Aldridge v. Social Security Administration, Commissioner
MEMORANDUM OPINION. Signed by Judge Inge P Johnson on 11/15/12. (ASL)
2012 Nov-15 AM 09:57
U.S. DISTRICT COURT
N.D. OF ALABAMA
IN THE UNITED STATES DISTRICT COURT
FOR THE NORTHERN DISTRICT OF ALABAMA
CASE NO.: CV-11-J-2470-J
MICHAEL J. ASTRUE,
Commissioner of Social Security,
This matter is before the court on the record and the briefs of the parties. This
Court has jurisdiction pursuant to 42 U.S.C. § 405. The plaintiff is seeking reversal
or remand of a final decision of the Commissioner of Social Security.
administrative remedies have been exhausted.
The plaintiff applied for disability insurance benefits due to diabetes, high
blood pressure, insomnia, arthritis in his knees, ankles and back, gastrointestinal
reflux disease, and gout, which together limit his ability to stand, walk, climb and sit
(R. 127). He also suffers from problems with dizziness and concentration (R. 127).
His initial application was denied (R. 101-107) and the plaintiff requested a hearing
in front of an administrative law judge (ALJ),which was subsequently held on
October 21, 2009 (R. 49). The ALJ thereafter found that the plaintiff was not under
a disability at any time through the date of the decision (R. 10-30). The plaintiff’s
request for administrative review of the ALJ’s decision by the Appeals Council was
denied on May 16, 2011 (R.1-3). The ALJ’s decision thus became the final order of
the Commissioner of Social Security. See 42 U.S.C.§ 405(g). This action for judicial
review of the agency action followed (doc. 1). The plaintiff argues that the ALJ’s
determinations are not based on substantial evidence (doc. 16).
The court has considered the record and the briefs of the parties. For the
reasons set forth herein, the decision of the Commissioner is REVERSED and this
case is REMANDED to the Commissioner for calculation of the plaintiff’s benefits.
The plaintiff was born on November 21, 1959, making him 49 at the time of
his hearing (R. 53). He completed high school but received no additional training (R
54), and has worked for the last 28 years as a plant control operator for the power
company (R. 55). The plaintiff had issues with alcohol, but quit drinking in 2007 and
believes his physical health has improved some since then (R. 60-61). However, he
feels as though his mental health has gotten worse, and needs assistance with his
finances and day to day “keeping up” (R. 61). He is forgetful, gets confused easily
and cannot complete simple tasks (R. 62). He takes medication for anxiety and
depression, but does not think it helps (R. 75). He has trouble walking and issues
with gout flare ups in his left knee and ankle (R. 66). When his gout flares up, about
four times a year, he stays off his feet for a week to ten days at a time (R. 67). He also
has trouble maintaining his balance and has fallen (R. 69-70).
The plaintiff testified he could walk one city block, after which he would be
weak and tired (R. 77-78).
He believed he could stand 3-4 minutes because of
dizziness and lack of balance (R. 79-80). He did not have any idea how long he could
sit and did not think he could lift ten pounds (R. 80-81).
According to the Vocational Expert (VE), the plaintiff’s past work was light
and semi-skilled, but had components which were heavy and skilled as well (R. 90).
When asked to assume an individual with a high school education who could perform
medium work, with limitations of no driving, no unrestricted heights, no pushing or
pulling with his lower extremities, with only repetitive, non-complex tasks, the VE
stated numerous jobs would exist which accommodated such limitations (R. 90-91).
Jobs would also exist at the light and sedentary levels (R. 91-92). None of the
plaintiff’s past relevant work would meet the above limitations, however (R. 92). If
a sit/stand option was added to the above limitations, it would rule out all the jobs
identified by the VE (R. 93-94).
The plaintiff’s medical records reflect a history of gout as least since 1993 (R.
189). Similarly, the plaintiff’s history of dizziness is first noted in medical records
from 1992 (R. 209-210). A record from 1998 reflects that the plaintiff has a history
of essential hypertension, diabetes and gout (R. 220). GERD was added to the
plaintiff’s list that year as well (R. 227).
In February 2007, Dr. Bill Yates, one of plaintiff’s treating physicians, opined
that the plaintiff should be placed on disability (R. 274). He noted that as the
plaintiff’s blood sugar goes up and down combined with his problems with dizziness,
the plaintiff is unable to think clearly, causing him to make mistakes at work (R. 274,
342). Additionally, the plaintiff could pass out if his blood sugar drops too much (R.
A consultative evaluation in May 2007 found the plaintiff to suffer from a
hypertension, gout, degenerative joint disease in his knees and ankles, non-insulin
dependent diabetes, GERD, and peripheral neuropathy (R. 282). The examiner noted
strength of 4/5 in plaintiff’s extremities, and decreased sensation in plaintiff’s feet (R.
280). He also noted that the plaintiff’s gait was slow, he was unable to stoop, kneel
or crouch due to poor balance (R. 281). The plaintiff was also unable to heel toe walk
or stand with his eyes closed (R. 281). He was also unable to flex his lower spine due
to poor balance and pain (R. 283). The examiner opined that the plaintiff could do
minimal standing, was unable to walk without a walker, could do no lifting over 15
pounds, no carrying over 10 pounds, and could perform minimal handling of objects,
In May 2007 the plaintiff was hospitalized for worsening dizziness, and
diagnosed with anemia secondary to chronic renal disease, end-stage renal disease,
gout, psoriasis, osteoarthritis, hypertension and diabetes (R. 292-293). The plaintiff
was again hospitalized that month due to hepatic failure secondary to alcohol abuse
(R. 307-331, 336).
A physical residual functional capacities assessment completed by a nonmedical examiner in July 2007 found that the plaintiff was unable to work at the
present time, but thought he would be able to return to work in less than twelve
months (R. 367). Dr. Jack Mauldin, another of plaintiff’s treating physicians, wrote
a letter in August 2007 stating that he followed the plaintiff for chronic liver disease
(R. 372). Dr. Mauldin stated that a component of that disease was chronic hepatic
encephalopathy, which causes mental confusion, slowness of activity, difficulty with
mental requirements and sometimes bizarre activity (R. 372). Dr. Mauldin noted this
was a chronic process and that disability was in order (R. 372).
In April 2008 the plaintiff was referred by his attorney to John R. Goff, Ph.D.,
for a psychological consultation (R. 373-378). Dr. Goff noted the plaintiff admitted
to depression and fell in the borderline range of intelligence (R. 375). Dr. Goff,
through testing, found that the plaintiff exhibited organic brain dysfunction, deficits
in manual dexterity, deficits in memory function, and a suggestion of the onset of
dementia (R. 376-377). He opined that the prognosis for recovery of these deficits
was “nearly nonexistent,” and that the plaintiff suffered from a dementia which
“easily represents a severe impairment.” (R. 377-378). In completing a Mental
Source Opinion Form (Mental), Dr. Goff noted that the plaintiff had marked or
extreme limitations in all areas of functioning, except for maintaining activities of
daily living, in which the plaintiff had moderate limitations (R. 379-380).
Medical records from Dr. David Tharpe in April 2008 noted that physically,
the plaintiff was improving (R. 381-382), although in 2008 Dr. Alderson recorded
ongoing depression1 (R. 435, 441, 461). In February 2008 Dr. Mauldin noted that the
plaintiff had made a “remarkable recovery” from hepatic failure and anemia, and in
August 2008 found that the plaintiff was making “exquisite progress” (R. 400-401).
However, he continued to have problems with dizziness (R. 415, 422, 492). A record
in May 2008 reflects that the plaintiff has an endovascular repair of an abdominal
aortic aneurysm (R. 512).
Dr. Alderson first noted depression in August 2007. He stated he did not add
antidepressants to plaintiff’s medical regime because he wanted to allow more time for plaintiff’s
kidneys and liver to recover (R. 461).
In March 2009 the plaintiff was sent to David Gordon, M.D., for a physical
consultative evaluation, Dr. Gordon found the plaintiff to have full muscle strength
and full sensation in all extremities (R. 469). He found the plaintiff to have no
problems sitting, standing, squatting, walking, and toe and heel walking (R. 469). He
diagnosed the plaintiff with gouty arthritis in both knees, kidney stones, gallstones,
hepatic cirrhosis, diabetes, and hypertension (R. 470). In a Medical Source Statement
(Physical), Dr. Gordon found the plaintiff able to lift and carry up to 10 pounds
continuously and up to 20 pounds frequently, able to sit four 4 hours at a time and 8
hours with breaks, able to stand and walk for 1 hour each at a time and 4 hours a day
with breaks, could perform reaching and handling activities with both hands on a
frequent to continuous basis, and could use his feet to operate foot controls on a
frequent basis (R. 471-473). He did note the plaintiff could not climb ladders, but
found the plaintiff could climb stairs, stoop, kneel and crouch on an occasional basis
(R. 474). He also assigned some environmental limitations to the plaintiff (R. 475).
A February 2009 follow up visit with Dr. Alderson found the plaintiff to be
doing fairly well and noted his depression and anxiety were improving, his anemia,
reflux and diabetes were stable, and his hepatorenal failure was resolved (R. 487488). In March 2009 Dr. Mauldin noted problems of cirrhosis, gallstones, and skin
lesions, which he believed to be psoriasis (R. 524). In a May 2009 follow-up visit
with Dr. Yates, the plaintiff was found to have made “remarkable” progress (R. 484).
Full return of renal function was noted (R. 485).
In sworn testimony taken from Dr. Alderson in March 2009, Dr. Alderson
stated his diagnoses of plaintiff included a previous history of alcoholism, anemia,
anxiety with depression, arthritis, compulsive personality disorder, Type II diabetes,
hyperlipidemia, and hepatorenal failure, since resolved (R. 556-557). Dr. Alderson
believed that ongoing issues with anxiety and depression were the plaintiff’s most
debilitating ailments, but also noted arthritis would be too (R. 557). He was doubtful
the plaintiff could return to full time work and noted his ailments would require
excessive work absences (R. 561-563).
The ALJ concluded that plaintiff suffered from the severe impairments of gout,
depression, and anxiety (R. 21). No mention is made of arthritis, or chronic hepatic
encephalopathy, and diabetes, hypertension, GERD and kidney disease were all found
by the ALJ to be “non-severe” (R. 21). The ALJ discounted the plaintiff’s testimony
and medical records concerning dizziness, because one-time examiner Dr. Gordon did
not observe balance problems (R. 22). The ALJ stated that “[n]o treating, examining,
or reviewing physician has suggested the existence of any impairment or combination
of impairments that would meet or equal the criteria of any listed impairment” (R.
In order to reach such a conclusion, the ALJ implicitly ignored the findings of
Dr. Goff, who believed the plaintiff suffers from marked to extreme mental
Indeed, the ALJ substituted his judgment in assessing such
impairments, finding the plaintiff had no more than mild to moderate difficulties (R.
The ALJ concluded that the plaintiff could perform a limited range of light
work (R. 27). On that basis, the ALJ ruled that the plaintiff was not under a disability
at any time through the date of the decision (R. 30).
Standard of Review
In a Social Security case, the initial burden of establishing disability is on the
claimant, who must prove that due to a mental or physical impairment he is unable
to perform his previous work. Walker v. Bowen, 826 F.2d 996, 999 (11th Cir.1987).
If the claimant is successful, the burden shifts to the Commissioner to prove that the
claimant can perform some other type of work existing in the national economy. Id.
This court’s review of the factual findings in disability cases is limited to
determining whether the record contains substantial evidence to support the ALJ’s
findings and whether the correct legal standards were applied. 42 U.S.C. § 405(g);
Richardson v. Perales, 402 U.S. 389, 401, 91 S.Ct. 1420 (1971); Wolfe v. Chater, 86
F.3d 1072, 1076 (11th Cir.1996); Martin v. Sullivan, 894 F.2d 1520, 1529 (11th
Cir.1990). “Substantial evidence” is generally defined as “such relevant evidence as
a reasonable mind would accept as adequate to support a conclusion.” Richardson,
402 U.S. at 401 (quoting Consolidated Edison Co. v. NLRB, 305 U.S. 197, 229, 59
S.Ct. 206 (1938)); Miles v. Chater, 84 F.3d 1397, 1400 (11th Cir.1996); Bloodsworth
v. Heckler, 703 F.2d 1233, 1239 (11th Cir.1983). This court must be satisfied that the
decision of the Commissioner is grounded in the proper application of the appropriate
legal standards. McRoberts v. Bowen, 841 F.2d 1077, 1080 (11th Cir.1988); Bridges
v. Bowen, 815 F.2d 622, 624 (11th Cir.1987); Davis v. Shalala, 985 F.2d 528 (11th
However, no such presumption of correctness applies to the Commissioner’s
conclusions of law, including the determination of the proper standard to be applied
in reviewing claims. Brown v. Sullivan, 921 F.2d 1233, 1235 (11th Cir.1991);
Cornelius v. Sullivan, 936 F.2d 1143, 1145 (11th Cir.1991). The Commissioner’s
“failure to ... provide the reviewing court with sufficient reasoning for determining
that the proper legal analysis has been conducted mandates reversal.” Cornelius, 936
F.2d at 1145-1146.
It is well established that the ALJ, in making a disability determination, must
consider the combined effects of all impairments. See Wilson v. Barnhart, 284 F.3d
1219, 1224-25 (11th Cir.2002); Jones v. Dept. of Health & Human Servs., 941 F.2d
1529, 1533 (11th Cir.1991). If the claimant alleges multiple impairments, the claimant
may be found disabled even though no single impairment is considered disabling.
Walker v. Bowen, 826 F.2d 996 (11th Cir.1987).
The ALJ determined the plaintiff retained the residual functioning capacity to
perform a limited range of light work. To reach this conclusion, the ALJ disregarded
large portions of medical evidence, misrepresents other records and completely
ignores plaintiff’s treating and consulting medical professional’s opinions. Most
glaringly, the ALJ ignores the testing by Dr. Goff, and the ongoing nature of gout and
As set forth above, Dr. Goff, through testing, found that the plaintiff exhibited
organic brain dysfunction, deficits in manual dexterity, deficits in memory function,
and a suggestion of the onset of dementia (R. 376-377). He opined that the prognosis
for recovery of these deficits was “nearly nonexistent,” and that the plaintiff suffered
from a dementia which “easily represents a severe impairment.” (R. 377-378). In
completing a Mental Source Opinion Form (Mental), Dr. Goff noted that the plaintiff
had marked or extreme limitations in all areas of functioning, except for maintaining
activities of daily living, in which the plaintiff had moderate limitations (R. 379-380).
No other mental health professional has examined the plaintiff, and his treating
physicians have noted that the plaintiff suffers from ongoing depression and anxiety.
The ALJ chose, without any evidentiary support, to simply ignore Dr. Goff’s findings
and the testing underlying them, and substitute his own opinions as to plaintiff’s
mental state. The ALJ further chose to ignore the plaintiff’s unrefuted testimony that
gout flare ups cause him to be bedridden for seven to ten days at a time. The ALJ
finds Dr. Goff’s opinions to be “at odds with and cannot be reconciled with the
overall weight [of the] objective medical records.... particularly those reports from his
treating physicians” (R. 24). The ALJ then finds the treating physicians opinions to
be “at odds with the contemporaneous objective medical records....” (R. 26).
However, the court finds a straight reading of the medical opinions in this record
reveals that the only doctor who believed the plaintiff was employable was the one
time examiner Dr. Gordon.
The ALJ also disbelieves plaintiff’s treating physician’s opinion that the
plaintiff’s arthritis contributes to his inability to work because “the only pain
medication the claimant takes is Ultram” (R. 27). However, the plaintiff is also
prescribed Indocin, which is
used to relieve moderate to severe pain, tenderness, swelling, and
stiffness caused by osteoarthritis (arthritis caused by a breakdown of the
lining of the joints), rheumatoid arthritis (arthritis caused by swelling of
the lining of the joints), and ankylosing spondylitis (arthritis that mainly
affects the spine). Indomethacin is also used to treat pain in the shoulder
caused by bursitis (inflammation of a fluid-filled sac in the shoulder
joint) and tendinitis (inflammation of the tissue that connects muscle to
bone). Indomethacin immediate-release capsules, suspension (liquid)
and suppositories are also used to treat acute gouty arthritis (attacks of
severe joint pain and swelling caused by a build-up of certain substances
in the joints). Indomethacin is in a class of medications called NSAIDs.
It works by stopping the body's production of a substance that causes
pain, fever, and inflammation.
Similarly, Ultram is used to
relieve moderate to moderately severe pain. Tramadol extended-release
tablets are only used by people who are expected to need medication to
relieve pain around-the-clock for a long time. Tramadol is in a class of
medications called opiate agonists. It works by changing the way the
body senses pain.
Thus, the court can find no relevance in the ALJ’s observation that the “only
pain medication the claimant takes is Ultram” (R. 27).
The ALJ concludes that because the plaintiff can bathe himself and make a
sandwich, he has only minimal restrictions in his daily activities (R. 22). The plaintiff
testified he relies on his sister for help with “day to day, routine, everyday business”
(R. 61). He does not go to the store by himself, he gets confused and forgetful, and
has trouble with short term memory (R. 62). This testimony was wholly ignored by
the ALJ, but completely supported by Dr. Goff’s findings.
The fact that the plaintiff can make a sandwich and other minimal daily
activities do not translate into being able to perform work on a full time regular basis.
See Lewis v. Callahan, 125 F.3d 1436, 1441 (11th Cir.1997); Venette v. Apfel, 14
F.Supp.2d 1307, 1314 (S.D.Fla.1998). This is especially true in light of plaintiff’s
testimony that he is forgetful, gets confused and has bouts of dizziness. Of course,
the plaintiff’s testimony concerning his memory deficits is wholly supported by the
findings of Dr. Goff, who confirmed the same through objective testing.
The court further finds the record devoid of substantial evidence to support the
ALJ’s decision with regard to the medical evidence. Although the ALJ uses
subsequent medical records to discount all the treating physicians’ opinions that the
plaintiff is unable to work, no such retraction by the treating physicians appears in the
record. Rather, approximately two years after opining the plaintiff was unable to
work, Dr. Alderson again opined that the plaintiff was unable to work. However, the
ALJ opted to give little weight to Dr. Alderson’s opinions because the month before
he opined that the plaintiff was unable to work, he noted in a medical record that the
plaintiff’s mental state was stable and improving (R. 27).
The court notes
“improving” does not mean “improved.” Likewise, in finding the plaintiff “improved”
the ALJ ignored Dr. Mauldin’s diagnosis of chronic hepatic encephalopathy, which
causes mental confusion, slowness of activity, difficulty with mental requirements
and sometimes bizarre activity, as well as Dr. Mauldin’s statement that it was a
chronic process. (R. 372). Dr. Mauldin’s statement clearly supports a finding that
“improving” does not amount to “capable of gainful employment.”
When evaluating an applicant’s claim for social security disability benefits, the
ALJ must give “substantial weight” to the opinion of the applicant’s treating
physician “unless good cause exists for not heeding the treating physician's
diagnosis.” Edwards v. Sullivan, 937 F.2d 580, 583 (11th Cir.1991). Here, that good
cause is lacking. The Eleventh Circuit has defined “good cause” as: (1) the treating
physician’s opinion was not bolstered by the evidence; (2) the evidence supported a
contrary finding; or (3) the treating physician’s opinion was conclusory or
inconsistent with the doctor's own medical records. Lewis, 125 F.3d at 1440
(quotation marks and citations omitted). If the ALJ disregards or accords less weight
to the opinion of a treating physician, the ALJ must clearly articulate his reasons, and
the failure to do so is reversible error. Id. The court finds none of the indicia of “good
cause” in the facts before this court.
Nothing in the record supports the ALJ’s conclusion that the plaintiff can
perform the range of light work crafted by the ALJ. The court finds that the ALJ
could only reach his conclusions by ignoring or substituting his judgment for the
medical evidence contained in the record, as set forth above.
This court finds that the records of the treating physician offers substantial
support for the plaintiff’s allegations. No medical evidence contradict their opinions
and conclusions, none of those opinions were ever withdrawn, and none of them ever
opined that the plaintiff was malingering. Rather, the improvements in medical
records seem to reflect plaintiff’s recovery from complete renal failure, and not that
he was physically or mentally capable of substantial gainful employment. No medical
evidence in the record refutes the plaintiff’s allegations.
This Court may reverse the decision of the Commissioner and order an award
of disability benefits where the Commissioner has already considered the essential
evidence and it is clear that the cumulative effect of the evidence establishes
disability without any doubt. Davis v. Shalala, 985 F.2d 528, 534 (11th Cir.1993);
accord, Bowen v. Heckler, 748 F.2d 629, 631, 636-37 (11th Cir.1984). A claimant
may be entitled to an immediate award of benefits where the ALJ has erred and the
record lacks substantial evidence supporting the conclusion of no disability. Spencer
v. Heckler, 765 F.2d 1090, 1094 (11th Cir.1985). Because the ALJ’s findings
contradict the medical evidence in the record, this case is due to be reversed.
When evidence has been fully developed and unequivocally points to a specific
finding, the reviewing court may enter the finding that the Commissioner should have
made. Reyes v. Heckler, 601 F.Supp. 34, 37 (S.D.Fla.1984). Thus, this court has the
authority under 42 U.S.C. §405(g) to reverse the Commissioner's decision without
remand, where, as here, the Commissioner determination is in plain disregard of the
overwhelming weight of the evidence. Davis v. Shalala, 985 at 534; Bowen v.
Heckler, 748 F.2d 629 (11th Cir.1984).
Based on the lack of substantial evidence in support of the ALJ's findings and
the ALJ's failure to apply the proper legal standards, it is hereby ORDERED that the
decision of the Commissioner is REVERSED this case is REMANDED to the
Agency to calculate the plaintiff's monetary benefits in accordance with this Opinion.
DONE and ORDERED this the 15th day of November, 2012.
INGE PRYTZ JOHNSON
U.S. DISTRICT JUDGE
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