00-4417. Social Security Ruling, SSR 00-2p.-Titles II and XVI: Evaluation of Claims Involving the Issue of “Similar Fault” in the Providing of Evidence

AGENCY:

Social Security Administration.

ACTION:

Notice of Social Security Ruling.

SUMMARY:

In accordance with 20 CFR 402.35(b)(1), the Commissioner of Social Security gives notice of Social Security Ruling, SSR 00-2p. This Ruling sets forth the standards that we will apply at all levels of the administrative review process in determining whether there is reason to believe that “similar fault” was involved in providing evidence in connection with a claim for benefits. The Ruling sets forth the standards we will apply at all levels of adjudication pursuant to provisions of The Social Security Independence and Program Improvements Act of 1994 (Public Law 103-296), which amended sections 205 and 1631 of the Social Security Act (the Act). This Ruling applies to all claims for benefits under title II and title XVI of the Act; i.e., claims for old-age and survivors benefits and disability benefits under title II of the Act, and claims for Supplemental Security Income benefits for the aged, blind, and disabled under title XVI.

EFFECTIVE DATE:

February 25, 2000.

FOR FURTHER INFORMATION CONTACT:

Len McMahon, Office of Disability, Division of Disability Process Policy, Social Security Administration, 6401 Security Boulevard, Baltimore, MD 21235, [phone].

SUPPLEMENTARY INFORMATION:

Although we are not required to do so pursuant to 5 U.S.C. 552(a)(1) and (a)(2), we are publishing this Social Security Ruling in accordance with 20 CFR 402.35(b)(1).

Social Security Rulings make available to the public precedential decisions relating to the Federal old-age, survivors, disability, supplemental security income, and black lung benefits programs. Social Security Rulings may be based on case decisions made at all administrative levels of adjudication, Federal court decisions, Commissioner's decisions, opinions of the Office of the General Counsel, and policy interpretations of the law and regulations.

Although Social Security Rulings do not have the same force and effect as the statute or regulations, they are binding on all components of the Social Security Administration, in accordance with 20 CFR 402.35(b)(1), and are to be relied upon as precedents in adjudicating cases.

If this Social Security Ruling is later superseded, modified, or rescinded, we will publish a notice in the Federal Register to that effect.

(Catalog of Federal Domestic Assistance, Programs 96.001 Social Security—Disability Insurance; 96.002 Social Security—Retirement Insurance; 96.003 Social Security—Special Benefits for Persons Aged 72 and Over; 96.004 Social Security—Survivors Insurance; 96.005 Special Benefits for Disabled Coal Miners; 96.006 Supplemental Security Income)

February 2, 2000.

Kenneth S. Apfel,

Commissioner of Social Security.

Policy Interpretation Ruling—Titles II and XVI: Evaluation of Claims Involving the Issue of “Similar Fault” in the Providing of Evidence

Purpose: To explain the rules that govern the evaluation and adjudication of claims when there is reason to believe that “similar fault” was involved in the providing of evidence in support of the claim.

Citations (authority): Sections 205(u) and 1631(e)(7) of the Social Security Act, as amended; Regulations No. 4, sections 404.704, 404.708, 404.1512, 404.1520, and 404.1527; Regulations No. 16, sections 416.912, 416.920 416.924, and 416.927; and Regulations No. 22, section 422.130(b).

Introduction: The Social Security Independence and Program Improvements Act of 1994, Public Law 103-296, amended the Social Security Act (the Act) concerning fraud or similar fault. These amendments to sections 205 and 1631 of the Act provide that the Social Security Administration (SSA) shall immediately redetermine an individual's entitlement to monthly insurance benefits under title II or eligibility for benefits under title XVI if there is reason to believe that fraud or similar fault was involved in the individual's application for such benefits. This legislation further provides that, when redetermining entitlement or eligibility, or when making an initial determination of entitlement or eligibility, SSA “shall disregard any evidence if there is reason to believe that fraud or similar fault was involved in the providing of such evidence.”

This Ruling sets forth the standards we (SSA and State agency adjudicators) will apply at all levels of the administrative review process in determining whether there is reason to believe that “similar fault” was involved in providing evidence in connection with a claim for benefits. It also provides guidance for the evaluation of such claims when there is reason to believe that “similar fault” was involved. It applies to all claims for benefits under title II and title XVI of the Act; i.e., claims for old-age and survivors benefits and disability benefits under title II of the Act, and claims for Supplemental Security Income benefits for the aged, blind, and disabled under title XVI.

This Ruling does not replace or limit other appropriate standards and criteria for development and evaluation of claims. There may be instances in which evidence will not be disregarded under the statutory provisions discussed in this Ruling, but factors nevertheless may exist that justify giving the evidence in question less credence than other evidence. For example, in disability claims such standards frequently include those set forth in 20 CFR 404.1527 and 416.927 for evaluating medical opinions, and those set forth in Social Security Ruling (SSR) 96-7p, “Titles II and XVI: Evaluation of Symptoms in Disability Claims: Assessing the Credibility of an Individual's Statements.”

Interpretation

General

1. Sections 205(u) and 1631(e)(7) of the Act provide that evidence shall be disregarded if there is reason to believe that fraud or similar fault was involved in the providing of that evidence. These sections explain that “similar fault” is involved if: “(A) an incorrect or incomplete statement that is material to the determination is knowingly made; or (B) information that is material to the determination is knowingly concealed.”

2. Adjudicators may disregard evidence based on “similar fault” of a claimant, a recipient of benefits, or any other person connected with the claim. The other person need not have any direct relationship to the claimant or recipient, or be acting on behalf of the claimant or recipient.

3. A “similar fault” finding can be made only if there is reason to believe, based on a preponderance of the evidence, that the person committing the fault knew that the evidence provided was false or incomplete. A “similar fault” finding cannot be based on speculation or suspicion.

4. A “similar fault” finding is sufficient to take the administrative actions described in this Ruling. Although a finding of “fraud” made as part of a criminal prosecution can serve as a basis for the administrative actions described below, such a finding is not required.

5. A “similar fault” finding concerning a material fact may constitute evidence to be considered in determining whether there is reason to believe that “similar fault” was involved with respect to other evidence provided by the same source, and may justify disregarding other evidence from that source. Also, the evidence relied on to make a “similar fault” finding in one claim may be considered in deciding whether there is “similar fault” in another claim or in deciding whether to give less weight to evidence in another claim.

6. A “similar fault” finding does not constitute complete adjudicative action in any claim. A person may still be found entitled to, or eligible for, monthly benefits despite the fact that some evidence in the case record has been disregarded based on “similar fault.”

Definitions

1. Similar Fault. As defined in section 205(u) and 1631(e)(7) of the Act, “similar fault” is involved if: “(A) an incorrect or incomplete statement that is material to the determination is knowingly made; or (B) information that is material to the determination is knowingly concealed.” “Similar fault” differs from “fraud” in that fraud (but not similar fault) includes an element of intent to defraud.

2. Material. Used to describe a statement or information, or an omission from a statement or information, that could influence SSA in determining entitlement to monthly benefits under title II or eligibility for monthly benefits under title XVI of the Act.

3. Knowingly. Used to describe how a person acts in furnishing information that he or she knows is false or incomplete.

4. Preponderance of evidence. A standard for deciding questions of fact and other issues. To apply this standard, the adjudicator weighs the evidence to decide which side of an issue is supported by the evidence with the greater weight. Preponderance is established by that piece or body of evidence that, when fairly considered, produces the stronger impression and is more convincing as to its truth when weighed against the evidence in opposition. Thus, “preponderance” does not require that a certain number of pieces of evidence (e.g., five or six) must be present. It is possible that just one piece of evidence may be so convincing that it outweighs more than one piece of evidence in opposition.

Development and Evaluation

Adjudicators at all levels of the administrative review process are responsible for taking all appropriate steps to resolve “similar fault” issues in accordance with the standards in this Ruling. Adjudicators must adhere to existing due process and confidentiality requirements during the process of resolving “similar fault” issues.

In making determinations whether there is “similar fault,” all adjudicators must:

1. Consider all evidence in the case record before determining whether specific evidence may be disregarded.

2. Apply the preponderance of evidence standard, as defined in this Ruling.

3. Fully document the record with the evidence that was the basis for the finding that, based on a preponderance of the evidence, there is reason to believe that “similar fault” was involved in providing the evidence that is being disregarded.

Notice of Determination or Decision

In determinations or decisions in which a “similar fault” finding is being made and evidence is being disregarded, the notice of determination or decision must:

1. Explain the applicable provision of the Act that allows the adjudicator to disregard particular evidence due to a “similar fault” finding.

2. Identify the documents or other evidence that is being disregarded.

3. Provide a discussion of the evidence that supports a finding to disregard evidence. The discussion must explain that, in accordance with the law, the evidence identified cannot be used as evidence in the claim because, after considering all the information in the case record, the adjudicator has reason to believe that “similar fault” was involved in providing the evidence and it must be disregarded. Again, a “similar fault” finding can be made only if there is reason to believe, based on a preponderance of the evidence, that the person knew that the evidence provided was false or incomplete. A “similar fault” finding cannot be based on speculation or suspicion.

4. Provide a determination or decision based on an evaluation of the remaining evidence in accordance with other rules and procedures. A “similar fault” finding does not constitute complete adjudicative action in any claim. A person may still be found entitled to, or eligible for, monthly benefits despite the fact that some evidence in the case record has been disregarded based on “similar fault.” For example, a person may be found to be under a “disability” based on impairments that are established by evidence that is not disregarded because of “similar fault.”

5. Include standard appeal language.

EFFECTIVE DATE: 

This Ruling is effective February 25, 2000.

CROSS-REFERENCES: 

SSR 96-7p, “Titles II and XVI: Evaluation of Symptoms in Disability Claims: Assessing the Credibility of an Individual's Statements,” SSR 85-23, “Title XVI: Reopening Supplemental Security Income Determinations at Any Time for “Similar Fault.” Program Operations Manual System, DI 23025.001-DI 23025.095.