Court Opinion

ID: 999727
Source: CourtListenerOpinion
Date Created: 2013-07-04 17:29:55.788815+00
Date Added: 2024-06-11T10:38:13.523621
License: Public Domain

UNPUBLISHED

UNITED STATES COURT OF APPEALS

FOR THE FOURTH CIRCUIT

CAROLYN G. GRAY,
Plaintiff-Appellant,

v.
                                                                       No. 98-2576
KENNETH S. APFEL, COMMISSIONER OF
SOCIAL SECURITY,
Defendant-Appellee.

Appeal from the United States District Court
for the Middle District of North Carolina, at Greensboro.
N. Carlton Tilley, Jr., District Judge.
(CA-96-1042-2)

Submitted: May 28, 1999

Decided: September 13, 1999

Before MURNAGHAN, NIEMEYER, and TRAXLER,
Circuit Judges.

_________________________________________________________________

Vacated and remanded by unpublished per curiam opinion.

_________________________________________________________________

COUNSEL

Marilyn L. Allen, Greensboro, North Carolina, for Appellant. Frank
W. Hunger, Assistant Attorney General, Walter C. Holton, Jr., United
States Attorney, Mary Ann Sloan, Chief Counsel, Region IV, Dennis
Williams, Deputy Chief Counsel, Haila Kleinman, Acting Branch
Chief, James M. Flournoy, Assistant Regional Counsel, Office of
General Counsel, SOCIAL SECURITY ADMINISTRATION,
Atlanta, Georgia, for Appellee.
Unpublished opinions are not binding precedent in this circuit. See
Local Rule 36(c).

_________________________________________________________________

OPINION

PER CURIAM:

Carolyn Gray appeals an order of the district court affirming the
denial of her application for social security disability benefits. Gray
challenges the ALJ's refusal to subpoena the office notes of Dr.
Wilkes, her treating physician; the district court's denial of her
motion to remand the case for consideration of Dr. Khan's report; the
ALJ's failure to assess her residual functional capacity between
December 31, 1993, and March 5, 1995; and the denial of benefits
itself. Because we agree with Gray that the ALJ should have subpoe-
naed Dr. Wilkes' notes, and that a remand for reconsideration is
required, we need only address that issue today.

We review an ALJ's refusal to issue a requested subpoena for
abuse of discretion. Taylor v. Weinberger, 528 F.2d 1153, 1156 (4th
Cir. 1975). The limits of that discretion are of course drawn not only
by the particular factual situation, but also by the substantive law gov-
erning disability adjudications.

Unlike their colleagues in other agencies, Social Security ALJ's are
not simply arbiters, but also inquisitors. They have a duty "to inquire
fully into each issue." Marsh v. Harris, 632 F.2d 296, 299 (4th Cir.
1980). Indeed, in its own regulations, the Social Security Administra-
tion promises to assist claimants in developing an adequate medical
record:

           Our responsibility. Before we make a determination that
          you are not disabled, we will develop your complete medi-
          cal history for at least the 12 months preceding the month
          in which you file your application unless there is a reason
          to believe that development of an earlier period is necessary
          or unless you say that your disability began less than 12
          months before you filed your application. We will make

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          every reasonable effort to help you get medical reports from
          your own medical sources when you give us permission to
          request the reports.

20 C.F.R. § 404.1512(d) (1998).* Because Gray filed her claim in
June 1994, her "complete medical history" would extend back to at
least June 1993. Dr. Wilkes' office notes surely are a part of that his-
tory; more importantly, their absence creates a large temporal gap in
the record at precisely the most critical period.

In his letter declining to issue the subpoena, the ALJ emphasized
that Dr. Wilkes likely lacked the expertise to diagnose and assess the
severity of Gray's impairments. This emphasis was misplaced. The
existence of Gray's cardiomyopathy and chronic obstructive pulmo-
nary disease is established; Dr. Wilkes' notes are not needed in that
respect. The issue of importance is the date of onset of disability, and
her notes may be very pertinent to that issue. We will briefly explain
why.

It is easy to assign a date of onset to disability caused by a congeni-
tal defect or traumatic injury, but chronic, progressive diseases
require a great deal more inquiry. Whether Dr. Wilkes' records show
the diagnosis of any heart or respiratory condition before Decem-
ber 31, 1993, they very likely contain contemporaneous descriptions
of Gray's symptoms and complaints (or the lack thereof). These con-
temporaneous descriptions are precisely the sort of evidence ALJ's
are commanded to call upon when a date of onset in the past must be
inferred. Social Security Ruling (SSR) 83-20 describes how this infer-
ence should be drawn (in relevant part, emphasis added):

           With slowly progressive impairments, it is sometimes
          impossible to obtain medical evidence establishing the pre-
          cise date an impairment became disabling. Determining the
_________________________________________________________________
*This regulation does not in and of itself bind the ALJ to issue a sub-
poena. "Every reasonable effort" is defined as a request for information
and a follow-up ten to twenty days afterward if the information has not
been received. 20 C.F.R. § 404.1512(d)(1). Nevertheless, the regulation
expresses the general duty of inquiry and policy of assisting claimants
that we applied to subpoena denials in Marsh.

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          proper onset date is particularly difficult, when, for exam-
          ple, the alleged onset and the date last worked are far in the
          past and adequate medical records are not available. In such
          cases, it will be necessary to infer the onset date from the
          medical and other evidence that describe the history and
          symptomatology of the disease process.

          . . .

           In some cases, it may be possible, based on the medical
          evidence to reasonably infer that the onset of a disabling
          impairment(s) occurred some time prior to the date of the
          first recorded medical examination, e.g., the date the claim-
          ant stopped working. How long the disease may be deter-
          mined to have existed at a disabling level of severity
          depends on an informed judgment of the facts in the particu-
          lar case. This judgment, however, must have a legitimate
          medical basis. At the hearing, the administrative law judge
          (ALJ) should call on the services of a medical advisor when
          onset must be inferred. If there is information in the file
          indicating that additional medical evidence concerning
          onset is available, such evidence should be secured before
          inferences are made.

This passage reveals several flaws in the ALJ's decision. First, the
ALJ failed to even infer an onset date for Gray's disability, choosing
instead the "first recorded medical examination"--the March 6, 1995,
pulmonary function test--that authoritatively proved it. He failed to
consult the medical advisor, Dr. Collman, to support any inference.
See Bailey v. Chater 68 F.3d 75, 80 (4th Cir. 1995) (medical advisor
must be consulted "in all but the most plain cases"). But more funda-
mentally, he erred by failing to "secure[ ]" Dr. Wilkes' office notes,
which could very well have provided, through documentation of
Gray's symptoms, a "legitimate medical basis" for an inference.

We thus conclude that the ALJ abused his discretion in refusing to
subpoena Dr. Wilkes' office records concerning her treatment of Car-
olyn Gray, and the appropriate remedy is a remand to the agency for
issuance of such a subpoena.

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For this reason, the judgment of the district court is vacated, and
the case is remanded with instructions to remand the claim to the
Social Security Administration for reconsideration in light of this
opinion. We dispense with oral argument because the facts and legal
contentions are adequately presented in the materials before the court
and argument would not aid the decisional process.

VACATED AND REMANDED

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