Opinion ID: 2974635
Heading Depth: 3
Heading Rank: 1

Heading: Living Miner’s Benefits Claim

Text: Mrs. Clonch argues that ALJ Kane improperly rejected the medical opinions of Dr. Baker and Dr. Holly. Clonch contends that ALJ Kane substituted his own opinion of objective medical 4 evidence for that of Mr. Clonch’s examining physicians. Thus, Clonch asserts that ALJ Kane’s finding that the physician’s reports do not establish the existence of total disability is not supported by substantial evidence. Coal workers’ pneumoconiosis (black lung disease) is an illness which causes severe and chronic respiratory impairment in many coal miners. Congress provided benefits to victims of the disease with the enactment of the Federal Coal Mine Health and Safety Act of 1969, 30 U.S.C. § 901. Implementing regulations for the statute are provided in 20 C.F.R. § 718.1 et seq. Under the regulations, a claimant is entitled to benefits if he can show that (1) he has pneumoconiosis, (2) his pneumoconiosis arose out of his coal mining employment, and (3) that he is totally disabled as a result. 20 C.F.R. §§ 718.202, 718.203, 718.204; see also Adams v. Director, OWCP, 886 F.2d 818, 820 (6th Cir. 1989). The claimant bears the burden of proving each of these elements by a preponderance of the evidence, except where he is aided by a presumption. Adams, 886 F.2d at 820. In reviewing Clonch’s case, ALJ Kane found that Clonch had established the existence of pneumoconiosis and that his condition arose out of his coal mining employment. Clonch v. S. Ohio Coal Co., Decision and Order Den. Benefits at 4 (Dec. 22, 2003) [hereinafter Kane Order Denying Benefits]. Therefore, ALJ Kane concluded, the only issue in the case was whether Clonch was “totally disabled.” A claimant is totally disabled “when pneumoconiosis prevents him or her from engaging in gainful employment requiring the skills and abilities comparable to those of any employment in a mine or mines in which he previously engaged with some regularity and over a substantial period of time.” 30 U.S.C. § 902(f)(1)(A)(2000). A claimant may demonstrate total disability 5 through any one of four methods: (1) a qualifying1 pulmonary function test; (2) a qualifying arterial blood-gas test; (3) a diagnosis of cor pulmonale with right-sided congestive heart failure; or (4) the opinion of a qualified physician. 20 C.F.R. § 718.204(b)(2). The fourth method – through physician opinion – is described in the regulation as follows: Where total disability cannot be shown under [the other three methods through qualifying medical tests], total disability may nevertheless be found if a physician exercising reasoned medical judgment, based on medically acceptable clinical and laboratory diagnostic techniques, concludes that a miner’s respiratory or pulmonary condition prevents or prevented the miner from [performing his or her usual coal mine work and engaging in gainful employment with some regularity over a substantial period of time]. 20 C.F.R. § 718.204(b)(2)(iv). In his request for modification, Mr. Clonch sought to establish that he was totally disabled through the medical opinions of Glen Baker, M.D. and Robert M. Holly, M.D. In opposition, Southern Ohio Coal submitted the consultative report of Eric R. Pacht, M.D., who found that Clonch was not totally disabled. ALJ Kane ultimately discredited the opinions of all three doctors. ALJ Kane rejected the medical opinion of Dr. Pacht as equivocal and based upon inadequate data. As to Dr. Baker’s findings, ALJ Kane stated, Glen Baker, M.D., a B-reader and Board-certified Pulmonologist, examined the Miner on December 13, 2000 at which time he reviewed the Miner’s symptoms and his occupational (thirty-two years in the coal mines, last worked in 1989), medical (difficulty breathing, attacks of wheezing, dyspnea, orthopnea, chest pain, paroxysmal nocturnal dyspnea) and performed a physical 1 Medical tests are considered “qualifying” when certain procedures enumerated in the regulations are followed and when the results are within the guidelines set forth in 20 C.F.R. § 718, Appendix B. 6 examination (coarse wheezing), pulmonary function study (moderate restrictive defect), arterial blood gas study (mild resting arterial hypoxemia), and interpreted an x-ray (coal worker’s pneumoconiosis, 1/0). Dr. Baker diagnosed: (1) coal workers’ pneumoconiosis, category 1/0, based on the abnormal chest x-ray and significant duration of exposure to the coal mines; (2) mild resting arterial hypoxemia, based on the arterial blood gas analysis; and (3) moderate restrictive defect, based on the pulmonary function test. In Dr. Baker’s opinion, Mr. Clonch did not retain the respiratory capacity to perform coal mine or comparable work where his pulmonary function study, FVC/FEV1, was less than 60%. Kane Order Denying Benefits at 5. In spite of Dr. Baker’s expertise as a Board-certified Pulmononologist, ALJ Kane rejected Dr. Baker’s findings as poorly reasoned. ALJ Kane stated, [T]he reasoning of Dr. Baker’s opinion demonstrates several analytical deficiencies. Primarily, the basis for the “moderate severity of impairment” is unsupported by the evidence. The pulmonary function study relied on is non-qualifying and thus, the “moderate impairment” rating is unfounded. Additionally, the arterial blood gas studies suggest only a mild hypoxemia and the chest x-ray showing simple pneumoconiosis (1/0). Neither of which is indicative of a totally disabling impairment. Id. at 8. Finally, ALJ Kane rejected Dr. Holly’s opinion stating: The doctor’s finding of “total disability” appears to rely almost completely on a physical examination with the attendant observations. The only objective data relied on, the chest x-rays, evidenced “mild pneumoconiosis” and pleural thickening. The opinion lacks indications of pulmonary function studies or arterial blood gas test. In addition, the doctor does not differentiate between Mr. Clonch’s significant cardiac ailments from any pulmonary impairments in reaching the total and permanent disability conclusion. Id. at 9. The Court finds ALJ Kane’s rejection of Dr. Holly’s testimony to be well-founded. A 7 claimant must demonstrate a causal connection between the pneumoconiosis and the total disability, and by failing to differentiate between the cardiac and pulmonary ailments, Dr. Holly failed to meet this burden. However, the Court finds ALJ Kane’s rejection of Dr. Baker’s opinion problematic, in light of the governing regulation and the Sixth Circuit’s holding that the Federal Coal Mine Health and Safety Act is remedial in nature and “‘must be liberally construed to include the largest number of miners as benefit recipients.’” Tussy v. Island Creek Coal Co., 982 F.2d 1036, 1042 (6th Cir. 1993) (quoting Southard v. Director, OWCP, 732 F.2d 66, 71 (6th Cir. 1984). The qualified physician opinion provision, 20 CFR § 204(b)(2)(iv), is only applicable where, inter alia, total disability cannot be shown through a qualifying pulmonary function test. Paragraph (b)(2)(iv) allows a physician’s opinion to override the strict numerical criteria set forth in paragraphs (b)(2)(i) - (iii), so long as that opinion is based upon “reasoned medical judgment” which, in turn, is “based on medically acceptable clinical and laboratory diagnostic techniques.” Yet, in reviewing Dr. Baker’s opinion, the ALJ arrived at this conclusion: “The basis for the ‘moderate severity of impairment’ is unsupported by the evidence. The pulmonary function study relied on is non-qualifying and thus, the ‘moderate impairment’ rating is unfounded.” Kane Order Denying Benefits at 8 (emphasis added). The ALJ’s rejection of Dr. Baker’s opinion on grounds that it is based on a non-qualifying pulmonary function study is directly at odds with paragraph (b)(2)(iv)’s terms and its clear purpose, i.e., to provide a more flexible approach than is otherwise allowed under paragraphs (b)(2)(i) - (iii). The ALJ effectively imposed the requirements of paragraph (b)(2)(i) on paragraph (b)(2)(iv), which was intended as a fourth means for establishing total disability, independent of the other three. 8 As the finder-of-fact, it is the role of the ALJ to weigh the evidence and determine whether the opinions of medical experts are well-reasoned. The ALJ may find a physician’s opinion unreasonable, for instance, when the opinion does not indicate what factors were relied on, when it does not discuss the claimant’s physical condition, when the doctor fails to explain the conclusion reached, or where there are inconsistencies in the doctor’s testimony. See Brazzalle v. Director, OWCP, 803 F.2d 934, 936 (8th Cir. 1986); Phillips v. Director, OWCP, 768 F.2d 982, 984 (8th Cir. 1985); Parsons v. Director, OWCP, 6 BLR 1-272, 1-276 (B.R.B.1983); Duke v. Director, OWCP, 6 BLR 1-673 (B.R.B.1983). In addition, if the physician’s testimony is not based on “medically acceptable clinical and laboratory diagnostic techniques,” the ALJ would have valid grounds for rejecting such testimony. 20 C.F.R. § 718.204(b)(2)(iv). However, the ALJ does not have discretion to reject a medical expert’s opinion simply because he disagrees with the physician’s interpretation of the claimant’s medical evidence. Kertesz v. Crescent Hills Coal Co., 788 F.2d 158 (3rd Cir. 1986); Marcum v. Director, OWCP, 11 BLR 1-23 (B.R.B.1987); Hucker v. Consolidation Coal Co., 9 BLR 1-137 (B.R.B.1986); Fuller v. Gibraltar Coal Corp., 6 BLR 1-1291 (B.R.B.1984). While ALJ Kane asserts that his rejection of Dr. Baker’s opinion was based on defective reasoning, or “analytical deficiencies,” the defects noted by ALJ Kane do not fall within any of the accepted bases – improper procedure, documentation, or credentials, etc. – for finding a physician’s opinion unreasonable. His findings as to Dr. Baker’s opinion instead focus on the inadequacy of each of Dr. Baker’s findings standing alone – pulmonary function test, arterial gas study, chest x-ray – to establish total disability. As such, ALJ Kane’s findings are contrary to the regulation governing claims of total disability based upon a physician’s opinion, 20 C.F.R. 9 718.204(b)(2)(iv), and cannot be sustained by this Court. See Cornett v. Benham Coal, Inc., 227 F.3d 569, 577 (6th Cir. 2000) (finding doctor was entitled to base a reasonable opinion on nonqualifying results); Jonida Trucking, Inc. v. Hunt, 124 F.3d 739, 744 (6th Cir. 1997) (“pulmonary tests exhibiting levels of impairment below that required to establish total disability under section 718.240(c)(1) . . . can form a basis, along with other evidence, for a reasoned medical decision establishing total disability under section 718.240(c)(4))”). The Court’s view of the present case and the applicable precedent differs from that of the dissent in a number of respects. First, it is not apparent to the Court that Dr. Baker based his conclusion “solely on the results of non-qualifying pulmonary function tests.” According to the record, Dr. Baker reviewed Mr. Conch’s symptoms and his occupational and medical history. Kane Order Denying Benefits at 5. He performed a physical examination, a pulmonary function study and an arterial blood gas study. Id. He also examined and interpreted an x-ray. Id. He noted that Mr. Conch suffered from difficulty breathing, attacks of wheezing, dyspnea, orthopnea, chest pain, paroxysmal nocturnal dyspnea, coarse wheezing, moderate restrictive defect, mild resting arterial hypoxemia, and coal worker’s pneumoconiosis, 1/0. Id. From these findings, Dr. Baker concluded that “Mr. Clonch did not retain the respiratory capacity to perform coal mine or comparable work where his pulmonary function study, FVC/FEV1, was less than 60%.” Id. In the dissent’s view, this case is distinguishable from Cornett because, inter alia, in Cornett the doctors based their opinions on clinical data regarding the miner’s respiratory condition in addition to a non-qualifying pulmonary function test. Five doctors agreed that the miner suffered from mild to moderate respiratory impairment. Id. Nonetheless, two of the doctors (including Dr. Glen Baker) determined the miner to be totally disabled. Id. Their conclusions 10 were based on x-rays, an examination of the miner, his history in the mines, his history as a smoker, and pulmonary functions studies. Id. A side-by-side comparison of the factors considered by the doctors in Cornett and the present case reveal a remarkable similarity. It may well be that the doctors in Cornett did a better job of explaining their conclusions than did Dr. Baker in his evaluation of Mr. Clonch, but the variety of factors which informed the respective conclusions appears quite comparable. Finally, and perhaps most importantly, the dissent disregards Cornett’s unqualified and unequivocal statement that “[u]nder the regulations, [a doctor is] entitled to base a reasonable opinion on non-qualifying test results, . . . and the ALJ erred by rejecting [the doctor’s] opinion for this reason.” Cornett, 227 F.3d at 577. The ALJ in the present case committed an identical error. To affirm the ALJ’s decision would be to ratify this error in direct contradiction of the principle articulated by this Court in Cornett. Because ALJ Kane erred in the standards by which he evaluated Dr. Baker’s opinion, we hereby REVERSE and REMAND for further consideration of the evidence in accord with this opinion.