Document ID: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-ca10-89-07084/USCOURTS-ca10-89-07084-0/pdf.json

Parties Involved:
Audrey Hill
Appellant
Louis W. Sullivan
Appellee

Document Text:

( 

PUBLISH 

FI LED 

Uoited States Court of Appeals 

Tenth Circuit 

UNITED STATES COURT OF APPEALS 

TENTH CIRCUIT 

JAN 2 8 1991 

ROBERT L. HOECKER 

Clerk 

AUDREY HILL, 

Plaintiff-Appellant, 

v. 

LOUIS W. SULLIVAN, M.D., Secretary of 

Health and Human Services, 

Defendant-Appellee. 

) 

) 

) 

) 

) 

) 

) 

) 

) 

) 

No. 89-7084 

APPEAL FROM THE UNITED STATES DISTRICT COURT 

FOR THE EASTERN DISTRICT OF OKLAHOMA 

(D.C. No. 88-548-C) 

Submitted on the briefs: 

Richard C. Howard of Legal Services of Eastern Oklahoma, Inc., 

Muskogee, Oklahoma, Mary Mosshamrner of Legal Services of Eastern 

Oklahoma, Inc., Hugo, Oklahoma, for Plaintiff-Appellant. 

Roger Hilfiger, United States Attorney, Eastern District of 

Oklahoma, Sheldon J. Sperling, Assistant U.S. Attorney, Gayla 

Fuller, Chief Counsel, Region VI, Karen J. Sharp, Principal 

Regional Counsel, Social Security Disability, Litigation Branch, 

Rodney A. Johnson, Assistant Regional Counsel, Office of the 

General Counsel, United States Department of Health and Human 

Services, Dallas, Texas, for Defendant-Appellee. 

Before MOORE and BARRETT, Circuit Judges, and SPARR,** District 

Judge. 

**Honorable Daniel B. Sparr, District 

District Court for the District Court of 

designation. 

Judge, United States 

Colorado, sitting by 

Appellate Case: 89-7084 Document: 010110016383 Date Filed: 01/28/1991 Page: 1 
PER CURIAM. 

After examining the briefs and appellate record, this panel 

has determined unanimously that oral argument would not materially 

assist the determination of this appeal. See Fed. R. App. P. 

34(a); 10th Cir. R. 34.1.9. The case is therefore ordered 

submitted without oral argument. 

Claimant appeals from an order of the district court 

affirming the final decision of the Secretary of the Department of 

Health and Human Services denying claimant supplemental security 

income (SSI) benefits under Title XVI of the Social Security Act, 

42 u.s.c. §§ 1381-1383d. Claimant filed her application for 

benefits on March 16, 1987, alleging disability due to high blood 

pressure, back problems, and breathing problems. Her claim was 

denied administratively; she sought and received a de novo hearing 

before an administrative law judge (A.L.J.) on October 8, 1987. 

On January 11, 1988, the A.L.J. rendered his decision denying 

claimant benefits on the ground that her impairments did not 

prevent her from returning to her past relevant work and, 

therefore, she was not disabled. The Appeals Council denied 

claimant's request for review, so the decision of the A.L.J. 

became the final decision of the Secretary. The district court 

affirmed the Secretary's final decision and this appeal followed. 

The Secretary's decision must be upheld if it is supported by 

substantial evidence and if the correct legal standards were 

2 

Appellate Case: 89-7084 Document: 010110016383 Date Filed: 01/28/1991 Page: 2 
applied. See Frey v. Bowen, 816 F.2d 508, 512 (10th Cir. 1987). 

Claimant raises three issues on appeal: whether the Secretary 

applied the correct legal standard when he failed to obtain 

medical records from Dr. Wiebe, one of claimant's treating 

physicians; whether the Secretary applied the correct legal 

standard when he failed to have a psychological evaluation of 

claimant's possible mental impairment performed; and whether the 

Secretary's determination that claimant was not disabled was 

supported by substantial evidence. We conclude that the Secretary 

failed to follow the proper procedures in evaluating claimant's 

potential mental impairment and, therefore, reverse. 

Dr. Riddle, a specialist in psychiatry and family medicine, 

examined claimant on May 5, 1987, at the request of the 

Secretary. He diagnosed claimant as follows: 

DIAGNOSIS I. Lumbar back strain, secondary to 

automobile accident with chronic pain and slightly 

decreased range of motion due to this. However, the 

patient had basically normal range of motion during the 

examination. DIAGNOSIS II. Hypertension-moderate; this 

has been controlled with Hydrochlorothiazide in the 

past; however, a second medication could be indicated at 

this time. DIAGNOSIS III. Chronic fatigue and lack of 

energy; this possibly could be more likely to be chronic 

mental depression in this patient. DIAGNOSIS IV. 

Occasional non-specific pains in the upper 

abdomen-etiology unknown. 

R. Vol. II at 131-32 (emphasis added). 

"[U]nder the Social Security Act, the claimant has the burden 

of proving a disability." Dixon v. Heckler, 811 F.2d 506, 510 

(10th Cir. 1987). Nonetheless, "the ALJ has a basic duty of 

inquiry, 'to inform himself about facts relevant to his decision 

and to learn the claimant's own version of those facts.'" Id. 

3 

Appellate Case: 89-7084 Document: 010110016383 Date Filed: 01/28/1991 Page: 3 
(quoting ~H=e=c=k=l~e=r=--_v.:.....:..•--=C=am=p=b=e=l=-=l, 461 u. s. 458, 471 n.1 

(1983)(Brennan, J., concurring)). Furthermore, this duty of 

inquiry "takes on special urgency when the claimant [like claimant 

here] has little education and is unrepresented by counsel." Id. 

Claimant contends that the Secretary failed to develop the 

record fully and fairly by having a psychiatrist or psychologist 

evaluate her possible chronic depression. See 42 u.s.c. § 421(h); 

20 C.F.R. § 416.920(a). The Secretary, relying on Garcia v. 

Califano, 625 F.2d 354 (10th Cir. 1980), argues that claimant's 

potential mental impairment was not related to her claim for 

disability and, therefore, the Secretary had no duty of inquiry 

with respect to her chronic depression. See id. at 356 ("With or 

without representation, [claimant] was responsible for raising the 

matter of his depression if he relied on it as a basis for the 

disability claim."). We disagree. 

Garcia v. Califano was decided prior to enactment of the 

Social Security Disability Benefits Reform Act of 1984, Pub. L. 

No. 98-460, 98 Stat. 1794 (1984), and the promulgation of new 

regulations thereunder, both of which altered the standards for 

cases involving mental impairments. The new statutory provisions 

and regulations "appear[] to require a consultative examination on 

less evidence than may have been required previously." McCall v. 

Bowen, 846 F.2d 1317, 1320 (11th Cir. 1988). 

Section 8(a) of the Reform Act added subsection 421(h) to 

Title 42, which now provides that 

[a]n initial determination .. 

not under a disability, in any 

evidence which indicates the 

impairment, shall be made only 

. that an individual is 

case where there is 

existence of a mental 

if the Secretary has made 

4 

Appellate Case: 89-7084 Document: 010110016383 Date Filed: 01/28/1991 Page: 4 
every reasonable effort to ensure that a qualified 

psychiatrist or psychologist has completed the medical 

portion of the case review and any applicable residual 

functional capacity assessment. 

42 u.s.c. § 421(h). This provision applies to claims for SSI, as 

well as those for disability insurance benefits. 

§ 1382c(a)(3)(G). Following enactment of the Reform Act, the 

Secretary promulgated new regulations regarding the evaluation of 

mental impairments. These regulations require that a particular 

procedure be followed in evaluating a mental impairment and that a 

standard document outlining the steps of this procedure be 

completed at the initial, reconsideration, A.L.J. hearing, and 

Appeals Council levels. See 20 C.F.R. § 404.1520a. 

In the present case, a psychiatrist diagnosed claimant as 

suffering from chronic fatigue, possibly as a result of chronic 

depression. Depression is a mental impairment contained in the 

Listings of Impairments. Id. Part 404, Subpt. P, App. 1, 12.04. 

Furthermore, a witness for claimant testified at the hearing 

before the A.L.J. that claimant was tired all the time and fell 

asleep frequently throughout the day; claimant averred in an 

affidavit submitted to the Appeals Council: "I am just weak and 

tired all the time. I am just give out and I have to sit down. 

When I sit down, I fall over asleep. I am just beat all the 

time;" and claimant's friend averred in an affidavit submitted to 

the Appeals Council: "Audrey can not stay awake .. Audrey is 

always trying to move around to stay awake. My two daughters 

always pick at her to try to make her stay awake. She can't work 

because she is tried [sic] and sleepy all the time and her back 

hurts." R. Vol. II at 10, 11. 

5 

Appellate Case: 89-7084 Document: 010110016383 Date Filed: 01/28/1991 Page: 5 
Since the record contained evidence of a mental impairment 

that allegedly prevented claimant from working, the Secretary was 

required to follow the procedure for evaluating the potential 

mental impairment set forth in his regulations and to document the 

procedure accordingly. See 20 C.F.R. § 404.1520a. The Secretary 

failed to follow the appropriate procedure, so we must remand the 

case for proper consideration of claimant's potential mental 

impairment. 

On remand, the Secretary also should make every reasonable 

effort to obtain the records from claimant's treating physician, 

Dr. Wiebe. See 42 u.s.c. § 423(d) (5) (B) ( "In making any 

determination the Secretary shall make every reasonable effort to 

obtain from the individual's treating physician ... all medical 

evidence, including diagnostic tests, necessary in order to 

properly make such determination, prior to evaluating medical 

evidence obtained from any other source on a consultative 

basis."); id. § 1382c ( a) ( 3) (G) ( "In making determinations with 

respect to disability under this title, the provisions of sections 

421(h), 421(k), and 423(d)(5) of this title shall apply in the 

same manner as they apply to determinations of disability under 

this subchapter [SSI].") 

The judgment of the United States District Court for the 

Eastern District of Oklahoma is REVERSED, and the case is REMANDED 

to the district court for remand to the Secretary for further 

proceedings consistent with this opinion. 

6 

Appellate Case: 89-7084 Document: 010110016383 Date Filed: 01/28/1991 Page: 6