Source: https://docs.justia.com/cases/federal/district-courts/alabama/alsdce/1:2011cv00202/49598/18
Timestamp: 2017-05-24 15:36:24
Document Index: 101849295

Matched Legal Cases: ['§ 1381', '§ 636', '§ 405', '§ 423', '§ 404', 'art, 355', '§ 404']

Order entered that the decision of the Commissioner of Social Security, denying Plaintiffs claim for disability insurance benefits and supplemental security income, be REVERSED and REMANDED for Clausell v. Astrue :: Justia Dockets & Filings Log In
Clausell v. Astrue
Order entered that the decision of the Commissioner of Social Security, denying Plaintiffs claim for disability insurance benefits and supplemental security income, be REVERSED and REMANDED. Signed by Magistrate Judge Sonja F. Bivins on 8/8/2012. (mjn)
JAMES C. CLAUSELL,
MICHAEL J. ASTRUE, Commissioner *
of Social Security,
CIVIL ACTION 11-00202-B
(“Plaintiff”
“Clausell”)
brings this action seeking judicial review of a final decision
of the Commissioner of Social Security denying his claim for
Security Act, 42 U.S.C. § 1381 et seq.
On July 23, 2012, the
parties consented to have the undersigned conduct any and all
referred to the undersigned to conduct all proceedings and order
the entry of judgment in accordance with 28 U.S.C. § 636(c) and
Fed.R.Civ.P. 73. (Doc. 15). Oral argument was held on August 7,
2012. Upon careful consideration of the administrative record
decision of the Commissioner be REVERSED and REMANDED.
supplemental security income on January 14, 2008.1 (Tr. 148-55).
Plaintiff alleges that his alleged onset of disability date is
November 19, 1975, but that his impairments have limited his
anemia. (Id. at 95-96, 148, 156, 165).
His application was
denied at the initial stage (Id. at 95-101), and he filed a
timely Request for Hearing before an Administrative Law Judge
(“ALJ”). (Id. at 104-6).
On October 29, 2009, Administrative
Law Judge Ricardo Ryan held an administrative hearing2, which was
attended by Plaintiff and his non-attorney representative, Ella
Ewing3. (Id. at 54-86, 124).
On November 10, 2009, the ALJ
issued an unfavorable decision finding that Plaintiff is not
(Id. at 15-27).
Plaintiff’s request for review was
On that same date, Plaintiff also filed an application for
Disability Insurance Benefits. His application was denied
because he did not meet the insured requirements. Plaintiff does
not appeal that denial. (Tr. 156-8).
A previous administrative hearing was commenced on August
13, 2009. However, Plaintiff’s attorney had recently withdrawn
from the case, and Plaintiff indicated that he wished to retain
other counsel. As a result, the ALJ continued the hearing to
afford Plaintiff an opportunity to obtain new counsel. (Id. at
87-94).
Plaintiff points out that his representative at the
hearing is incorrectly referred to as “Ms. Healey” throughout
the transcript. (Id. at 6).
denied by the Appeals Council (“AC”) on March 14, 2011.
(Id. at
1-6, 14).
The parties agree that this case is now ripe for judicial
review and is properly before this Court pursuant to 42 U.S.C.
§§ 405(g) and 1383(c)(3).
Whether the ALJ erred by failing to fully develop
the record and to provide Plaintiff with a full
and fair hearing?
Whether the Appeals Council erred in failing to
the case for proper consideration of
newly submitted evidence?
Plaintiff testified that he has a 9th grade education and that he
failed to complete the 10th grade due to being incarcerated.
(Id. at 60).
Plaintiff has past relevant work (“PRW”) as an
assembly line worker.
(Id. at 80-1, 96, 171).
Plaintiff testified that he worked at Standard Furniture in
Bay Minette, Alabama on three different occasions. According to
Plaintiff, he was initially employed at Standard Furniture in
2001 for two and one-half months. Plaintiff indicated that he
was laid off because he no longer had a place to live in Bay
Minette once his relationship with his girlfriend ended. (Id. at
64-6).
Furniture a second time in 2003, that he worked there for a
“couple of months,” and that he lost his employment after being
incarcerated for failure to pay restitution arising from a prior
manslaughter conviction4. (Id. at 66-7). Plaintiff reported that
testified that he quit after two months due to his illness. (Id.
at 63). Plaintiff further testified that he worked as a cook at
Hardee’s for a short period of time. Plaintiff reported that he
left this job due to issues with transportation. (Id. at 69).
since birth and that the illness prevents him from working. (Id.
at 71-2). Plaintiff reported that he experiences severe weakness
and joint pain as a result of his illness. (Id. at 170, 180).
According to Plaintiff, he experiences pain with indeterminable
frequency and that the pain can last “from a couple hours, a
day, a week or even go on for longer.” (Id. at 72). He testified
that he takes iron pills once daily, folic acid twice a day, and
Lortab as needed for pain. (Id.)
Plaintiff testified that he spent five years in prison as a
result of the manslaughter conviction. (Id. at 60).
With respect to his daily activities, Plaintiff testified
that he tries to exercise by walking 10 to 15 minutes, that he
drives although his license has been revoked, that he reads
books and draws, and that he spends most days at home with his
wife. (Id at 59- 77).5
In reviewing claims brought under the Act, this Court=s
supported by substantial evidence and 2) whether the correct
legal standards were applied.
1520, 1529 (11th Cir. 1990).6
Martin v. Sullivan, 894 F.2d
A court may not decide the facts
anew, reweigh the evidence, or substitute its judgment for that
Sewell v. Bowen, 792 F.2d 1065, 1067 (11th
affirmed if they are based upon substantial evidence.
Sullivan, 921 F.2d 1233, 1235 (11th Cir. 1991); Bloodsworth v.
Plaintiff testified that he resides with his wife and her
children, and that his wife cleans, cooks, does laundry, and
gets groceries. (Id.)
This Court’s review of the Commissioner’s application of
legal principles is plenary. Walker v. Bowen, 826 F.2d 996, 999
(11th Cir. 1987).
substantial evidence is defined as “more than a scintilla but
preponderance”
evidence as a reasonable person would accept as adequate to
support a conclusion[]”).
In determining whether substantial
evidence exists, a court must view the record as a whole, taking
into account evidence favorable, as well as unfavorable, to the
Commissioner=s decision.
Chester v. Bowen, 792 F.2d 129, 131
(11th Cir. 1986); Short v. Apfel, 1999 U.S. Dist. LEXIS 10163
(S.D. Ala. 1999).
An individual who applies for Social Security disability
416.912.
404.1512,
Disability is defined as the “inability to do any
determinable physical or mental impairment which can be expected
to result in death or which has lasted or can be expected to
42 U.S.C. § 423(d)(1)(A), 404.1505(a), 416.905(a).
Security regulations provide a five-step sequential evaluation
process for determining if a claimant has proven her disability.
20 C.F.R. § 404.1520, 416.920.7
The claimant must first prove that he or she has not
engaged in substantial gainful activity.
requires the claimant to prove that he or she has a severe
In the case sub judice, the ALJ determined that Plaintiff
has not engaged in substantial gainful activity since December
impairment of sickle cell anemia. (Tr. 20). The ALJ found that
Plaintiff does not have an impairment that meets or medically
Subpt. P, App. 1, Regulations No. 4.
(Id.) The ALJ determined
cause the alleged symptoms but that his statements concerning
impairment or combination of impairments. If, at the third step,
the claimant proves that the impairment or combination of
impairments meets or equals a listed impairment, then the
claimant is automatically found disabled regardless of age,
education, or work experience.
If the claimant cannot prevail
at the third step, he or she must proceed to the fourth step
where the claimant must prove an inability to perform their past
relevant work.
Jones v. Bowen, 810 F.2d 1001, 1005 (11th Cir.
1986). In evaluating whether the claimant has met this burden,
the examiner must consider the following four factors: (1)
objective medical facts and clinical findings; (2) diagnoses of
examining physicians; (3) evidence of pain; (4) the claimant=s
age, education and work history. Id. at 1005. Once a claimant
meets this burden, it becomes the Commissioner’s burden to prove
at the fifth step that the claimant is capable of engaging in
another kind of substantial gainful employment which exists in
claimant’s residual functional capacity, age, education, and
work history. Sryock v. Heckler, 764 F.2d 834 (11th Cir. 1985).
If the Commissioner can demonstrate that there are such jobs the
claimant can perform, the claimant must prove inability to
perform those jobs in order to be found disabled.
Apfel, 190 F.3d 1224, 1228 (11th Cir. 1999). See also Hale v.
Bowen, 831 F.2d 1007, 1011 (11th Cir. 1987) (citing Francis v.
Heckler, 749 F.2d 1562, 1564 (11th Cir. 1985)).
the intensity, persistence and limiting effects of the alleged
symptoms were not credible to the extent they are inconsistent
20-1).
specialist, the testimony of the vocational expert (“VE”), and
retains the residual functional capacity (“RFC”) to perform a
considering Plaintiff’s RFC and vocational factors, such as age,
economy. (Id. at 22-23). Thus, the ALJ concluded that Plaintiff
is not disabled. (Id. at 24).
The relevant evidence of record reflects that Plaintiff has
been treated in the D.W. McMillan Memorial Hospital emergency
department on several occasions in 2007, 2008, and 2009 for a
number of symptoms including generalized pain, abdominal pain,
212-391).
November 29, 2007 visit, he reported exhaustion, abdominal pain,
“blacking
distress. He was diagnosed with complications from sickle cell
anemia and was directed to increase fluids, take folic acid, and
to take medications as directed. He was further directed to
return the following day for a gallbladder ultrasound.(Id. at
221-28).
department, Plaintiff reported pain on a level of 10 out of 10,
burning on the right side of his back, loss of appetite, and
nausea. On exam, Plaintiff was oriented times three and had a
depressed affect. He had no extremity tenderness or pedal edema.
effusion. Small calcifications over the left lateral portion of
the central pelvis, that were most likely phleboliths, were also
noted. (Id. at 216-7). Plaintiff’s diagnosis was sickle cell
anemia, and upon his discharge the same day, he was directed to
push fluids, take medications for pain, utilize an over-thecounter stool softener, and to follow up with Dr. Eddins or the
emergency room at Monroeville hospital. (Id. at 212-20).
Plaintiff continued to seek treatment through the emergency
room for generalized pain resulting from sickle cell crises and
other related ailments. The medical records reflect treatment
January 13, 2008 (Id. at 257-64), March 3, 2008 (Id. 265-72),
March 31, 2008 (273-6, 284-93), May 23, 2008 (Id. at 295-301),
June 4, 2008 (Id. at 302-14), July 20, 2008 (Id. at 315-334),
August 4, 2008 (Id. at 335-41), August 22, 2008 (Id. at 342-56),
September 6, 2008 (Id. at 357-64), September 22, 2008 (Id. at
366-76), December 1, 2008 (smoke inhalation) (Id. at 377-83),
January 26, 2009 (knee injury) (Id. at 277-83), and August 1,
384-91).
emergency room physicians routinely attributed Plaintiff’s pain
complaints to sickle cell anemia. He was advised to take iron
pills and folic acid, and prescribed tramadol and Lortab for
He was also directed to follow up with Dr. Haynes or Dr.
Eddins.
Plaintiff was treated by Charles Eddins, M.D. (hereinafter
“Dr. Eddins”), at Doctors Clinic of Monroeville from at least
November 27, 1991 to January 22, 2008. (Id. at 228-38). The
record reflects that Dr. Eddins first noted Plaintiff’s sickle
Eddins’
treatment notes dated September 2005, he noted that Plaintiff
was being treated by a sickle cell specialist in Mobile. (Id. at
234-5). During a visit on September 22, 2006, Plaintiff reported
numbness in his left hand lasting at least three weeks and blood
in his stool approximately three weeks earlier.
physical exam was normal, and Dr. Eddins scheduled Plaintiff for
appointment with a gastroneuroligst at USA Medical Center were
A colonoscopy was performed on September 26, 2006. (Id.
231). External hemorrhoids were observed, but no mucosal
abnormalities, polyps, growths, etc. were noted.
Plaintiff was seen by Dr. Eddins on December 7, 2007, for a
ultrasound at the emergency room and that it was normal except
that an heterogeneous spleen was observed. Dr. Eddins encouraged
Plaintiff to follow-up with his sickle cell specialist. (Id. at
On January 22, 2008, Dr. Eddins penned a handwritten note
“[h]as
sickle cell anemia) since birth.” (Id. at 232).
Plaintiff was admitted to Mobile Infirmary from January 19
to January 22, 2008, with complaints of left sided chest pain
which was described as a burning sensation. The treatment notes
reflect that Plaintiff has a history of sickle cell disease and
a history of palpitations, and that upon further evaluation,
Plaintiff’s palpations were premature atrial complexes. On exam,
Plaintiff was alert and oriented times three and in no acute
fluctuation and showed loss of range of motion.
consolidation versus scarring of left lower lobe. Plaintiff was
diagnosed with pneumonia. An echocardiogram was ordered to rule
out septic thrombi and blood cultures were obtained.
was provided Rocephin and Zithromax for pneumonia, morphine for
respectively. An incision on Plaintiff’s fifth metacarpal (pinky
finger) was drained, and the pus tested positive for Staph. Upon
discharge, Plaintiff was in good condition and was given a good
Levaquin twice a day. He was further directed to follow up with
his primary care physician, with Dr. Johnson Haynes, and with an
orthopedic surgeon. (Id. at 239-42).
Plaintiff returned to Mobile Infirmary and reported left sided
251-6). A chest x-ray
compared to a study taken the prior week. The cardiac silhouette
and mediastinal structures were normal in size and shape. New
airspace opacity in the left lung base and a left pleural fluid
correlation was recommended. (Id. at 251). The treatment notes
reflect that during Plaintiff’s previous hospital admission on
January 19, 2008 for lower lobe pneumonia, he was treated with
intravenous antibiotics and upon discharge, he was instructed to
complete a course of antibiotics; however, Plaintiff did not
have the prescription filled and did not complete the course of
antibiotics. Plaintiff was thus treated with IV antibiotics and
was provided morphine for pain and Zofran for nausea. He was
discharged the following day.
The record contains a Physical RFC Assessment which was
completed on January 27, 2007 by Petra Chnapekova-Simmons. (Id.
at 243-50).
While Ms. Chnapekova-Simmons is referenced as a
medical consultant, as best the undersigned can discern, she is
Ms. Chnapekova-Simmons listed Plaintiff’s diagnosis as
sickle cell disease and opined that Plaintiff could lift and/or
carry 20 pounds occasionally and 10 pounds frequently, stand
and/or walk about 6 hours in an 8-hour workday, sit about 6
unlimited amount of time. She further opined that Plaintiff has
communicative limitations. (Id.)
submitted a letter to the Appeals Council dated December 14,
2009. She opined that Plaintiff has been unable to perform any
gainful work for years due to sickle cell disease and other
complaints. She reported that he is unable to follow up with
finances. (Id. at 14).
Ms. Ewing also submitted to the Appeals Council on January
20, 2010, a letter signed by Adrienne Petite, who is referenced
Association of America – Mobile Chapter, Inc. In the letter, Ms.
Petite asserts that Plaintiff is “routinely followed” by Dr.
Johnson Haynes at the Sickle Cell Clinic, and further asserts
that Plaintiff “has been unable to seek or secure employment
recently due to issues associated with his condition.” (Id. at
209-11)8.
Whether the ALJ erred in failing to
fully develop the record and to provide
Plaintiff with a full and fair hearing?
Plaintiff contends that the ALJ erred in failing to fully
develop the record and to provide Plaintiff with a full and fair
Ms. Ewing also submitted to the Appeals Council a letter
dated February 16, 2011, from Dr. Elizabeth Low, of the Brewton
Medical Center. In the letter, Dr. Low states that Plaintiff is
a patient under her care and that he is routinely followed by
Dr. Johnson Haynes of the University of South Alabama
Comprehensive Sickle Cell Clinic. She opined that Plaintiff is
“unable to work due to his medical condition and the
intermittent episodes he experiences. It is my medical opinion,
that this patient is disabled, secondary to his medical
condition.” (Id. at 392).
Plaintiff’s sickle cell specialist. According the Plaintiff, the
treatment for sickle cell disease although the medical records
put the ALJ on notice that Plaintiff was also being treated by a
Commissioner counters that Plaintiff is responsible for proving
that he is disabled and for providing the medical documentation
to support his claim. The Commissioner further contends that
while the ALJ has a duty to develop a full and fair record, the
record in this case was comprehensive and sufficient so that the
ALJ was able to properly decide Plaintiff’s disability status.
As additional support for his contention, the Commissioner notes
that Plaintiff’s non-attorney representative reported that the
It is well established that a hearing before an ALJ in
social security cases is inquisitorial and not adversarial. A
producing evidence in support of his claim while the ALJ has “a
Barnhart, 355 F.3d 1272, 1276 (11th Cir. 2003) (per curiam); see
also Ingram v. Comm. of Soc. Sec. Admin., 496 F.3d 1253, 1269
(11th Cir. 2007). This duty to develop the record exists even
when the claimant is represented by counsel. Brown v. Shalala,
44 F.3d 931, 934 (11th Cir. 1995). Indeed, applicable Social
Security regulations provide that the Commissioner will pay the
Commissioner needs or requests. Hargove v. Astrue, 2012 U.S.
Dist. LEXIS 69821, *31 (N.D. Fla. Mar. 15, 2012). The ALJ’s duty
evidence or when the record is inadequate to allow for proper
evaluation of the evidence. Strawder v. Astrue, 2011 U.S. Dist.
LEXIS 122843, *20 (N.D. Fla. Aug. 8, 2011). However, “[t]here is
no bright line test for determining when the administrative law
judge has ... failed to fully develop the record.” Lashley v.
Sec’y of Health & Human Servs., 708 F.2d 1048, 1052 (6th Cir.
circumstances of a particular case.
Plaintiff claims the ALJ
failed to fully and fairly develop the record because he did not
Haynes’
medical records before the ALJ, and was mentioned by Plaintiff
during the administrative hearing.9 Plaintiff further argues that
because he failed to follow prescribed treatment by not seeking
the care of a sickle cell specialist, but this finding was based
on the ALJ’s mistaken belief that Plaintiff had not been treated
by a sickle cell specialist. The relevant part of the ALJ’s
opinion reads as follows:
damaged by his failure to follow the
direction of his health care providers. The
record shows that one of the claimant’s
treating physicians, Dr. Charles Eddins,
referred him to a sickle cell anemia
specialist in Mobile, Alabama on numerous
evidence on file contains no records from
the sickle cell specialist or any other
evidence that the claimant even attempted to
Eddins....The claimant’s failure to follow
medical advice is not consistent with his
allegations of disabling symptoms.
(Tr. 22).
Based upon the record before the Court, the undersigned
finds that the ALJ failed to properly develop the record. The
medical evidence reflects that on numerous occasions Plaintiff
At the administrative hearing, the ALJ questioned Plaintiff
about who provided his prescription for Lortab tablets, and
Plaintiff responded “Dr. Hines,” which appears to be a reference
to “Dr. Haynes”. (Tr. 73, 78).
devoid of any medical evidence which sheds any light on the
In his decision, the ALJ gave considerable weight to
the opinion of a “[s]tate agency medical consultant who opined
functional capacity to perform the full range of light work.”
However, upon review, it does not appear that the person who
medical professional of any sort.
Social Security Ruling 96-6p provides that findings of fact
made by State agency medical consultants regarding the nature
and severity of an individual’s impairment(s) must be treated as
non-examining
administrative review. SSR 96-6p.
The Ruling also provides that
the medical opinions of such consultants must be considered and
that “[s]tate agency medical and psychological consultants are
highly qualified physicians and psychologists who are experts in
the evaluation of the medical issues in disability claims under
the Act.” 20 C.F.R. § 404.1527(f). A review of the record in
this case does not establish that Ms. Petra Chnapekova-Simmons,
consultant whose opinion qualifies as a medical source opinion.
Chnapekova-Simmons is identified as a “disability specialist.”
(Id. at 177, 195). Traylor v. Astrue, 2010 U.S. Dist. LEXIS
23410 (M.D. Ala. 2010)(“the referenced opinion, however, is not
that of a physician; it is the opinion of the DDS disability
examiner, Karen Wiggins.
Her opinion is not, as the Appeals
expert medical opinion.”)(internal citation omitted.); Foxx v.
Astrue, 2009 U.S. Dist. LEXIS 80307 (S.D. Ala. 2009)(“While the
considered and can be relied upon when they do not conflict with
the opinions of examining sources, there is no evidence before
the Court that Carol M. Davis, S.D.M., the person who completed
the RFC assessment is a medical source whose opinion qualifies
as a medical source.); Casey v. Astrue, 2008 U.S. Dist. LEXIS
47515 (S.D. Ala. June 19, 2008)(an RFC assessment completed by a
disability specialist is entitled to no weight); Hall v. Astrue,
2007 U.S. Dist. LEXIS 95776 (S.D. Ala. Nov. 7, 2007) (holding
determination”).
In this case which involves a claimant with a documented
history of treatment for sickle cell condition, the absence of
medical evidence addressing the functional impairments, if any,
from his condition necessitates reversal.
As noted supra, the
appears to have been authored by a person who lacks medical
credentials. Thus, not only did the record omit
any medical
records from the sickle cell medical specialist who has treated
Plaintiff, but there is no medical evidence regarding functional
limitations, if any, arising from Plaintiff’s condition.
absence of medical evidence of the functional limitations, if
reversed and remanded for further review as to this issue.
Robinson v. Massanari, 176 F. Supp. 2d 1278, 1280 & n.2 (S.D.
Ala. 2001); cf. Pendley v. Heckler, 767 F.2d 1561, 1563 (11th
Cir. 1985) (“Because the ‘misuse of the expert's testimony alone
warrants reversal,’ we do not consider the appellant's other
claims.”).
For the reasons set forth, and upon careful consideration
of the administrative record and memoranda of the parties, it is
hereby ORDERED that the decision of the Commissioner of Social
DONE this 8th day of August, 2012.
/s/ SONJA F. BIVINS____