Document ID: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-ca10-88-02865/USCOURTS-ca10-88-02865-0/pdf.json

Parties Involved:
Dorothy J. Baker
Appellant
Otis R. Bowen
Appellee

Document Text:

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P.UBLISH 

UNITED STATES COURT OF APPEALS 

TENTH CIRCUIT 

DOROTHY J. BAKER, 

Plaintiff-Appellant, 

FILED 

Uoited States Court of Appeals 

Tenth Circuit 

SEP 2 7 1989 

ROBERT L. HOECKER 

Clerk 

v. 

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No. 88-2865 

OTIS R. BOWEN, M.D., Secretary of 

the Department of Health & 

Human Services, 

Defendant-Appellee. 

APPEAL FROM THE UNITED STATES DISTRICT COURT 

FOR THE EASTERN DISTRICT OF OKLAHOMA 

(D.C. No. 87-611-C) 

Submitted on the briefs: 

Richard C. Howard, Muskogee, Oklahoma, for Plaintiff-Appellant. 

Roger Hilfiger, United States Attorney, Donald A. Gonya, Chief 

Counsel for Social Security, Randolf w. Gaines, Deputy Chief 

Counsel for Social Security, A. George Lowe, Chief, Disability 

Litigation Branch, Nigel Jamieson, with the Office of the General 

Counsel, Social Security Division, Department of Health and Human 

Services, for the Defendant-Appellee. 

Before MOORE, ANDERSON, and BRORBY, Circuit Judges. 

PER CURIAM. 

Appellate Case: 88-2865 Document: 01019936279 Date Filed: 09/27/1989 Page: 1 
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 cause is therefore ordered 

submitted without oral argument. 

Dorothy J. Baker appeals a determination by the Secretary of 

Health and Human Services, as affirmed by the district court, that 

she is not disabled for the purposes of Supplemental Security 

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

42 U.S.C. SS 1381-85 (1982 & Supp. IV 1986). The Secretary, 

acting through an administrative law judge (ALJ), determined that 

there was no definitive medical evidence that Mrs. Baker was 

suffering from a disabling impairment. Mrs. Baker now appeals, 

arguing that the Secretary failed to consider certain x-rays which 

indicated that she suffered from degenerative arthritis and that 

the Secretary's decision was not supported by substantial 

evidence. We reverse and remand for additional proceedings by the 

Secretary. 

Mrs. Baker 

February 13, 1986. 

filed her 

At the 

application 

time of her 

for SSI benefits 

application, she 

on 

was 

fifty-nine years old. Mrs. Baker has an eleventh grade education 

and has previously worked as a child care attendant, cashier, and 

store employee. Her most recent employment was as a nurse's aide, 

where she provided medication and direct care for patients at a 

nursing home. Mrs. Baker left her job as a nurse's aide in 

August, 1984, because she could no longer handle the physical 

requirements of her position. 

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Appellate Case: 88-2865 Document: 01019936279 Date Filed: 09/27/1989 Page: 2 
On her application for disability benefits, Mrs. Baker stated 

that she was suffering from painful arthritis, diminished use of 

her hands, numbness in her legs and feet, balance difficulties, 

incontinence, gastritis, glaucoma, anxiety and other ailments. 

She also indicated that she had undergone sixteen surgeries in 

recent years, including a radical mastectomy for cancer of the 

left breast, after which she refused chemotherapy treatment due to 

concern over its cost. 

surgery for breast 

Medical records relating to Mrs. Baker's 

cancer were provided to the Secretary, 

including certain x-ray reports of her spine. 

Although she requested her treating physician, Dr. Robert 

Smith, to provide her medical records to the Secretary, he failed 

to do so. The Secretary then made two written requests to Dr. 

Smith for these documents, and again he failed to comply. No 

further action was taken by the Secretary to secure these records; 

however, the Secretary did order consultative examinations by an 

internist and a psychiatrist. 

Mrs. Baker's application 

September 12, 1986, and her 

Appeals Council was similarly 

for benefits was denied on 

request for reconsideration by the 

denied. Mrs. Baker thereafter 

requested a hearing on her application, which was held before the 

ALJ on April 20, 1987. Mrs. Baker testified as to the pain she 

experienced while on her feet and sitting, her problems writing 

and holding objects, and the limitations on her daily activities 

caused by her ailments and the fact that her husband was 

terminally ill. Mrs. Baker's neighbor, Ms. Lila Gregory, 

confirmed that Mrs. Baker required assistance with household 

3 

Appellate Case: 88-2865 Document: 01019936279 Date Filed: 09/27/1989 Page: 3 
chores, that she was often falling down and dropping things, and 

that she experienced strong pain after the consultative 

examination, during which the examining physician passively moved 

her extremities. 

On May 20, 1987, the ALJ issued his decision denying Mrs. 

Baker SSI benefits. The ALJ concluded that 

[a] review of the evidence in this file shows 

claimant currently alleges she could not engage in any 

type of work activity on a sustained basis due to 

constant pain and swelling in back, shoulders, arms, 

hands, fingers, hips, knees, and feet caused by 

arthritis [and due to other ailments]. There are no 

x-rays in this file or laboratory data to support a 

diagnosis of arthritis and examination by a physician on 

August 28, 1986, showed no evidence of swelling, heat, 

or redness in any joint. There is no definitive 

diagnostic testing to confirm numpness in the legs and 

feet and ••• there is no medical evidence in this file 

to suggest she has ever sought or required medical 

treatment for injuries suffered in [her] alleged 

frequent falls. Claimant alleges she is unable to lift 

heavy objects, oppose her thumb to her fingertips, or 

hang on to items, however, the file clearly shows she 

does all of her own housework and cooking and is 

required to care for a seriously ill husband 24-hours a 

day. 

Vol. II at 16. The ALJ also noted in his findings that 

consultative examinations were required because no medical 

evidence was provided by Mrs. Baker or her physician concerning 

her current impairments. The ALJ then concluded that objective 

medical evidence did not support Mrs. Baker's claim that her pain 

and impairments originated from a medically determinable 

disability. The ALJ's determination of non-disability was 

thereafter upheld by the district court. 

Mrs. Baker raises several arguments in this appeal. First, 

she contends that, as a matter of law, the Secretary erred in 

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Appellate Case: 88-2865 Document: 01019936279 Date Filed: 09/27/1989 Page: 4 
failing to consider the x-rays taken prior to Mrs. Baker's 

mastectomy which indicated that there had been degenerative 

changes of Mrs. Baker's mid lumbar spine. She also claims that 

the Secretary erred by failing to assemble a complete record as to 

her disability. Finally, Mrs. Baker asserts that, even without 

the x-rays and other data which could have substantiated her 

claimed impairments, there was other objective medical evidence of 

record to support a finding of disability and that the Secretary's 

decision that she was not disabled was therefore not supported by 

substantial evidence. We do not reach this issue, as we conclude 

that the Secretary erred by not considering relevant medical 

evidence and by failing to order certain medical tests and 

records. 

The Social Security Ac~ provides that, in considering whether 

a person is disabled under Title II, "[o]bjective medical evidence 

of pain or other symptoms established by medically acceptable 

clinical or laboratory techniques must be considered in 

reaching a conclusion as to whether the individual is under a 

disability." 42 u.s.c. § 423(d)(5)(A)(Supp. IV 1986)(emphasis 

added). This requirement equally applies to disability 

determinations for the purposes of SSI benefits. Id. 

§ 1382c(a)(3)(G). Thus, the Act makes clear that the Secretary 

must consider all relevant medical evidence of record in reaching 

a conclusion as to disability. See Ray v. Bowen, 865 F.2d 222, 

226 (10th Cir. 1989)("[t]he ALJ must determine the claimant's 

eligibility for disability benefits in light of the entire 

record"); Herbert v. Heckler, 783 F.2d 128, 130 (8th Cir. 

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Appellate Case: 88-2865 Document: 01019936279 Date Filed: 09/27/1989 Page: 5 
1986)(it is insufficient that there are inconsistencies in 

objective medical evidence to support the Secretary's denial of 

benefits, "[t)he Secretary must demonstrate that she evaluated all 

the evidence"). 

In this case, we cannot be certain that the ALJ took into 

consideration Mrs. Baker's pre-mastectomy x-rays. His findings 

state that "[t)here are no x-rays in this file or laboratory data 

to support a diagnosis of arthritis," Vol. II at 16, and there is 

no further discussion of the x-rays in the remainder of his 

report. The Secretary argues that, while the ALJ's statement as 

to the lack of x-rays is ambiguous, "[i]t is reasonable, however, 

to infer that he may have meant that there was no x-ray evidence 

to support a claim for disabling arthritis, rather than there was 

no x-ray at all." B~ief of Defendant-Appellee at 11 n.2. We may 

not engage in such speculation. "There are specific rules of law 

that must be followed in weighing particular types of evidence in 

disability cases," and the failure to follow these rules is 

reversible error. Reyes v. Bowen, 845 F.2d 242, 244 (10th Cir. 

1988). Where the record on appeal is unclear as to whether the 

ALJ applied the appropriate standard by considering all the 

evidence before him, the proper remedy is reversal and remand. 

See Williams v. Bowen, 844 F.2d 748 (10th Cir. 1988). 

Mrs. Baker additionally asserts that the Secretary failed its 

burden to fully and fairly develop the record. See Jordan v. 

Heckler, 835 F.2d 1314, 1315 (10th Cir. 1987). We agree. We are 

at a loss to understand why the Secretary ordered a consultative 

physical examination without requesting that recent x-rays of Mrs. 

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Appellate Case: 88-2865 Document: 01019936279 Date Filed: 09/27/1989 Page: 6 
( 

Baker's spine be taken. This failure is especially egregious in 

light of the fact that Mrs. Baker was not represented by counsel, 1 

was unable to secure her treating physician's records or afford 

new x-rays, and was complaining primarily of pain and stiffness 

due to arthritis, a disease commonly confirmed by x-rays. See 

Banks v. Bowen, 67~ F. Supp. 310, 320 (N.D. Ill. 1987); Diller v. 

Bowen, 654 F. Supp. 628, 630 (W.D. Pa. 1987). In addition, given 

the potential probative value of the records of Mrs. Baker's 

treating physician, cf. Reyes v. Bowen, 845 F.2d at 244 ("the 

Secretary must give substantial weight to the evidence and opinion 

of the claimant's treating physician"), we question why the 

Secretary did not subpoena those records pursuant to 20 C.F.R. 

S 404.950(d)(l988) when it appeared that Dr. Smith was 

recalcitrant in providing them. See,~, Donato v. Secretary of 

Dep't of Health & Human Servs., 721 F.2d 414, 419 (2d Cir. 

1983)(Secretary had duty to take further post-hearing action to 

obtain treating physician's records); Smith v. Bowen, 687 F. 

Supp. 902, 906 (S.D.N.Y. 1988)(directing ALJ on remand to obtain 

complete medical records on plaintiff and further assessments by 

treating and consulting physicians). Consequently, we conclude 

that the Secretary failed in his important burden of fully and 

fairly developing the record by neglecting to obtain new x-rays of 

1 Mrs. Baker was represented by Kaethe Wainwright, a paralegal 

with Legal Services of Eastern Oklahoma, Inc. While we recognize 

that paralegals do possess certain legal training and experience, 

see Hudson v. Heckler, 755 F.2d 781, 784 (11th Cir. 1985), the ALJ 

nevertheless has the affirmative duty to fully and fairly develop 

the record regardless of whether the applicant is represented by 

an attorney or a paralegal, Todd v. Heckler, 736 F.2d 641, 642 

(11th Cir. 1984); Smith v. Bowen, 687 F. Supp. 902, 906 (S.D.N.Y. 

1988); Ceballos v. Bowen, 649 F. Supp. 693, 698 (S.D.N.Y. 1986). 

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Appellate Case: 88-2865 Document: 01019936279 Date Filed: 09/27/1989 Page: 7 
Mrs. Baker's spinal region and the notes, laboratory results, and 

other records of Mrs. Baker's treating physician. Moreover, his 

reliance on the dearth of objective medical evidence to support 

the denial of benefits was, under these circumstances, erroneous. 

See Cruz v. Heckler, 593 F. Supp. 45, 52 (S.D.N.Y. 1984). 

The judgment of the United States District Court for the 

Eastern District of Oklahoma is REVERSED and the cause is REMANDED 

for further proceedings in accordance herewith. On remand, the 

ALJ should procure Mrs. Baker's medical records from her treating 

physician, as well as further consultative x-rays. The ALJ should 

then evaluate all the evidence to determine whether Mrs. Baker's 

medical conditions render her disabled. 

The mandate shall issue forthwith. 

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