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Brinson v. Apfel

June 29, 1999


The opinion of the court was delivered by: Simandle, District Judge



This matter comes before the Court pursuant to section 205(g) of the Social Security Act ("Act"), as amended, 42 U.S.C. § 405(g), to review the final decision of the Commissioner of the Social Security Administration ("Commissioner"), denying plaintiff's claim for Disability Insurance benefits under Title II of the Act and Supplemental Security Income ("SSI") benefits under Title XVI of the Act. The main issues in this case are (1) whether the ALJ committed reversible error in finding plaintiff was alcoholic and that absent this alcoholism plaintiff would be not be disabled; (2) whether the ALJ improperly considered two state Residual Functional Capacity Assessment forms as medical evidence, or alternatively that the ALJ gave excessive weight to these forms; and (3) whether the ALJ failed to comply with Social Security Ruling 96-8p, which requires that a Residual Functional Capacity assessment be the product of a function-by-function analysis of the job-related abilities and restrictions of the claimant. This court finds that the ALJ properly applied the law regarding alcoholism, that the finding of plaintiff's alcoholism is supported by substantial evidence, and that the ALJ properly considered the state assessment forms as medical evidence, but that the ALJ's incomplete articulation of his reasoning and unsatisfactory RFC analysis violate Ruling 96-8p. The ALJ's opinion does not provide an adequate record for us to consider the questions of whether the ALJ excessively relied on the state assessment forms or whether the finding that plaintiff's ailments other than alcoholism do not render him disabled is supported by substantial evidence. This matter is therefore remanded for further consideration consistent with this opinion and Ruling 96-8p.


A. Procedural History

Plaintiff, James T. Brinson, filed an application with the Social Security Administration ("SSA") for disability insurance benefits and SSI on July 17, 1995 for a disability allegedly commencing on January 2, 1991 due to multiple impairments. (R. 71). His application was denied initially and on reconsideration. (70, 75). Defendant determined that, while plaintiff could not return to his past relevant work, his medical condition allowed him to do less demanding work in the national economy. (R. 75-76).

Plaintiff's ensuing request for a hearing before an Administrative Law Judge ("ALJ") was granted. The hearing was held on September 17, 1996 before Administrative Law Judge Joseph M. Davidson. In his decision dated October 2, 1996, the ALJ found: that plaintiff met the insured status requirements of the Act on January 2, 1991, the date the plaintiff stated he became unable to work, and would continue to meet these requirement through December 31, 1995 (R. 19); that plaintiff has not engaged in substantial gainful activity since January 2, 1991 (Id.); that plaintiff suffers from hypertension, a seizure disorder, hearing problems and lower back pain, but that he does not have an impairment or combination of impairments listed in, or equal to, one listed in 20 C.F.R. § 404, Subpart P, Appendix 1, Regulation 4 (Id.); that plaintiff is unable to perform any of his past relevant work (R. 20); that plaintiff has the residual functional capacity ("RFC") to perform the physical exertion and non-exertional requirements of light work (R. 19); that given this RFC and plaintiff's age, education and work experience, table No. 2 of 20 C.F.R. § 404, Subpart P, Appendix 2 would direct a conclusion that plaintiff is not disabled (R. 20); that plaintiff's non-exertional limitations would not significantly reduce his capacity to perform the full range of light work, and therefore, using the table No. 2 as a framework, plaintiff is not disabled (Id.); and that plaintiff would not have been disabled if he stopped consuming alcohol (Id.).

On July 28, 1997, plaintiff timely requested the SSA Appeals Council to review the ALJ decision. The Appeals Council denied this request for review on August 27, 1996. (R. 3). Accordingly, the October 2, 1996 ALJ denial became the final decision of defendant Commissioner of Social Security.

Plaintiff timely filed this action in the United States District Court on April 25, 1997, claiming that the ALJ failed to follow administrative policy in its RFC analysis by giving weight to two state agency RFC forms. Plaintiff further contends that the ALJ erred by not meeting the requirements of Social Security Ruling 96-8p, which requires a function-by-function analysis of the specific abilities and limitations of the plaintiff prior to the selection of the RPC level. Plaintiff also claims that the ALJ performed reversible error in holding that the medical evidence establishes that the plaintiff would not have been disabled if he stopped using alcohol.

B. Personal and Medical History

1. Plaintiff's Testimony

At the September 17, 1996 hearing before the ALJ, plaintiff testified to many things. He has testified that he has decreased his consumption of alcohol from a pint of gin per day to a pint of gin per week, beginning in January 1985. This decrease was apparently motivated by a desire to increase the efficacy of the medicine which he has been taking. (R. 36-38). He testified that he suffers approximately three seizures per year (R. 38); that he no longer drives because his nerves are too bad (R. 39); that he is able to walk up and down the steps of his house, although he sometimes experiences pain in his back and knees while doing so (R. 40); that he can sit for only one hour before his alleged rectal problem becomes painful (R. 43); that he is able to cook for himself, but does not do so often, and does not do any other household chores (R. 45-46); that he does not leave the house often, but that he does visit his mother every couple of weeks, taking the bus to get there (R. 47); that he is able to bathe and dress himself, although he often suffers acute pain while bending over for activities such as tying his shoes (R. 48); that he is able to lift a gallon of milk and a ten pound bag of potatoes (R. 48); that he is able to walk four blocks before he must stop (R. 49); that he is not able to stand for long periods of time (R. 50); that he suffers from arthritis in his right shoulder which bothers him occasionally, and when the arthritis acts up, he would be unable to lift an object such as a pen with his right arm (R. 50); that he can see adequately with prescription glasses (Id.); that he has hearing problems in both ears (R. 51); that he is occasionally short of breath (R. 51); that he can not speak effectively on the telephone (R. 57); that he smokes a pack and a half of cigarettes per day (R. 51-52); that he suffers from anxiety (R. 52); that he has suffered memory loss (Id.); that he frequently experiences headaches (R. 53); that he takes walks for exercise (R. 54); that he takes medication for high blood pressure, arthritis and hives (R. 54); and that he was in an automobile accident in 1969, which rendered him paralyzed for twelve weeks (R. 60).

2. Medical Evidence

The medical evidence before the ALJ was relatively insubstantial. There were only two medical reports given by examining physicians. It also appears that no empirical tests were performed to verify plaintiff's alleged impairments. Plaintiff's treating physician, Dr. Jack Goldstein, filled out a "General Medical Report" at the request of the SSA (R. 122 & 126). The record also contains the September 18, 1995 report of an examining physician, Dr. Rasheed Ahmad (R. 130-140), two completed state agency RFC forms (R. 141-48 & 149-56) and illegible notes from the CamCare Medical Center ("CamCare") (R. 172). A summary of these findings follows.

a. Dr. Goldstein's Reports:

Dr. Goldstein was the plaintiff's treating physician and repeatedly treated plaintiff prior to his filing for benefits. At the SSA's request, Dr. Goldstein submitted a general medical report on July 12, 1995, stating that plaintiff suffers from alcoholism, hypertension and lumbosacral strain. (R. 122). He further stated that plaintiff is totally disabled (R. 123), and should perform neither heavy lifting nor bending over. (R. 125). However, Dr. Goldstein also indicated that plaintiff would be capable of performing part-time work. (R. 125). Further, in his notes following an August 27, 1994 consultation with plaintiff, Dr. Goldstein stated that plaintiff's range of motion was 90% of normal. (R. 128).

b. Dr. Ahmad's Report:

Dr. Ahmad produced a report on September 18, 1995, following an examination of plaintiff. Dr. Ahmad reported that plaintiff stated that he had been employed as a construction laborer and a railroad manufacture laborer for twenty-six years, up until 1991, when an automobile accident rendered him unable to work. (R. 130). Plaintiff told Dr. Ahmad that he has suffered frequent sporadic back pain ever since this accident. (R. 130). Plaintiff also told Dr. Ahmad that his back pain has prevented him from working in his previous relevant work as a laborer.

Dr. Ahmad concluded that plaintiff suffers from a history of seizures, although plaintiff had suffered no seizures in the preceding eight months, even without taking medication (R. 131); that plaintiff suffers hearing difficulties in both ears, but that "communication is easily possible with loud questioning" (R. 133); that plaintiff has suffered from hypertension for twenty-five years and from low backache for three years (R. 132); that plaintiff had not taken any medication in almost a year (Id.); that plaintiff's heart, lungs, liver, spleen and kidneys and bowels are normal (Id.); that plaintiff's blood pressure was markedly elevated at 190/118 (R. 133); that plaintiff told Dr. Ahmad his back aches are intermittently highly painful (R. 131); that the periods of acute back aches may last for days (R. 130); that plaintiff has difficulty performing daily routines, especially those involving bending movements, during periods of acute back aches (Id.); and that plaintiff is able to walk between two and four blocks before he must rest before resuming activities, depending on the acuteness of his backache at that particular time (R. 131). Dr. Ahmad made no mention of plaintiff suffering from any lumbrosacral strain.

c. State Agency RFC Forms:

The record also contains two Residual Functional Capacity Assessment forms which were filled out by non-examining physicians. Both forms were signed and contained an identifying medical consultant's code. The first form was completed by a Dr. H. Simmons on December 3, 1995. Dr. Simmons' form acknowledged plaintiff's hearing troubles and high blood pressure (R. 145-46), but said that the medical records on file with the SSA did not establish any exertional, postural, manipulative or visual limitations (R. 142-44). The second form was completed on December 5, 1995. The physician's signature is illegible, but as noted above, the physician is identified by his medical consultant's code. The form indicates an opinion that plaintiff is able to occasionally lift objects weighing 100 pounds or more, to frequently lift objects of 50 pounds or more, and to either sit or stand for six hours in an eight hour day (R. 150).

d. CamCare Report:

Plaintiff has received medical attention through the CamCare. At the request of plaintiff's attorney, CamCare submitted copies of plaintiff's medical records with them. However, these records were illegible. Both parties agreed to this in the section of the Joint Medical Abstract regarding the CamCare report.


A. "Disability" Defined and Burdens of Proof 1.ñDisability Defined and Burdens of Proof

The Social Security Act defines "disability" for purposes of plaintiff's entitlement to benefits as the inability "to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months." 42 U.S.C. § 1382c(a)(3)(A). Under this definition, a claimant qualifies as disabled "only if his physical or mental impairment or impairments are of such severity that he is not only unable to do his previous work but cannot, considering his age, education, and work experience, engage in any other kind of substantial gainful work which exists in the national economy, regardless of whether such work exists in the immediate area in which he lives, or whether a specific job vacancy exists for him, or whether he would be hired if he applied for work." 42 U.S.C. § 1382c(a)(3)(B).

The Commissioner has promulgated regulations for determining disability applicable to Disability Insurance cases. See 20 C.F.R. §§ 404.1501-404.1599. Under these regulations, substantial gainful activity is defined as "work that - (a) involves doing significant and productive physical or mental duties; and (b) is done (or intended) for pay or profit." 20 C.F.R. § 404.1510. Importantly, this definition presupposes a regular, continuing, and sustained ability to perform such work. Kangas v. Bowen, 823 F.2d 775, 778 (3d Cir. 1987).

The Commissioner has promulgated regulations that determine disability by application of a five-step sequential analysis codified in 20 C.F.R. § 404.1520. The Commissioner evaluates each case according to a five-step process until a finding of "disabled" or "not disabled" is obtained. 20 C.F.R. § 404.1520(a). This five-step process is summarized as follows:

"1. If the claimant currently is engaged in substantial gainful employment, he will be found "not disabled."

"2. If the claimant does not suffer from a "severe impairment," he will be found "not disabled."

"3. If the severe impairment meets or equals a listed impairment in 20 C.F.R. Part 404, Subpart P, Appendix 1 and has lasted or is expected to last for a continuous period of at least ...

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