CLAIMS, APPEALS, AND COURT REVIEW
The Social Security Disability review path.
SSDI and SSI claims usually move through an administrative review system before federal court is available: initial determination, reconsideration, hearing, Appeals Council review, and then judicial review if necessary.
Administrative procedure
From first decision to final agency action.
Federal court review usually depends on completing the administrative steps SSA requires. The record built in those steps becomes the foundation for court review.
- 01 Initial disability determinationThe process begins when SSA makes an initial determination about whether a claimant is entitled to benefits or whether benefits should continue. If SSA denies the claim, the written decision should explain the evidence considered, the determination made, and the reasons for the decision when the determination involves disability and is unfavorable in whole or in part. If the claimant disagrees, the next step is usually to request reconsideration within the required time period. If the claimant does not take the next step within the stated time, the claimant may lose the right to further administrative review and judicial review unless good cause is shown for the late request.
- 02 ReconsiderationReconsideration is the first level of appeal after an initial denial. For disability cessation cases—where SSA finds that an impairment has ceased, did not exist, or is no longer disabling—federal law provides for an opportunity for an evidentiary hearing at the reconsideration stage on the cessation finding before the later hearing stage. A claimant must timely request review. Courts have dismissed Social Security actions where a claimant failed to complete required administrative steps. In *Escalera*, the court affirmed dismissal where the claimant did not timely submit a written request for reconsideration within the required 60-day period and no exception excused the failure to exhaust administrative remedies. *Escalera v. Comm'r of Soc. Sec.*, 457 F. App'x 4, 6 (2d Cir. 2011).
- 03 Hearing before an Administrative Law JudgeIf reconsideration is unsuccessful, the claimant may request a hearing before an Administrative Law Judge. The Social Security Act requires that the claimant receive reasonable notice and an opportunity for a hearing, and if a hearing is held, the Commissioner must decide the matter based on the evidence presented at the hearing. The hearing process is administrative and generally informal. SSA regulations state that the administrative review process is conducted in an "informal, non-adversarial manner," and the claimant may present information personally or through a representative, including an attorney. Evidence may be received in Social Security hearings even if it would be inadmissible under the rules of evidence that apply in court proceedings. If the ALJ issues an unfavorable decision, the claimant may request review by the Appeals Council.
- 04 Appeals Council reviewThe Appeals Council is the final administrative review level before federal court. It may affirm, modify or reverse the administrative law judge hearing decision or it may adopt, modify or reject a recommended decision. If the Appeals Council denies review, the ALJ's decision becomes binding unless the claimant files a civil action in federal district court or the decision is revised. If the Council grants review and issues its own decision, that decision is binding unless the claimant seeks federal court review or the decision is revised. In *Melnichuk v. Kijakazi*, the District of Alaska explained that a Social Security decision is not final for purposes of federal court review until the Appeals Council denies review or, if it accepts review, issues its own decision on the merits.
- 05 Federal district court reviewAfter the claimant completes the required administrative review steps and SSA has issued its "final decision," the claimant may seek judicial review in federal district court. Federal law allows an individual to obtain review of a final decision of the Commissioner of Social Security made after a hearing by filing a civil action in federal district court. The Supreme Court in *Mathews v. Eldridge* explained that judicial review of a denial of Social Security benefits is available under 42 USCS § 405(g), and that the statute requires a "final decision" after a hearing as a prerequisite to federal court review. The Court further explained that the "final decision" requirement includes a nonwaivable requirement that the claim first be presented to SSA, and a waivable exhaustion component requiring completion of the administrative remedies prescribed by the agency.
How a law firm can help
Legal work at each stage affects what is possible later.
A Social Security disability attorney can assist at each stage of the process by identifying appeal deadlines, developing the administrative record, preparing the claimant for an ALJ hearing, submitting Appeals Council arguments, and, when appropriate, filing a federal district court complaint after SSA issues a final decision.
Because missing a deadline can result in the loss of further administrative and judicial review unless good cause is established, prompt legal review after any denial is important.
The ALJ hearing record, medical evidence, hearing testimony, and representative submissions become the court-review record.
The Appeals Council stage can affect finality, timing, and how legal issues are framed for later review.
Once the final decision is issued, the complaint preserves the claimant's right to judicial review and starts the court case.
What is required for a federal district court complaint
A federal court appeal is not a new disability application.
Instead, the claimant files a civil action asking the federal court to review the Commissioner's final decision based on the administrative record. A district court complaint for Social Security review should generally address the following requirements.
The claimant must have a final decision from SSA. This usually means the claimant has completed the administrative steps through Appeals Council review, or the Appeals Council has denied review of the ALJ decision.
The civil action must be filed within 60 days after notice of the final decision, or within any additional time allowed by the Commissioner. Courts recognize a receipt presumption within five days of the date indicated on the Appeals Council's notice.
The action must be filed in the United States district court for the judicial district where the plaintiff resides.
The federal court case is commenced by filing a civil complaint.
There is a filing fee for bringing a civil action in federal court. If a claimant cannot afford the filing fee, the claimant may seek permission to proceed without prepayment of fees, or in forma pauperis (IFP).
The federal court has authority to enter judgment affirming, modifying, or reversing the Commissioner's decision, with or without remanding the case for another hearing.
After the complaint is filed, the Commissioner must file a certified copy of the transcript of the administrative record. The court's review is based on the pleadings and that administrative transcript.
Next step
Federal court review starts after the agency process ends.
If you have reached final agency action and want to discuss whether federal court review is available, the office can review your deadline, venue, and record.