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case experience, we are developing additional criteria for making decisions on this issue.
With respect to the requirement that the miner be totally disabled due to pneumoconiosis, we had to establish diagnostic criteria for determining the presence of the disease, criteria for measuring its severity in terms of its effect on the applicant's ability to work, and criteria establishing the level of severity that would be considered totally disabling within the meaning of the law. The act, of course, prescribes that the term “total disability” shall have the meaning given by regulations of the Secretary of Health, Education, and Wel. fare. But such regulation shall not provide more restrictive criteria than those applicable under the Social Security Act, which defines "disability" under our regular program.
There is clearly expressed congressional intent that initially the criteria should be those now applied under the Social Security law and the President, in signing the act into law, expressly suggested such application. Accordingly, in addition to the specific presumptions provided by law, the regulations reflect the basic evaluation principles and criteria followed under our regular disability program to the extent that they are applicable to cases in which pneumoconiosis is the disabling impairment.
Under these regulations, the miner is found to be disabled if he meets a presumptive test described in the law, which means that the X-ray or pathological findings show that he has what is commonly referred to as complicated pneumoconiosis. Alternatively, as under our regular program, he can be found to be disabled if he meets certain medical criteria showing severe breathing impairment due to pneumoconiosis or has another serious condition resulting from that disease, for example, cor pulmonale.
If he is not disabled by any of these prescribed medical standards, he may nevertheless be found to be disabled if he has pneumoconiosis and such functional breathing limitation as to prevent him from doing coal mining work, and if he cannot engage in any other type of substantial gainful activity consistent with his vocational competence. Thus, the older, longtime miner with limited education and skills, who is shown to be unable to do heavy work because of pneumoconiosis, will ordinarily be found to be disabled. These criteria follow closely the evaluation guides under our regular disability program.
For a widow to qualify for benefits under the program, her husband must have been drawing benefits under the act, or it must be established that he died from pneumoconiosis growing out of underground coal mine work. The law provides an irrebuttable presumption that death was due to pneumoconiosis, if the miner had the disease in its complicated stage. It provides a rebuttable presumption that a miner's death was due to pneumoconiosis, if he had at least 10 years of work in an underground coal mine and died of a respirable disease.
Our regulations provide that death will be found due to pneumoconiosis when, in the absence of evidence to the contrary, death is ascribed to chronic dust disease or other chronic disease of the lung, with certain specified exceptions.
One requirement for payment of benefits is that the coal miner's pneumoconiosis be due to work in an underground coal mine. Our regulations reflect a liberal interpretation that work in an underground coal mine includes not only work under the surface but also work above the surface in processing coal.
Reimbursement to applicants for necessary medical expenses in establishing their claims is specifically provided in the law. We have interpreted this to permit reimbursement or direct payment for medical evidence in miners' claims, as well as for death certificates as evidence of cause of death in widows' claims. Of course, any such special examinations or tests required of the applicant are also paid for by the Government.
Another significant provision unique to the coal miners' benefit program is a statutory requirement that no claim be considered until a State workman's compensation claim has also been filed, unless such filing would be futile. We have interpreted this provision in such a way that we will accept and adjudicate coal miners' claims prior to filing the required workman's compensation claim, but withholding actual payment until the workman's compensation filing requirement is met.
We are also making every effort to advise applicants about when such filing will be unnecessary because it would be futile as, for example, when the time period for filing under the State law has expired.
As I previously indicated, the law provides no retroactivity in benefit payments. In fact, it provides that no benefits can be paid for any period before the date the claim is filed. Taken literally, this could mean, for example, that a widow would lose benefits if she did not file her claim on the day her husband died. However, through regulatory interpretation we found it possible to pay benefits for the entire month in which the claim was filed and for assuring that no interruption in benefit payments for the wife in the event of her husband's death would take place, even though there might be delay in filing the claim.
Many of the people who have filed application for Federal coal miners' benefits are already receiving social security benefits or workman's compensation or occupational disability benefits under a State program. Both the Social Security Act and the Federal Coal Mine Health and Safety Act contain provisions which are designed to reduce the extent of overlapping and duplication of benefits.
The Social Security Act has, since 1965, contained what we call a workman's compensation offset provision. For people below age 62 and who become disabled after June 1, 1965, the law limits the amount of combined income from social security disability benefits and workmen's compensation benefits to 80 percent of the worker's average current earnings before he becomes disabled. If the combined benefits were to exceed this amount, the social security benefits are reduced by the amount of the excess. This is not a dollar-for-dollar offset. As a result of this, some current social security disability beneficiaries will have these benefits reduced when they become entitled to coal miners' benefits. However, we estimate that only about 5 percent will be so affected. Most miner applicants are age 62 or older and the offset would therefore not apply at all. Incidentally, there is proposed social security legislation in H.R. 175502 which has passed the House and is now pending in the Senate, containing a provision which would raise the ceiling on combined benefits from 80 to 100 percent.
The Coal Mine Health and Safety Act contains a somewhat similar provision with similar intent, but different method of application. The amount of Federal benefits payable is reduced if the miner or widow is receiving benefits under a State program based on the miner's disability. This is a dollar-for-dollar offset. For example, if a miner would be entitled to $144.50 a month from the Federal program, but is already receiving $100 a month under a State program, the Federal benefit is reduced to $44.50.
While we have made significant progress in launching this new and important benefit program and the pace of claims processing is accelerating to peak levels, so that a very large number of claims are now moving rapidly through the pipeline to final decision, realistically we recognize of course that a great deal of effort still lies ahead, both from a program and operating viewpoint. And we would not want to underestimate the job that remains to be done.
To mention one important area of challenge to us, we need to knorr more about pneumoconiosis itself, as a disease entity, its cause, techniques for diagnosis, its disabling effects, and its relationship to other diseases of the lung--so that we can refine our evaluation policies to advance the objectives of the program.
Toward this end we will be closely analyzing our case experience and we will continue to seek out new medical knowledge and professional advice and guidance. We will be working closely with the Public Health Service to contribute to the planning and encouragement of medical research and studies to be carried out under title V of the act and the leadership of the Public Health Service, and we will be alert to opportunities for applying to the fullest extent possible the added knowledge gained from such studies to improving the administration of the benefit program.
From the standpoint of our immediate task of processing the pending claims load, we will continue to do our utmost to give applicants their final decisions and the benefits to which they are entitled as promptly as possible, while naintaining the standard of service that is basic to all social security claims operations; namely, to provide every assistance we can to applicants in establishing their rights to benefits under the law and to give full and fair consideration to each claim.
Thank you, Mr. Chairman.
Senator Williams. Thank you very much, Mr. Popick. I will say that the law presented to you a job that could be compared to scaling Mount Everest. From where I sit, you are well toward the summit. You have done a magnificent job.
Mr. Popick. Thank you, Senator. We have had a lot of help in this. It is encouraging to have such remarks that acknowledge the progress we have made and the effort we are trying to carry out.
Senator WILLIAMS. It comes from the heart with full knowledge of what you are doing.
Now I have just one question, and then I will turn to counsel. The social security disability now can be established at age 50. Am I right or wrong?
Mr. Popick. At any age below age 65 for the disabled worker.
Mr. Popick. The disability program was first enacted in the early 1950's, yes. Later cash benefits became payable to disabled workers age 50 and over. Then the age limit was removed. Now widows, disabled widows and widowers may be entitled to benefits, but only at age 50 and over.
Senator WILLIAMs. You do have an overlap on disability and black lung?
Mr. Popick. That is right. Of course we have taken advantage of this by using very extensively the records we have in our disability claims in order to expedite the handling of some of the black lung claims. But it does bring up other considerations that come into play, like the offset requirement where in a small portion of cases the social security disability benefits plus the black sung benefits exceed that 80-percent limitation.
Mr. FEDER. The question of total disability in which you pointed out the President signed the legislation does not exactly give you carte blanche to provide less restrictive criteria in respect to 203 (d), but the language of the statute does suggest that there will be some liberalization criteria at some point in time.
Has there been any projection made when this will be settled? Will this lead to more liberalization?
Mr. POPICK. There are medical studies that are going now in many places and might be further sponsored and planned under the research provisions of the act, which could ultimately give us some guidance on this. But we will also be gathering a good deal of data and information out of our day-to-day case experience. We are hoping that before too long we will have enough experience in the handling of cases and the decision results that may provide us a basis for further consideration and refinement in our criteria. That is as definite a reply I can give to your question at this time.
Mr. FEDER. Thank you.
Mr. SIEGEL. Mr. Popick, both Senator Scott, the senior Senator from Pennsylvania, and Senator Schweiker have written to you regarding the processing of claims of Pennsylvania claimants under this program. It would seem to us that it would be rather easy and straightforward for you to service these Pennsylvania claims, because these people for the most part are already contained within the Pennsylvania benefit system and there is a class of some 25,000 to 30,000 beneficiaries in Pennsylvania.
The specific question has been raised, why is it necessary for additional medical examinations to be conducted in the case of these Pennsylvania recipients? I wonder if you would comment on it?
Mr. POPICK. Yes. I am familiar with this question. We have been asked this several times. Of course, in response directly to your last point, a medical examination is not required in all of the Pennsylvania claims, far from it. As a matter of fact, I would say that of the 20,000, roughly, claims we have already paid in Pennsylvania, only a small portion of those that have been paid thus far actually required additional medical examinations.
The large majority of those claims were handled on the basis of evidence that we got from existing sources. Primarily, in many in
stances, right from the files of the Pennsylvania occupational disease program.
Now, I might add in further answer to that question that actually the requirements for eligibility under the Pennsylvania occupational disease law are not exactly parallel or identical with those under this statute. There are significant differences.
The Pennsylvania law pays benefits in cases other than pneumoconiosis. It has no requirement that I know of that the pneumoconiosis have arisen out of work in an underground coal mine. So we cannot automatically accept those decisions.
In addition, of course, this law requires us to establish criteria for making evaluations of these claims and for having the evidence that is called for by the regulations to make those decisions, and we are using knowledge of the Pennsylvania decision, we are using all the records they have and we are using all the other records available. But we are required from a legal standpoint to make an independent decision under the existing regulations and the law, and cannot accept automatically the decision by another program.
Mr. SIEGEL. Out of the 20,000 claims already approved for payment in Pennsylvania, what percentage or how many required additional medical examinations?
Mr. Popick. I am sorry that I am not in a position to give you that figure, but I would say it would be a very small percentage. Now in the Pennsylvania claims that will be approved from here on out, there will be a larger percentage of those that will require either an X-ray or some pulmonary function test. But the first large group, certainly much more than a half of those we have paid already, we had no need for medical examinations. We never would have been able to pay them as quickly as we did if we had had to have additional medical tests.
Mr. SIEGEL. What do you estimate the remaining number of claims you can expect to have from Pennsylvania ? Another 10,000?
Mr. Popick. We have over 185,000 claims already. Our actuarial estimate is that we will get a total of 220,000 claims by the end of the fiscal year. So, we have about 35,000 to go between now and the end of June. This is nationwide. But we are getting about 3,000 a week new claims, as I indicated before, and we are going to reach this margin of 35,000 new claims pretty fast if the new load does not begin to taper off.
But if you want to look at the 35,000 more estimated, Pennsylvania's claims are about 40 percent of the total load. So, I would say about 15,000, something like that, on the basis of our actuarial estimates. I think my figures are right on that.
Mr. Siegel. How long is the time cycle in your organization between the receipt of a claim application and the clearance for payment?
Mr. POPICK. You mean in our regular program or black lung!
Mr. Popick. That is really difficult to answer at this time because at the moment we are in a very extraordinary situation. We have had a lot of catching up to do in establishing policies and procedures and handling the very large load of claims that we have pending as quickly as possible. Most of the claims we have processed thus far on the basis of existing records, as I indicated to you before.