Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-cand-3_04-cv-03386/USCOURTS-cand-3_04-cv-03386-2/pdf.json

Nature of Suit Code: 863
Nature of Suit: Social Security - DIWC/DIWW (405(g))
Cause of Action: 42:405 Review of HHS Decision (DIWC)

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United States District Court

For the Northern District of California

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UNITED STATES DISTRICT COURT

NORTHERN DISTRICT OF CALIFORNIA

VICTOR EMEONYE,

Plaintiff,

 v.

MICHAEL J. ASTRUE, 

Commissioner of Social

Security,

Defendant.

 

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No. 04-03386 SC

ORDER GRANTING

PLAINTIFF'S MOTION

FOR SUMMARY JUDGMENT

AND DENYING

DEFENDANT'S CROSSMOTION FOR SUMMARY

JUDGMENT

I. INTRODUCTION

This matter is before the Court on cross-motions for summary

judgment filed by the plaintiff Victor Emeonye ("Plaintiff" or

"Claimant") and the defendant Michael J. Astrue ("Defendant"). 

Docket Nos. 28, 30. Plaintiff submitted a Reply. Docket No. 31. 

Plaintiff seeks review and reversal of the Social Security

Commissioner's final decision denying his claim for Social

Security Disability Insurance benefits. For the reasons set forth

below, the Court GRANTS Plaintiff's Motion for Summary Judgment

and DENIES Defendant's Cross-Motion for Summary Judgment.

 

II. BACKGROUND

A. Procedural

In August 2004, Plaintiff filed a Complaint seeking review of

the Social Security Commissioner's denial of disability benefits. 

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1

 As Plaintiff's claim has been remanded once already, two

separate Administrative Records exist. The more recent AR, dated

June 19, 2007, is the operative AR for the current action and shall

be referred to as simply "AR." The previous AR, which the Court

relied upon in it's initial Order remanding Plaintiff's claim, is

dated October 20, 2004, and shall be referred to as the "2004 AR."

2

Docket No. 1. After the parties filed cross-motions for summary

judgment, this Court issued an Order remanding the claim to the

Administrative Law Judge ("ALJ") for further consideration of

newly-discovered evidence of Plaintiff's recurring seizures. See

Order, Docket No. 23. A second hearing was held and Plaintiff's

claim for disability benefits was again denied. Administrative

Record ("AR") at 327-336.1 

On January 16, 2007, after the hearing but before the ALJ

issued a decision, Plaintiff unexpectedly died. AR at 309. 

Plaintiff was 49 years old. Id. Neither party has indicated the

cause of Plaintiff's death. The Court can only assume, therefore,

that his death was not related to his health issues. Were this

otherwise, Plaintiff's death could have provided key evidence of

the severity of Plaintiff's medical conditions. 

In any event, after Plaintiff died, the parties submitted a

stipulation, which this Court approved, substituting Plaintiff's

daughter, Thelma Brittany Emeonye, a minor child, in Plaintiff's

stead. Docket No. 27. Although Plaintiff's claim for

Supplemental Security Income benefits under Title XVI is

extinguished by this substitution, Plaintiff's claim for Social

Security Disability Insurance benefits under Title II is

unaffected. See Pl.'s Mot. Summ. J. at 3. Therefore, the

analysis regarding Plaintiff's claim is unchanged by the

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2 It is equally clear that this birth date does not pertain

to Plaintiff's daughter, who, at the time of this Order, is a

teenager.

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substitution of Plaintiff's daughter for Plaintiff.

B. Factual

As a preliminary matter, the Court must take note of several

disturbing factual inaccuracies in the record. Most prominently

and egregiously, the entire first paragraph of the Statement of

the Case in Defendant's Cross-Motion for Summary Judgment contains

not one fact or citation that is even remotely related to

Plaintiff's action. For example, the first sentence in this

paragraph states, "Plaintiff was born on February 13, 2007 (Tr.

22, 56)." Def.'s Mot. at 2. Plaintiff Emeonye, however, was born

August 15, 1958, as even the most cursory examination of the

record demonstrates.2 See, e.g., AR at 17. Submissions

containing such factual errors indicate a remarkable inattention

to even the most basic details. 

The other factual discrepancy worth noting is in the ALJ's

decisions themselves. In both the decision issued on February 19,

2004, AR 27-31, and the decision issued on February 2, 2007, id.

at 330-36, the ALJ inexplicably states that Plaintiff "was born in

Nicaragua." AR at 28, 331. As stated on his death certificate

and as noted by at least two of Plaintiff's medical examiners,

however, Plaintiff was from Nigeria, not Nicaragua. See AR at

151, 309, 528. Such factual mistakes are troubling. 

Plaintiff worked as a security guard from 1986 to 2002. 2004

AR at 28. On June 4, 2002, he was stabbed multiple times and

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suffered injuries to the chest, neck, abdomen, and hand. AR at

135. He was taken to San Francisco General Hospital, where he

underwent open-heart surgery to repair a "very complex laceration

of the right ventricle" and to remove a "large amount of clot" in

the pericardium. Id. Plaintiff's attending surgeons also

performed a limited upper abdominal exploration, but elected not

to undertake a full exploratory laparotomy because of the

extensive adhesions already present in his abdomen as a result of

a 1997 incident in which he was shot. Id. Plaintiff remained in

the hospital for eight days and was released with a good

prognosis. AR at 138. Plaintiff alleged that he had been

disabled since the date of the stabbing, June 4, 2002.

After his discharge from the hospital, Plaintiff began to

experience severe migraine headaches, nausea, watery eyes, and

dizziness. AR 215-17; 258-63. As a result of these symptoms,

Plaintiff visited medical centers in October, November, and

December 2002, and again in January, February, and March 2003. 

2004 AR at 213-17. 

On February 9, 2003, Plaintiff had a seizure and was treated

at San Francisco General Hospital. AR at 124. A CT scan taken

days later revealed a chronic subdural hematoma. Id. at 209-10. 

A subsequent CT scan taken May 6, 2003, confirmed this diagnosis

and also revealed a "left inferior temporal fossa, possibly

related to post traumatic encephalomalacia." Id. at 265. A third

CT scan was performed on March 3, 2004, after Plaintiff's initial

December 10, 2003, hearing. Id. at 483. This exam revealed no

significant changes in his physiological condition, although it

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was noted that there was "[m]ore focal volume loss . . . in the

left inferior temporal and frontal lobes." Id. 

Plaintiff experienced another seizure on April 28, 2004, for

which he was treated at Seton Medical Center. 2004 AR 19-20. 

Plaintiff was instructed to see a physician for follow-up care,

and was discharged with a prescription for Dilantin anti-seizure

medication. Id. at 19. On May 1, 2004, Plaintiff checked in to

the Emergency Department of the Saint Francis Medical Center,

where he received medical attention for hallucinations and

possibly another seizure. Id. at 21; AR at 332. In October 2005,

Plaintiff suffered another seizure. AR at 332. 

III. LEGAL STANDARD

To qualify for disability benefits, a claimant must show that

he or she is unable "to engage in any substantial gainful activity

by reason of any medically determinable physical or mental

impairment which can be expected to result in death or which has

lasted or can be expected to last for a continuous period of not

less than twelve months . . . ." 42 U.S.C. § 423(d)(1)(A). In

making this determination, "an ALJ conducts a five step inquiry. 

20 C.F.R. §§ 404.1520 & 416.920." Lewis v. Apfel, 236 F.3d 503,

508 (9th Cir. 2001). 

The ALJ first considers whether the

claimant is engaged in substantial

gainful activity; if not, the ALJ asks in

the second step whether the claimant has

a severe impairment (i.e., one that

significantly affects his or her ability

to function); if so, the ALJ asks in the

third step whether the claimant's

condition meets or equals one of those

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outlined in the Listing of Impairments in

Appendix 1 of the Regulations [20 C.F.R.

§§ 404.1520(d) & 416.920(d)]; if not,

then in the fourth step the ALJ asks

whether the claimant can perform in his

or her past relevant work; if not,

finally, the ALJ in the fifth step asks

whether the claimant can perform other

jobs that exist in substantial numbers in

the national economy. 20 C.F.R. §§

404.1520(b)-404.1520(f)(1) & 416.920(b)-

416.920(f)(1).

Id.

Courts may set aside a decision of the ALJ if it is not

supported by substantial evidence. 42 U.S.C. § 405(g); Holohan v.

Massanari, 246 F.3d 1195, 1202 (9th Cir. 2001). "Substantial

evidence" is the relevant evidence which a reasonable person might

accept as adequate to support the ALJ's conclusion. Reddick v.

Chater, 157 F.3d 715, 720 (9th Cir. 1998). In order to be

"substantial," the evidence must amount to "more than a

scintilla," but need not rise to the level of a preponderance. 

Holohan, 246 F.3d at 1202. Where the evidence could reasonably

support either affirming or reversing the ALJ's decision, a court

may not substitute its judgment for the ALJ's decision. Id.

IV. DISCUSSION

Plaintiff asserts three independent justifications for

reversing the ALJ's finding and granting disability benefits. 

Plaintiff's first argument is that the ALJ ignored evidence that

established that Plaintiff had an impairment equal to a listing

impairment of Appendix 1, and the ALJ therefore erred by not

finding Plaintiff disabled. As resolution of this issue disposes

of the entire action, the Court need not reach Plaintiff's

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remaining two arguments. 

A. Failure to Consider Evidence Establishing that

Plaintiff's Impairment Equals a Listed Impairment

As noted above, in the third step of his inquiry, "the ALJ

asks . . . whether the claimant's condition meets or equals one of

those outlined in the Listing of Impairments in Appendix 1 of the

Regulations." Lewis, 236 F.3d at 508 (citing 20 C.F.R. §§

404.1520(d) & 416.920(d)). 20 C.F.R. § 404.1525(c)(5) states that

if a claimant's impairment "does not meet the criteria of a

listing, it can medically equal the criteria of a listing." 

Medical equivalence may exist if the impairment "is at least equal

in severity and duration to the criteria of any listed

impairment." 20 C.F.R. § 404.1526(a). 

Plaintiff asserts that his mental impairments equal the

severity of the Listing Impairment for mental retardation and that

Plaintiff therefore is disabled. To satisfy the requirements for

the Listing for mental retardation, a plaintiff must "satisf[y]

the diagnostic description in the introductory paragraph and any

one of the four sets of criteria." 20 C.F.R. Pt. 404, Subpt. P,

App. 1, § 12.00. The introductory paragraph states:

Mental retardation: Mental retardation

refers to significantly subaverage

general intellectual functioning with

deficits in adaptive functioning

initially manifested during the

developmental period; i.e., the evidence

demonstrates or supports onset of the

impairment before age 22. The required

level of severity for this disorder is

met when the requirements in A, B, C, or

D are satisfied.

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Id. at § 12.05. 

The parties do not dispute that the requirements of subpart C

are the only requirements germane to the present action. These

requirements are: "A valid verbal, performance, or full scale IQ

of 60 through 70 and a physical or other mental impairment

imposing an additional and significant work-related limitation of

function . . . ." Id. Neither party disputes the fact that

Plaintiff was diagnosed with a performance I.Q. of 67. See AR

523. In addition, both parties agree that Plaintiff has a

"physical or other mental impairment . . . ." 20 C.F.R. Pt. 404,

Subpt. P, App. 1, § 12.05. Indeed, as Defendant concedes, "the

ALJ found that Plaintiff satisfied the severity requirement." 

Def.'s Mot. at 7. The ALJ, in his report, stated: "The medical

evidence establishes that the claimant has severe chronic subdural

hematoma . . . ." AR at 335. Finally, neither party argues that

there is any evidence to support onset of the impairment before

Plaintiff was 22. The issue, therefore, is whether it is possible

for Plaintiff to medically equal the Listing Requirements for

mental retardation if there is no evidence of early onset. The

Court answers this question in the affirmative.

As the regulations state, medical equivalence can be found in

three ways, two of which are relevant to the present action:

(1) If you have an impairment that is

described in appendix 1, but . . . [y]ou

do not exhibit one or more of the

findings specified in the particular

listing . . . [w]e will find that your

impairment is medically equivalent to

that listing if you have other findings

related to your impairment that are at

least of equal medical significance to

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the required criteria.

(2) . . . .

(3) If you have a combination of

impairments no one of which meets a

listing . . ., we will compare your

findings with those for closely analogous

listed impairments. If the findings

related to your impairments are at least

of equal medical significance to those of

a listed impairment, we will find that

your combination of impairments is

medically equivalent to that listing.

20 C.F.R. § 404.1526(b). 

The essence of these subsections is that strict conformity

with the Listing Requirements is not necessarily required for a

finding of disability. If a plaintiff is only able to demonstrate

most of the requirements for a Listing or if he or she is able to

demonstrate analogous or similar impairments to the impairments of

a Listing, the plaintiff may nonetheless still satisfy the

standards if the plaintiff can show impairments of equal medical

significance. See id. 

Under either subsection listed above, Plaintiff's medical

impairments equaled the requirements for mental retardation. It

is undisputed that Plaintiff was diagnosed with a performance I.Q.

of 67 and was found to have a severe impairment of a subdural

hematoma and suffer from seizures. The only requirement Plaintiff

did not satisfy for mental retardation was evidence of early

onset. The Court is convinced, however, that the severity of

Plaintiff's medical impairments today, rather than when evidence

of such impairments first presented, is the crucial question for

determining whether Plaintiff's impairments equal the Listing

requirements. 

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To satisfy § 404.1526(b)(1), Plaintiff must have "other

findings related to [his impairment] that are at least of equal

medical significance to the required criteria." 20 C.F.R. §

404.1526(b)(1). Plaintiff's severe impairment of subdural

hematoma and Plaintiff's pattern of seizures are of more than

equal medical significance to the required criteria of early

onset. Pursuant to § 404.1526(b)(1), therefore, Plaintiff's

impairments equal those of the Listing for mental retardation and

Plaintiff was disabled.

In the alternative, Plaintiff also satisfies §

404.1526(b)(3). Plaintiff's combination of impairments "are at

least of equal medical significance to those of [mental

retardation]." 20 C.F.R. § 404.1526(b)(3). Accordingly,

Plaintiff's "combination of impairments is medically equivalent to

that listing." Id. 

These findings are consistent with 20 C.F.R. §

404.1525(c)(5), which states that if a claimant's impairment "does

not meet the criteria of a listing, it can medically equal the

criteria of a listing." If a plaintiff were required to actually

meet every requirement of a listing, as Defendant suggests in his

brief, § 404.1525(c)(5) would be meaningless. For these reasons,

the Court finds that Plaintiff's medical impairments were equal to

the Listing requirements for mental retardation, and, therefore,

Plaintiff was disabled. 

Given the deference with which this Court must treat the

decision of the ALJ, this Court's analysis of the issue is not

necessarily dispositive. Thus, a brief examination of the ALJ's

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opinion is required. The ALJ stated: 

[A]lthough Dr. Kollath reported a . . .

performance I.Q. of 67, his recent

clinical findings and assessment of

mental capacities reveal no medically

determined mental disorders imposing more

than slight work related limitations.

The test scores are not associated with a

diagnosis of mental retardation or any

corroborating evidence of a history since

before age 22 of impaired intellectual

functioning, so the requirements of

section 12.05 C are not found to be met

or equaled.

AR at 334. 

It is clear from the ALJ's decision that he did not properly

analyze the issue of whether Plaintiff equaled, rather than met,

the Listing requirement for mental retardation. Although the ALJ

properly noted that because there was no evidence of early onset,

Plaintiff's medical impairments did not meet the Listing

requirements, there is no discussion of why Plaintiff did not

equal the listing requirements. 

"[I]n determining whether a claimant equals[, rather than

meets,] a listing under step three of the Secretary's disability

evaluation process, the ALJ must explain adequately his evaluation

of alternative tests and the combined effects of the impairments." 

Marcia v. Sullivan, 900 F.2d 172, 176 (9th Cir. 1990); see also

Galaspi-Bey v. Barnhart, No. 01-1770, 2002 WL 31928500, at *3

(N.D. Cal. Dec. 23, 2002) (stating that "in determining medical

equivalency under step three, the ALJ must adequately explain his

comparative evaluation of the applicant's impairment to the listed

impairment"). Applying this standard to the findings in this

case, the Court finds that the ALJ's statement that Plaintiff did

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not equal the listing was insufficient. Marcia, 900 F.2d at 176. 

The Court therefore finds that the ALJ committed legal error in

his medical equivalency analysis.

"The decision to remand the case for additional evidence or

simply to award the benefits is within the discretion of the

court." Erickson v. Shalala, 9 F.3d 813, 819 (9th Cir. 1993). 

Where the record is fully developed, remand is unnecessary. Id.

In the present case, the record is fully developed. There are no

"outstanding issues that must be resolved before a determination

of disability can be made." Harman v. Apfel, 211 F.3d 1172, 1178

(9th Cir. 2000). Nor would "additional proceedings . . . remedy

defects in the original administrative proceeding . . . ." 

Marcia, 900 F.2d at 176-77 (internal quotation marks omitted).

 

V. CONCLUSION

For the foregoing reasons, the Court GRANTS Plaintiff's

Motion for Summary Judgment and DENIES Defendant's Motion for

Summary Judgment. The matter is remanded to the Commissioner so

that he may calculate and award benefits with an onset date of

June 2, 2002. 

IT IS SO ORDERED.

Dated: May 5, 2008

 

UNITED STATES DISTRICT JUDGE

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