What is Considered a Critical Case?

When a person has to file a claim for disability benefits, that alone can constitute a difficult situation in that person’s life. However, due to several other factors that may come in to play in an individual’s claim, that difficult situation can become a critical one.

For SSA, a Critical Case is considered such if one or more of the following is true:

1.       The claimant’s illness is terminal (“TERI case”);

2.       The case involves a disability claim for any military service personnel injured October 1^st, 2001 or later, regardless of how the disability occurred and where;

3.       The claimant’s file is flagged as a Compassionate Allowance case;

4.       The claimant is without, and is unable to obtain, food, medicine or shelter (“dire need”); and

5.       There is an indication that the claimant is suicidal or homicidal.

Critical Cases are identified either by the Regional Chief Administrative Law Judge or Regional Management Officer in the regional office, or by the Chief Administrative Law Judge at a local hearing office. It is the responsibility of all regional and hearing office employees to bring possible critical cases to the attention of these officials so they are expedited.

TERI Cases

TERI (short for “Terminally ill”) cases are flagged when the impairments the claimant suffers from will inevitably result in death. This does not necessarily mean the claimant is deemed disabled, however. The claim will still be subject to the sequential evaluation process, but because time is of the essence in TERI cases, it is given priority to be evaluated as soon as possible. Disability adjudicators refer to POMS DI1105.601 in order to properly flag TERI cases.

Military Service Casualty Case (MSCC)

This applies to an active-duty military service member who is injured on or after October 1^st, 2001, regardless of how the disability occurred. It also does not matter where the disability occurred, whether it was in the United States or on foreign soil. These cases are processed in the same way as TERI cases, but are not classified as TERI unless there is the presence of a terminal illness.

Compassionate Allowance

A case in which a claimant suffers from a disease or condition previously determined as a Compassionate Allowance case (CAL). This must be identified with the help of objective medical evidence. A CAL case can be identified at any stage of the disability process when the claimant is found to have an enumerated disease or medical condition.

Dire Need

SSA defines a dire need situation as one that exists when a person has insufficient income or resources to meet an immediate threat to health or safety, such as the lack of food, clothing, shelter or medical care. The claimant must provide proof of a specific dire need situation, such as shut off notices from utility companies or an eviction/foreclosure notice.  It is also important to remember that SSA will investigate the claim of a dire need situation to determine whether expediting is warranted. Because many disability claims can be considered “dire,” designating all cases as critical under the dire need criteria would “defeat the effectiveness of any priority plan for the processing of the most serious claims” (Hallex I-2-1-40). Although SSA is instructed to err on the side of expediting vs. not expediting, it is important to remember that a claim in a dire need situation may not always be expedited.

Suicidal/Homicidal

If a claimant threatens suicide or homicide, the Office of the Regional Commissioner within the claimant’s jurisdiction must be notified immediately. According to HALLEX I-2-1-37, even though a threat of suicide or homicide is typically an extreme cry for help, each instance of a threat must be handled quickly and carefully, as not to cause harm to the claimant or any other individual. It must be determined whether the threat is imminent, and SSA has procedures in place to handle these situations, whether they are in-person or over the phone.

What Happens Next?

Once a Critical Case is identified, SSA employees refer to work up instructions outlined in HALLEX I-2-1-5. The case will then be evaluated to determine whether an On-The-Record (OTR) decision is possible. If an OTR decision is not deemed appropriate, the case is then expedited for pre-hearing development and scheduling.

Critical Cases are given the first available open hearing slots when they are ready to be heard by an ALJ. If there is a cancellation of another hearing, Critical Cases are given priority to take the opening. However, if the opening is in 20 days or less, the claimant and/or his representative must agree to waive the right to the 20-day advance notice in order to be given the open slot. After the hearing, the hearing office will also expedite the issuing and writing of the decision.

While waiting for a decision on a disability claim can be difficult for a claimant, it is heartening to know that SSA understands that some situations simply cannot wait for the long process. By being cognizant of the most critical cases and expediting the claims with care, SSA is helping our citizenry by identifying the most drastic situations and allowing those claimants to have their day in court as early as possible. 

Written by Anna Westfall & Attorney Andrew November


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