Claims filed

CHAPTER VII-OPERATING EXPERIENCE

As already indicated, within 1 week of enactment, 18,000 claims had been filed under the Act, and this number had grown to almost 100,000 by the end of the first month. Claims filings continued at a much higher rate than had been anticipated. By December 31, 1970, a total of over 247,000 claims had been filed, and by April 30, 1971, the total had reached 286,000.

Of these claims, two-thirds were concentrated in three StatesPennsylvania, West Virginia, and Kentucky. Adding five other States Virginia, Alabama, Illinois, Ohio, and Tennessee-accounts for about 90 percent of all applications filed. By April 30, 1971, new claims were continuing to be received at an average rate of over 2,000 a week. (Table 2)

Claims processed

Because of the necessity for developing regulations, policies and procedures, as well as securing supporting medical and nonmedical evidence for claims documentation, it was expected that it would take some time before the first claims could be processed to completion. The first claims processed were completed in April 1970. By the end of the next month, some 10,000 claims-all allowances-had been completed, and the rate of processing increased rapidly thereafter. By April 30, 1971, when the claims received in the first year of the program had largely been processed, over 245,000 claims had been completed. Total beneficiaries under the program, including dependents, were 190,000. (Table 3)

Current status of operations

At the time this report was prepared, the backlog of initial claims filed in the first year of program operations had been virtually eliminated. With a near-normal workload of pending initial claims, the delays encountered in handling initial claims in the first year are no longer being experienced. For claims now being filed, processing time should be more in line with regular social security disability claims experience, i.e., about 10-12 weeks from filing to completion, on the average. However, while the initial claims load has been largely processed, there is developing a substantial group of claims in which the denied claimant is exercising his right to request reconsideration. (See Chapter VIII on Reconsideration, Hearing and Appeal.) Claims decisions

Of the claims completed by April 30, 1971, 120,000 were allowances (68,000 miners and 52,000 widows) and 125,000 were denials (96,000 miners and 29,000 widows). (Table 3)

Of the miners approved for benefits, more than 95% are age 55 or older; more than 71% are age 65 or older. Among the eight major coal mining States, the miner beneficiaries in three (West Virginia, Kentucky, and Virginia) are somewhat younger on the average. (Table 4)

Most miners' claims were denied because X-ray evidence did not disclose the presence of pneumoconiosis. Most widows' claims were denied because the miner's death was not due to pneumoconiosis or qualifying "respirable disease". (Table 5)

Benefits disbursed

By April 30, 1971, total cumulative disbursements since enactment of the program had reached over $273 million and monthly recurring payments were over $21 million. Table 6 shows the distribution of cumulative benefit disbursements and the total monthly benefits paid as of December 31, 1970, and April 30, 1971.

Considering augmentation for dependents, the average monthly benefit paid to a miner or widow was $187.26. (Table 3)

Projected program costs

For fiscal year 1972, disbursements are expected to approach $400 million and total beneficiaries at the end of the year will approximate 260,000 (160,000 miners and widows and 100,000 dependents).

Table 7 shows the latest data and projections of the Office of the Actuary of the Social Security Administration for benefits in force and benefit disbursements for fiscal years 1970, 1971, and 1972. Administrative expenses

The manpower estimated for administration of the black lung program for calendar year 1970 was 260 man-years. The estimates in the 1972 Congressional budget for fiscal years 1971 and 1972 are 1310 manyears and 585 man-years, respectively. The necessary manpower is to be obtained by: (1) filling 600 permanent jobs in 1971 and most of 1972; (2) filling up to a maximum of 400 temporary jobs in 1971; and (3) overtime work. The man-years derived from these sources are budgeted as follows:

Obligations estimated for the Social Security Administration are $15.7 million for fiscal year 1971 and $8.5 million for fiscal year 1972. In addition, obligations by State agencies for the development of medical evidence to support valid determinations regarding the existence of a disability are estimated at $5.4 million in fiscal year 1971 and $1.1 million in fiscal year 1972.

CHAPTER VIII-RECONSIDERATION, HEARING AND APPEAL

Under the law and regulations, denied applicants have a right to challenge the Administration's decisions. They may request administrative reconsideration and if still dissatisfied, may ask for a hearing before a hearing examiner of the Bureau of Hearings and Appeals. There are also further appeal rights to the Appeals Council and, in some cases, to the Federal courts.

As individuals are notified of the disallowance of their claims and many of them exercise their right to request reconsideration, a substantial additional workload is developing in taking the necessary action to thoroughly reconsider (and in some cases, supplement) the evidence in their claims and make a new decision in each appealed case. As of April 30, 1971, 125,000 claims were denied and over 50,000 requests for reconsideration were received. Allowing for a reasonable lag between the denial notice and the request for reconsideration, the current rate of request for reconsideration is estimated at over 50 percent.

Projecting further into the future, it appears most likely that the workload of requests for hearing will be very large and will severely tax the resources of an already heavily burdened cadre of social security hearing examiners. Plans are already being made and implemented, however, to gear up the hearing process and take whatever special measures will be required to handle the large influx of new hearing requests.

It also appears likely that the Federal district courts in the coal mining region will eventually receive a substantial volume of litigation from this claims workload, which will undoubtedly place heavy additional demands on their already crowded dockets.

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CHAPTER IX-SUMMARY OF SIGNIFICANT PROBLEMS AND ISSUES IN ADMINISTRATION OF TITLE IV, PART B

Reference has already been made to the very serious administrative problems which resulted from the lack of lead time for planning for proper administration and the receipt of a huge volume of claims in a very brief time span in a limited geographical area. However, other problem areas and issues have been encountered and some remain and will condition program administration and claimant reaction in the future.

The basic program principle embodied in the law requiring an occupational or causal connection between disability or death and pneumoconiosis has posed a very difficult problem from a medical standpoint. At the same time, this occupational concept has also resulted in substantial claimant misunderstanding of program requirements and decision results. These and other significant problem areas are discussed below.

Diagnosis of pneumoconiosis

Under Part B of Title IV, a miner is entitled to benefits if he is totally disabled due to pneumoconiosis. In line with this requirement, the regulations specify that, regardless of other impairments, total disability must be found to be caused by pneumoconiosis which is defined in the statute as a chronic dust disease of the lungs which has arisen out of employment in underground coal mines.

To establish the causal or occupational connection with coal workers' pneumoconiosis, the regulations provide that there must be X-ray evidence of pneumoconiosis in the living applicant (in a rare case, a biopsy). This is based on the prevailing medical judgment that in the absence of positive X-ray evidence, the disease does not exist or exists to a degree that would have no significant effect on the claimant's functional capacity.

There is some minority medical opinion to the effect that disabling pneumoconiosis may exist in the absence of "positive" X-ray evidence thereof. However, this issue was thoroughly considered by the Social Security Administration, through extensive consultation with a wide. range of medical specialists, and the requirement was included in the regulations as reflecting the overwhelming consensus of medical judgment on the issue.

Regulations require X-rays to be taken in conformance with acceptable medical standards and to be classified in accordance with the ILO or UICC classification system for pneumoconiosis. X-rays of good diagnostic quality can be classified reliably according to these systems.

Where existing X-ray evidence is not available for a proper determination, State agencies are responsible through special agreement for making arrangements with qualified radiologists locally to provide X-rays of claimants at program expense. Most of these radiologists have participated in the special training courses (workshops) spon

sored by the Public Health Service in cooperation with the American College of Radiology and the American College of Chest Physicians, to improve techniques for taking X-rays and skills in classifying them according to the UICC and ILO systems.

To reinforce the accuracy and consistency of X-ray readings under the black lung program, the Social Security Administration is utilizing the services of a group of eminent radiologists with outstanding experience and skill in X-ray classification under the approved systems. Medical tests for determining eligibility

The regulations promulgated by the Secretary provide that where pneumoconiosis is shown to be present by X-ray, but the disease has not progressed to a "complicated" stage, other medical tests are necessary to determine whether the effects of the disease have reached disabling proportions.

To evaluate an applicant's reduced ability to work due to pneumoconiosis, the regulations call for conventional pulmonary function tests which measure his capacity to move air into and out of his lungs. These are relatively simple, accurate and widely accepted medical tests. They are commonly used for diagnostic treatment and functional evaluation purposes and have been regularly used in the social security disability insurance program.

The type of instruments specified to perform the tests and the documentation of the results called for serve to assure accurate and valid findings.

Breathing impairment may also result from reduction in an individual's capacity to transfer oxygen from his lungs into his blood stream where it is needed to provide energy for working. Tests for this type of impairment are more difficult to conduct and less widely used, involve greater physical exertion on the part of the subject, and require more extensive equipment and highly trained professional personnel to administer them with satisfactory results and safeguards to the individual being tested. Medical resources to perform these tests are in extremely short supply in most of the areas in which black lung claimants are concentrated.

The Social Security Administration and the Public Health Service are collaborating in a pilot project to evaluate the effectiveness and feasibility of providing testing of this type for black lung benefit claimants. The project will assess results and identify any problems encountered in such exercise testing on a relatively large scale for claimants under this program. This is expected to lead the way to the establishment of additional methods and criteria for evaluating total disability due to pneumoconiosis under this program, as well as to the availability of more adequate medical facilities in the coal mine areas to perform this testing.

Standards of disability determinations

In line with Congressional intent and the direection given by the President, every effort has been made to establish disability evaluation criteria consistent with those under the regular social security disability insurance program. However, some problems existed in implementing the statutory requirement of total disability due to pneumoconiosis.