lacked the mental capacity to timely request review of an adverse determination, decision, dismissal, or a review by a Federal district court, and the claimant had no one legally responsible for prosecuting the claim, the ALJ or Administrative Appeals Judge (AAJ) must address and resolve in the current decision (or dismissal) the issue of whether the claimant lacked the mental competence to pursue his appeal. If the claimant satisfies the substantive criteria, the time limits in the reopening regulations do not apply; so that, 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. If the ALJ or AAJ finds that good cause exists, he or she will extend the time for requesting review and take the action which would have been appropriate had the claimant filed a timely appeal. In that instance, administrative finality and administrative res judicata will not apply.
NOTE:
Social Security Ruling 91-5p contains a full discussion of the policy to be applied in determining whether good cause exists in claims involving mental incapacity.
An adjudicator may not decline to find good cause to reopen without first affording the claimant a separate evidentiary hearing on the incompetence issue. At the OHA level, therefore, a case may not be dismissed or reopening refused without a separate evidentiary hearing on the record on the issue of whether the claimant was mentally incompetent at the time of the earlier application. In cases which do go on to an evidentiary hearing, the hearing must be on the record and the issue must be addressed in the decision.
Under the amendments of the Act made by Section (§) 5107 of the Omnibus Budget Reconciliation Act of 1990 (OBRA 1990), if SSA makes an initial or reconsidered determination on an application for Title II or Title XVI benefits which is wholly or partially unfavorable to an individual and which becomes final, and the individual subsequently applies for benefits under the same title of the Act, SSA may not use the previous determination as a basis for denial of the subsequent application, even though the requirements for applying the doctrine of administrative res judicata would otherwise be met, if the conditions described below are met. Accordingly, under such circumstances the previous determination may not serve as a basis for dismissing a request for an ALJ hearing under 20 CFR 404.957(c)(1) or 416.1457(c)(1), either in whole (dismissing the request entirely) or in part (refusing to consider one or more issues present in the case), if the effect of such dismissal would be to deny the subsequent application for benefits.
The above exception applies if:
SSA issued the previous initial or reconsideration determination before July 1, 1991, and this notice did not explain that filing a new application instead of requesting review could result in a loss of benefits; or
SSA made the previous determination on or after July 1, 1991; and
The determination became final because the claimant (i.e., the individual who files the subsequent application), or another person who either was a party to the determination or could have been a party by showing in writing that his or her rights would have been adversely affected by the determination, failed to timely request review of the determination; and
The claimant demonstrates that he or she, or such other person, failed to so request review acting in good faith reliance upon incorrect, incomplete, or misleading information, relating to the consequences of choosing to reapply for benefits instead of requesting review of the determination, provided by —
The above notice issued prior to July 1, 1991; or
An officer or employee of SSA; or
An officer or employee of a State agency performing the disability and blindness determination function under 20 CFR 404.1503(a) or 416.903(a).
NOTE:
Social Security Ruling 95-1p contains an additional discussion of the policy to be applied in determining whether the above exceptions apply.
In cases which fall under the provisions in sections D. and E. above, in which administrative res judicata was improperly applied to dismiss the request for hearing, the Appeals Council will grant the request for review and remand the case to an ALJ for further proceedings (see Appeals Text Guide).
In cases falling under the provisions outlined in section F. above, the Appeals Council will consider whether the ALJ's dismissal action was appropriate. In reaching this conclusion, the Appeals Council will be guided by the case specific situations listed below.
When the claimant's allegations are consistent with § 5107 of OBRA 1990, and the ALJ did not consider whether § 5107 precludes dismissal, the Appeals Council's action will depend on whether the Appeals Council can determine the validity of the claimant's allegations based on the record, and, if so, on whether dismissal was proper.
When the Appeals Council cannot determine whether § 5107 precludes dismissal, it will grant the request for review, vacate the ALJ's dismissal, and remand the case to the ALJ for further proceedings. This may occur when the claimant made a statement which might be indicative of the type of situation in which dismissal on the basis of res judicata would be precluded by § 5107, the ALJ did not address the situation, and the Appeals Council does not feel that there is enough evidence in the record to determine whether the ALJ's dismissal was proper without further development. The remand order will instruct the ALJ to determine whether dismissal of the request for hearing is appropriate considering § 5107 and, if he or she determines that dismissal on the basis of res judicata is precluded, direct the ALJ to hold a hearing on the merits.
When the Appeals Council can determine from the record that § 5107 precludes dismissal, the Appeals Council will grant the request for review, vacate the ALJ's dismissal, and remand the case to the ALJ to hold a hearing on the merits.
When the Appeals Council can determine from the record that § 5107 does not preclude dismissal, the Appeals Council will deny the request for review. In cases in which the claimant raised an allegation consistent with § 5107, the ALJ did not consider the allegation, and the ALJ's dismissal was proper, the analyst will explain in the recommendation why § 5107 does not preclude dismissal.
When the claimant's allegations are consistent with § 5107 of OBRA 1990 and are raised for the first time with the request for Appeals Council review, the Appeals Council's action will depend on whether the Appeals Council can determine the validity of the claimant's allegations based on the record.
When the Appeals Council cannot determine from the record that § 5107 precludes dismissal, the Appeals Council will grant the request for review, vacate the ALJ's dismissal, and remand the case to the ALJ for further proceedings. The remand order will instruct the ALJ to determine whether dismissal of the request for hearing is appropriate considering § 5107 and, if he or she determines that dismissal on the basis of res judicata is precluded, direct the ALJ to hold a hearing on the merits.
When the Appeals Council can determine from the record that § 5107 precludes dismissal, the Appeals Council will grant the request for review, vacate the ALJ's dismissal, and remand the case to the ALJ to hold a hearing on the merits.
When the Appeals Council can determine from the record that § 5107 does not preclude dismissal, the Appeals Council will deny the request for review and include a statement in the notice of the denial of such request that the Appeals Council considered the claimant's allegations.
In cases in which the claimant raised an allegation consistent with § 5107 which was not raised before the ALJ, and the ALJ's dismissal was proper, the analyst will explain in the recommendation why § 5107 does not preclude dismissal.
The Appeals Council will deny the request for Appeals Council review, when the claimant:
did not raise an allegation consistent with § 5107, or
raised an allegation consistent with § 5107, and the ALJ properly dismissed the request for hearing on the basis of res judicata.
In cases in which the claimant raised an allegation consistent with § 5107, the ALJ considered whether § 5107 precluded dismissal, and the ALJ's dismissal was proper, the analyst will include a statement to that affect in the recommendation.