Opinion
Civ. No. 96-3602 (DRD)
March 16, 1999
Stephen Luminello, Esq., Secaucus, N.J., Attorneys for Plaintiff.
Faith S. Hochberg, Esq., United States Attorney, Peter G. O'Malley, Assistant U.S. Attorney, Newark, N.J., Attorney for Defendant.
OPINION
Plaintiff, Patricia DeSantis, appeals pursuant to 42 U.S.C. § 405 (g) from a final determination of the Commissioner of Social Security ("Commissioner"), denying her application for social security disability insurance benefits under Title II of the Social Security Act ("Act"). Plaintiff moves for a reversal of the dismissal of her claim by the Administrative Law Judge ("ALJ"). For the reasons set forth below, the Commissioner's decision will be reversed.
STATEMENT OF FACTS AND PROCEDURAL HISTORY
The administrative record discloses the following facts. Plaintiff, Patricia DeSantis, was born on August 18, 1947. (Tr. 84) Plaintiff has a ninth grade education. Plaintiff is able to read however, she reverses letters and numbers. (Tr. 86) Plaintiff attended secretarial school, but did not graduate from the program. (Tr. 87) Prior to 1980, Plaintiff was a housewife with no paid employment history. In 1980, Plaintiff began working as a tractor-truck driver. (Id.) Plaintiff's work as a truck driver included driving, and the loading and unloading of goods. As a truck driver, Plaintiff was required to lift and carry packages weighing up to 100 pounds. Plaintiff last worked as a truck driver in 1985. Plaintiff's truck driving work was her only paid employment up to 1985. (Tr. 89-90)
On April 20, 1992, Plaintiff applied for disability insurance benefits under the Act, alleging disability since October 1985 due to back, knee, and hip injuries, and emotional problems. Plaintiff's prior application for disability benefits was denied at the initial level in 1990. Plaintiff did not appeal. (Tr. 144-151, 197-204) Plaintiff's 1992 application for disability benefits, the subject of this action, was initially denied, and denied again on reconsideration. (Tr. 152-187) Plaintiff requested a hearing before an ALJ. (Id.) On May 15, 1995, a hearing was held before the ALJ, Honorable Irving Fliegler. (Tr. 81-143) The ALJ, in his decision of May 26, 1995, held that Plaintiff was not entitled to a period of disability or disability insurance benefits. (Tr. 33-45) The ALJ's decision became the final decision of the Commissioner when the Appeals Council denied Plaintiff's request for review on May 31, 1996. (Tr. 4-32) Plaintiff now seeks review of the ALJ's decision.
At the May 15, 1995 hearing, Plaintiff testified that she had suffered two accidents during February, 1985. Prior to February 1985, Plaintiff enjoyed good health with the exception of Plaintiff's condition of emphysema. (Tr. 90-91) Plaintiff testified that she suffers from congenital bronchial asthma. Also prior to February 1985, Plaintiff had breast and stomach surgery, respectively. (Id.) Plaintiff also testified that prior to 1985, she had experienced difficulties with her back and sciatic nerve. In 1978, Plaintiff had her coccyx removed. (Tr. 91-92)
Plaintiff testified that she injured her head, back, and left leg in her first accident occurring in February, 1985. (Tr. 92) Plaintiff dislocated her kneecap in an injury she suffered to her right leg in her second accident of February, 1985. (Id.) In July 1985, Plaintiff had arthroscopic surgery, and was advised by her physician to refrain from working. (Tr. 92-93) Plaintiff's post-surgery treatment included the application of heat packs and a TNS unit. Plaintiff testified that her knee seemed well following the surgery. Plaintiff further testified that she had suffered another accident in October 1985, in which, she injured her neck, back, and leg. (Tr. 94) Plaintiff also testified that she was unable to stand due to pain in her knee following her October, 1985 accident. Plaintiff had additional surgery performed in December, 1985. Plaintiff was doing well following her December, 1985 surgery, however, at the same time, Plaintiff seemed to be losing her memory. (Tr. 95-96) Plaintiff testified that, following her surgery, she needed to hold onto things while walking due to her knee's tendency to buckle. In addition, she was not able to go out alone because she experienced frequent falls. Since 1986, Plaintiff has been using a wheelchair as prescribed by Dr. Ricciardelli. (Tr. 96-97) Plaintiff does not always use the wheelchair during time spent at home; Plaintiff uses a cane instead. (Tr. 98) Plaintiff has seen Dr. Valdez, a neurologist, and Dr. Jacque, a psychiatrist. Dr. Jacque referred Plaintiff to Julia Baker, a therapist. In 1993, Plaintiff would cry at the sight of a tractor trailer, for which Plaintiff began seeing a psychiatrist. (Tr. 99-101) Plaintiff also testified that prior to Plaintiff's visits with the psychiatrist, Plaintiff experienced feelings of anger, and resentment toward her activities as a homemaker. (Tr. 100-101)
Plaintiff testified that she had surgery performed on her displaced right hip four years after her knee surgery. Dr. Ricciardelli performed Plaintiff's hip surgery in either 1988 or 1989. Plaintiff testified that her hip surgery corrected her hip displacement problem, and that she was then able to walk in a straight manner, although a measure of pain still remained. (Tr. 101-103) Plaintiff also received 10 days of therapy, and no further treatment thereafter.(Tr. 103) Plaintiff testified that she had maintained an approximate weight of 70 to 80 pounds from 1989 to 1991 due to a metabolic problem, and that this problem was corrected by Dr. Valdez. (Tr. 102) Plaintiff currently weighs 135 pounds. (Tr. 120)
Plaintiff further testified that Dr. Ricciardelli administered hot pack treatment to Plaintiff for her back injury. Plaintiff still experiences pain from her lower back, some of which, is relieved with Plaintiff's use of Tylenol 3 with codeine.(Tr. 104-107) Plaintiff testified that her back pain extends down into her legs with worse effect in the right leg. Plaintiff's condition has not improved in the past five years. (Tr. 105-107)
Plaintiff testified that her head suffered impact in the 1985 accident. An MRI and EEG were performed on the Plaintiff, the results of which were reportedly inconclusive. (Tr. 106-107) At present, Plaintiff experiences head pain during the day; the same head pain causes Plaintiff to wake from sleep. (Tr. 107)
Plaintiff further testified that she has had a problem with falling since 1985; she falls on an average of two or three times a week. (Tr. 108-109) Plaintiff has also experienced headaches and forgetfulness since her head suffered an impact in the truck.(Tr. 110) Plaintiff testified that she requires assistance with getting dressed and personal grooming. Plaintiff has not performed any housework since 1986. (Tr. 110-112) Plaintiff spends the majority of her time lying or sitting on a bed. (Tr. 114-115)
DETERMINATION OF DISABILITY AND BURDENS OF PROOF
Under Social Security guidelines, disability is defined 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. § 423(d)(2)(A).
The Secretary of Health and Human Services ("Secretary") has promulgated a five-step analysis for evaluating a claimant's disability.See C.F.R. § 404. The Secretary first considers whether the claimant is currently engaged in "substantial gainful activity." 20 C.F.R. § 404.1520(a). If the claimant is working and the work is substantially gainful activity, his application for disability benefits is automatically denied. See 20 C.F.R. § 404.1520(b). If the claimant is not employed, the ALJ then proceeds to step two and determines whether the claimant has a "severe impairment" or "combination of impairments." 20 C.F.R. § 404.1520(c). A claimant who does not have a "severe impairment" is not disabled. Id.
Third, if the impairment is found to be severe, the ALJ determines whether the impairment is listed in 20 C.F.R. Part 404, Subpart P, Appendix 1. If so, the claimant is conclusively presumed to be disabled, and the evaluation ends there. See 20 C.F.R. § 404.1520(d). If the impairment is not a listed impairment or its equivalent, the ALJ proceeds to step four.
At the fourth step, the ALJ determines whether the claimant can return to his previous type of employment. See 20 C.F.R. § 404.1520(e). If the claimant can perform his previous work, the claimant is not disabled. Id. The Plaintiff has the burden of proving that he is unable to return to his former occupation. Rossi v. Califano, 602 F.2d 55, 57 (3d Cir. 1979). The Rossi court noted that a "plaintiff satisfies her initial burden of showing that she is unable to return to her previous employment when her doctor substantiates her subjective claims." Id. If the claimant has satisfied his initial burden that he is no longer able to perform his previous type of employment, the evaluation must continue to the fifth and final step.
For the fifth step "the burden of proof shifts to the Secretary to show that the claimant, given [his] age, education and work experience, has the capacity to perform specific jobs that exist in the national economy." Id. at 55, 57. Entitlement to benefits is dependent on a finding that the claimant is incapable of performing some other type of work in the national economy. See 20 C.F.R. § 404.1520(f) (1995).
ADMINISTRATIVE FINDINGS
On May 26, 1995, ALJ Irving Fliegler determined the following:
1) The claimant met the disability insured status requirements of the Act of October 29, 1985, the date the claimant stated she became unable to work, and continued to meet them through December 31, 1990, but not thereafter.
2) The claimant has not engaged in substantial gainful activity since October 29, 1985.
3) The medical evidence establishes that the claimant was status post right knee arthrotomy and status post surgery for snapping hip syndrome on the right side prior to December 31, 1990, but that she did not have an impairment or combination of impairments listed in, or medically equal to one listed in Appendix 1, Subpart P Regulations No. 4 prior to December 31, 1990.
4) The claimant's complaints of severe, intractable pain instability of the right knee, as well as her complaints of chronic, severe low back and hip pain which rendered her disabled prior to December 31, 1990 are not credible.
5) Through December 31, 1990, the claimant had the residual functional capacity to perform the physical exertion requirements of work except for prolonged standing or walking for lifting or carrying more than 10 pounds. There are no significant nonexertional limitations ( 20 C.F.R. § 404.1545).
6) The claimant is unable to perform her past relevant work as a truck driver.
7) The claimant had the residual functional capacity to perform the full range of sedentary work at least through December 31, 1990 ( 20 C.F.R. § 404.1567).
8) The claimant was 43 years old as of December 31, 1990, which is defined as a younger individual ( 20 C.F.R. § 404.1563).
9) The claimant has a limited education (20 C.F.R. § 404. 1564).
10) In view of the claimant's age and residual functional capacity, the issue of transferability of work skills is not material.
11) Section 404.1569 of Regulations No. 4 and Rule 201.24, Table No. 1 of Appendix 2, Subpart P, Regulations No. 4, direct a conclusion that, considering the claimant's residual functional capacity, age, education, and work experience, she is not disabled.
12) The claimant was not under a "disability" as defined in the Social Security Act, at any time through the date her insured status expired on December 31, 1990 ( 20 C.F.R. § 404.1520(f)).
(Tr. 43-44)
STANDARD OF REVIEW
A court must accept the findings of fact by the Commissioner if those findings are supported by "substantial evidence." 42 U.S.C. § 495(g). The Supreme Court has defined substantial evidence as "such relevant evidence as a reasonable mind might accept as adequate to support a conclusion," which is "more than a mere scintilla." Richardson v. Perales, 402 U.S. 389, 401 (1971) (quoting Consolidated Edison Co. v. NLRB, 305 U.S. 197, 229 (1938)); Morales on behalf of Morales v. Bowen, 833 F.2d 481, 488 (3d Cir. 1987). The Court of Appeals for the Third Circuit has developed certain rules to scrutinize the evidentiary basis for administrative findings:
This oft-cited language [describing the standard of substantial evidence] is not, however, a talismanic or self-executing formula for adjudication; rather, our decisions make clear that determination of the existence vel non of substantial evidence is not merely a quantitative exercise. A single piece of evidence will not satisfy the substantiality test if the Secretary ignores, or fails to resolve, a conflict created by countervailing evidence. Nor is evidence substantial if it is overwhelmed by other evidence — particularly certain types of evidence (e.g., that offered by treating physicians) — or if it really constitutes not evidence, but mere conclusion. . . . The search for substantial evidence is thus a qualitative exercise without which our review of social security disability cases ceases to be merely deferential and becomes instead a sham.Kent v. Schweiker, 710 F.2d 110, 114 (3d Cir. 1983) (citations omitted). "However, `even if the Secretary's factual findings are supported by substantial evidence, a court may review whether the administrative determination was made upon correct legal standards.'" Friedberg v. Schweiker, 721 F.2d 445, 447 (3d Cir. 1983) (quoting Curtain v. Harris, 508 F. Supp. 791, 793 (D.N.J. 1981)).
To enable a court to properly perform its function of review, an administrative decision "should be accompanied by a clear and satisfactory explanation of the basis on which it rests." Cotter v. Harris, 642 F.2d 700, 704 (3d Cir.), reh'g denied, 650 F.2d 481 (1981). The ALJ should indicate not only the evidence which supports his or her conclusion, but also indicate "significant probative evidence" that was rejected in order for the reviewing court to determine whether such evidence was not credited or simply ignored. Id. at 705. Additionally, when faced with conflicting evidence, an administrative decision must adequately explain in the record its reasons for rejecting or discrediting competent evidence. Ogden v. Bowen, 677 F. Supp. 273, 278 (M.D.Pa. 1987).
DISCUSSION
The duty of a district court is not to review the case de novo, but instead to discern whether substantial evidence exists in the record to support the findings and determinations of the ALJ. See Bradley v. Bowen, 667 F. Supp. 161 (D.N.J. 1987).
Plaintiff asserts that the ALJ's decision, that Plaintiff was not entitled to disability insurance and benefits, was not supported by substantial evidence. Specifically, Plaintiff contends the following: 1) the Commissioner improperly rejected and discredited the examining and treating physicians' findings in favor of a non-examining medical advisor's opinions; 2) the Commissioner failed to consider evidence of a significant psychiatric disability; and 3) the Secretary improperly applied the "grids" (medical-vocational guidelines) to instances wherein Plaintiff suffered significant non-exertional impairments. 20 C.F.R. CH. III, Subpart P, Appendix. 2.
Plaintiff argues that the ALJ discredited the opinions of both treating physicians and Dr. Siegel in favor of Dr. Albert Mylod, a non-examining medical advisor. Plaintiff alleges that the ALJ adopted Dr. Mylod's opinion and gave inadequate weight to the opinions of the treating and examining physicians.
Generally, when the ALJ considers a claim for disability benefits, the ALJ gives greater weight to the opinions of physicians who have examined the claimant than to the opinion of physicians who have not examined the claimant. 20 C.F.R. § 404.1527(d)(1). In addition, the ALJ must give greater weight to the findings of treating physicians than to the findings of physicians who have examined the claimant as a consultant. 20 C.F.R. § 404.1527(d)(2); Adorno v. Shalala, 40 F.3d 43, 47 (3d Cir. 1994). Further, if the treating physicians have concluded that a claimant is "disabled," the ALJ must review medical findings and other evidence presented in support of the treating physicians' opinion of total disability. Wright v. Sullivan, 900 F.2d 675, 683 (3d Cir. 1990).
Moreover, in order for a claimant to be eligible for disability benefits, a claimant must be insured for disability. 20 C.F.R. § 404.315(a)(1). In addition, a claimant's condition must reach disabling severity prior to the expiration of the claimant's insured status. Matullo v. Bowen, 926 F.2d 240, 244-245 (3rd. Cir. 1990).
In cases where only exertional impairment exists, the Secretary may use the grids in order to determine whether there exist, in the national economy, jobs which a person with the claimant's qualifications and limitations could perform. In determining that the claimant is able to engage in gainful employment, the Secretary must show that the claimant's vocational profile is contained within the grid guidelines. See Santise v. Schweiker, 676 F.2d 925, at 934 (3rd Cir, 1982), cert. denied, 461 U.S. 911 (1983); 20 C.F.R. Part 404, Appendix 2,§ 200.00(d) The Secretary must consider four factors — physical ability, age, education, and work experience — to set forth rules that identify whether employment opportunities requiring specific combinations of these factors exist in significant numbers in the national economy. If such employment opportunity exists, the claimant is not considered disabled.Heckler v. Campbell, 461 U.S. 458 (1983); 20 C.F.R. § 404. 1529.
Use of the grids, however, may not be fully applicable where a "claimant suffers from non-exertional impairments, instead of, or in addition to, exertional impairments." 20 C.F.R. Part 405, Appendix 2, § 200.00(e); see 676 F.2d at 934-935. When both exertional and non-exertional impairments exist, the Secretary must rely on additional supporting evidence to demonstrate whether the claimant has the ability to perform the functions of employment available in the national economy. Washington v. Hackler, 756 F.2d 959, at 967 (3d Cir. 1985).
The ALJ found that plaintiff was not under a disability as defined in the Social Security Act at any time through the date her insured status expired on December 31, 1990. This ultimate finding was based upon the determination that the objective medical evidence did not support plaintiff's claims of severe physical impairment and that during the period prior to December 31, 1990 her psychological impairments were not of a sufficient intensity to interfere with her ability to meet the basic mental demands of work or limit her activities of daily living.
With respect to plaintiff's medical condition the ALJ wrote: ". . . the record contains little in the way of objective medical signs or laboratory findings to document the existence of musculoskeletal or neurologic pathology which could reasonably be expected to produce the persistent, debilitating symptoms she has alleged since [October 1985]." He noted the findings of virtually all, if not all, of the doctors as to the range of motion and stability of plaintiff's right knee, which should not under ordinary circumstances have produced the severe disablement of which plaintiff complained. He noted that Dr. Mylod, who testified at the hearing, stated that there was "no medical basis for her continued complaints of right knee pain and instability subsequent to the arthrotomy." The ALJ noted the absence of objective medical signs of painful, functionally limiting back disorder.
As to the suggestion that plaintiff's psychiatric condition was disabling, the ALJ rejected evidence of opinions given after December 31, 1990. He stated ". . . and since there were no objective findings to support her physical complaints, psychiatric signs and findings of a medically determinable depression or anxiety related disorder were not appreciated by Dr. Charles nor are they otherwise demonstrable in the record at any time prior to December 31, 1990." The ALJ observed that plaintiff had not sought and received treatment from a mental health clinic for psychiatric symptoms until June 1992 — 18 months after the expiration of insured status. He wrote "[t]hus while no doubt she experienced some emotional difficulties due to her inability to return to her past work during the period from October 1985 through December 31, 1990, that they were of a nature and intensity as to interfere with her ability to meet the basic mental demands of work or limit her activities of daily living prior to December 31, 1990 is not demonstrated in the record."
Finding that "non-exertional limitations which would have eroded her sedentary occupational base prior to December 31, 1990 are not demonstrated in the record," the ALJ applied the "grid" to determine that plaintiff was not disabled.
The ALJ's analysis is fundamentally flawed, as was the opinion of the expert upon whom he relied, Dr. Mylod. Plaintiff's disability cannot be evaluated without taking into account the combined effect of plaintiff's undisputed physical impairments and her psychiatric condition. Dr. Mylod took no account of plaintiff's psychiatric condition. He testified, "I'd say from the objective evidence I see here now, I don't see what would make her totally disabled from a physical point of view. Whether there's a psychological overlay or whatever, I don't know . . ." (Tr. 139). The ALJ's rejection of all psychiatric evidence arising after December 31, 1990 was erroneous, because that evidence is probative of plaintiff's condition prior to December 31, 1990. The ALJ's rejection of the evidence of plaintiff's psychiatric condition arising prior to December 31, 1990 was without justification.
As most of the treating physicians recognized plaintiff presented a difficult medical problem. In the first place it is indisputable that she suffered from major, disabling conditions after her October 1985 surgery, conditions which became progressively more serious as time passed. Her right knee continued to be painful. She suffered frequent right leg failure causing her to fall to the ground. This resulted in hospitalization on a number of occasions. She suffered weight loss, headaches, nausea, back distress. All the treating physicians took these conditions seriously and none even suggested that she was malingering. All were frustrated by their inability to cure them.
All the treating physicians agreed that ordinarily the objective physical conditions which plaintiff manifested would not produce the disabilities from which she suffered. The ALJ relied upon the treating physicians' comments to that effect to support his conclusion that plaintiff was not disabled. The treating physicians, however, recognized that notwithstanding the objective medical findings, plaintiff suffered from major impairments. Each in turn concluded that the cause was probably psychiatric in nature. Dr. Valdez, the neurologist, provided what is probably the most definitive diagnosis — multiple somatization from Major Affective Disorders. A somatization disorder is a psychological disorder where there are multiple physical complaints that suggest physical disorders without any physical impairment to account for them. Whether this is the precise diagnosis is immaterial; there is no evidence to rebut the opinions that some psychiatric overlay was responsible for plaintiff's untypical response to her injuries. The fact that diagnoses were made after December 31, 1990 and that treatment began after that date does not render those circumstances irrelevant to conditions existing prior to December 31, 1990 if, as in the present case, they cast light upon plaintiff's psychiatric condition during the relevant period. The fact that plaintiff's disabling conditions were in part of psychosomatic origin does not render them any less disabling. A review of the medical record leads to these general observations and demonstrates the ALJ's failure to apply the undisputed evidence in the case.
In February 1985 plaintiff suffered an injury to her right knee while getting off the truck which she had been driving. For a time Dr. Vassallo treated her, but in April she commenced treatment with Dr. Orlando P. Ricciardelli, an orthopedic surgeon, in whose overall care she continued thereafter. In an April 11, 1985 report Dr. Ricciardelli noted that plaintiff suffered from residuals of a patella tendonitis and certain other injuries. In a July 1, 1985 report the doctor noted improvement, the presence of some subjective pain, the need for physical therapy and his expectation that plaintiff would be able to return to work in three or four weeks.
A July 2, 1985 report recited the recurrence of right knee pain and recommended arthroscopic surgery. On July 19 the surgery was performed with shaving of the patella and resection of impinging synovial fat pad and synovial tissue.
After a period of recuperation plaintiff returned to work driving her truck. On October 29, 1985 she suffered another accident while driving which resulted in plaintiff striking her head on the cab roof and striking her right knee on the dashboard. Dr. Ricciardelli reported that "[t]his injury was almost identical to the injury she had originally sustained. She noticed a momentary subluxation of the patella which was reduced by her driving partner. On examination today [November 11, 1985], she shows signs of increasing pain about the superior patella area. X-rays were negative. I feel this patient has sustained a transitory subluxation of the patella, traumatic in nature and I am again beginning her on a course of physical therapy. I have advised her to refrain from work until further notice." Thereafter plaintiff suffered recurrent episodes of subluxations of the right patella.
On December 17, 1985 Dr. Ricciardelli diagnosed plaintiff as suffering from chronic subluxation of patella and patella chondromalacia. He performed another operation to relieve the situation — an exploratory arthrotomy and realignment of patella retinacular ligament and plication of these ligaments, curettage of undersurface of the patella, excision of hypertrophied synovial fat pad.
Plaintiff was placed in a cast for about three weeks and then placed in a splint. She resumed physical therapy. On or about July 1 Dr. Paul Foddai, an orthopedic surgeon, examined plaintiff on behalf of an insurance carrier. He reported that plaintiff continued to have episode swelling and knee buckling, that "the patient is obviously improving but continues to have symptoms which are referable to her disease." Although not ready to resume work which would put a great demand on her extremity Dr. Foddai was of the opinion that plaintiff would probably be able to resume work in approximately six weeks.
Dr. Ricciardelli continued to see plaintiff each month. She reported pain and knee collapse despite rehabilitative exercises. At this point Dr. Ricciardelli began to suspect that the physical difficulties from which plaintiff was suffering had neurological or psychological origins as well as physical origins. He wrote in a December 3, 1986 report that "[t]his patient objectively is doing quite well. She has attained a full range of motion, has normal stability." He opined that ". . . she has reached the limits of therapeutic response and that she would be able to do sedentary type work. . . . I am afraid I cannot offer her anything additional other than support from a psychological point of view."
On January 12, 1987 Dr. Ricciardelli reported that [o]bjectively there is no sign of the patella subluxating. She has full range of motion once again." On February 11 Dr. Ricciardelli noted plaintiff was still complaining of pain with occasional buckling. In April plaintiff was admitted to the hospital after her knee gave way. The resulting fall resulted in injuries to her head, back and trunk areas. At Dr. Ricciardelli's request, James A. Charles, M.D., a neurologist, examined plaintiff. He observed that "the right knee is exquisitely painful to touch and palpation." He advised "that [t]heir appears to be severe psychiatric overlay, rule out borderline personality, rule out depression. . . . Patient needs a psychiatric consultation and possible follow-up."
In his April and May 1987 reports Dr. Ricciardelli continued to report plaintiff's complaints of pain, knee buckling and falls resulting from the buckling. Noting that objectively plaintiff "has a very stable knee", Dr. Ricciardelli stated that further surgical intervention would be unjustified but that "[s]he is manifesting considerable emotional overlay and I feel at this point that there is nothing else I can offer her medically." He recommended a second opinion of Kim W. Sloan, M.D.
Dr. Sloan examined plaintiff in June 1987, noting that she was "extremely thin, under 90 pounds." He detected no gross instability and prescribed physical therapy. When plaintiff returned to Dr. Sloan in mid-August she was still complaining of pain and knee buckling. Dr. Sloan prescribed more physical therapy. After a September 28 visit, when plaintiff described the same problems and more falls, Dr. Sloan recommended an MRI and a neurological consultation. He, like Dr. Ricciardelli, voiced obvious frustration with his inability to resolve plaintiff's problems orthopedically, stating: "I am not sure what is going on with her but I feel this might be more than orthopedic since she described stocking like distribution numbness."
In November Dr. Charles performed another neurological examination which disclosed nothing remarkable. He stated "I feel that the right thigh atrophy is probably disuse atrophy rather than neurogenic atrophy."
Dr. Ricciardelli continued to see plaintiff periodically. In May 1988 he reported recurrent right knee problems and almost weekly episodes of knee buckling, especially when descending stairs. He sought authorization from the insurance carrier to order a chair lift.
On or about August 3, 1988 orthopedist Jack G. Siegel, M.D., examined plaintiff, apparently at the request of an insurance carrier. He reported:
The patient is a 40 year old female. She appears to be very cachectic. She is almost emaciated. She is 5'4" tall and weighs 88 pounds. She was in a wheelchair. When asked to walk with the aid of a cane, she had considerable disability and is very unstable.
HEAD: It was extremely difficult to examine this lady because of her inability to stand unaided. However, she complains of severe pain on all motions of the
head and neck. Motions of both shoulders are markedly restricted andunaccompanied by complaints of pain.
This is a most unusual case. Mrs. DeSantis is 40 years old and presents the appearance of a "cadaver". I called Dr. Ricciardelli who advised me that he has known this woman for a long period of time. He states that she was always a very thin person. Incidentally, Mrs. DeSantis states that her usual weight is 145 pounds and she had lost most of this weight since the accident of 1985. Dr. Ricciardelli states that as long as he has known this woman, she had never been heavy and in his opinion, she never weighed over 100 pounds. He further states that this lady has a chondromalacia as well as subluxation of the patella. He is unable to account for her complaints at this time and her entire physical condition. He advised me that he had her seen by several neurologists, none of whom were able to pinpoint a definite diagnosis.
I cannot help but feel that there is a tremendous medical problem. I strongly suggest that this woman be given a thorough medical as well as neuropsychiatric examination. Incidentally, this woman was also seen in consultation by Dr. Sloan who in my opinion is one of the best knee surgeons in this area.
In summary, I wish to state that this lady's appearance and complaints are certainly bizarre. As I find her today, she is certainly not capable of working. Incidentally, I cannot see how this woman could ever have performed as a cross country trailer driver.
On June 2, 1989 Dr. Ricciardelli reported that plaintiff had developed a snapping hip syndrome on her right side, probably related to her type of ambulation performed during the past many months. He recommended surgery. On June 29 he performed the operation, which was successful.
On November 29, 1989 plaintiff was once again admitted to the hospital after suffering loss of consciousness following one of her falls.
Dr. Siegel examined plaintiff once again on May 18, 1990. He reported:
The patient is an extremely emaciated 42 year old female. She was in a wheelchair and also carried a cane. She weighs 88 lbs. She was asked to walk with the cane but could hardly ambulate and complained of severe pain in the right leg. The examination was performed with the patient sitting on the edge of the table.
BACK: As above stated, this lady could not stand in the erect position. Therefore, she was assisted on the table and sitting on the edge of the table, any attempt to elevate the right leg was markedly restricted and accompanied by severe pain so that she started to cry. Straight leg raising on the left is easily carried to almost 90 degrees. In the supine position, comparative serial measurements of both lower extremities a ½ — 3/4 inch atrophy of the right thigh as compared to the left. Any attempt to flex her knee in the supine position, was markedly restricted and accompanied by severe pain. Motions of the left knee and thigh were normal. When tested by means of pinwheel there were no sensory disturbances. At this time there is marked tenderness over the sacral coccygeal junction. . . .
As indicated in my previous report to you of 7/22/88, this is a most bizarre case. . . .
You will also note in my previous report that this lady was cachectic and in my opinion she had some serious underlying medical problems. However, in reviewing Dr. Burke's report he makes no mention of this lady being in a wheelchair and he states that the medical examination was essentially normal. MRI performed on Jan. 17, 1990 showed a mild bulging of the L4-disc but otherwise was normal. . . .
In summary, I wish to state that the examination today shows a markedly emaciated lady who has had considerable pain in the back prior to the injury of 1985. However, she states she was fine after the coccyx was removed until the accident in question. She further states that prior to the accident she weighed 124 lbs. and at this time weighs 88 lbs.
Regardless, as I find this lady today, she is totally disabled.
On November 2, 1990 Dr. Ricciardelli reported to the insurance carrier of a recent injury plaintiff suffered when her leg gave way, causing her to fall and strike her right rib cage. She visited a hospital and x-rays showed multiple rib fractures.
All of the events described above occurred prior to December 31, 1990 during the period of plaintiff's insured status. No doctor had concluded that she was able to work. No doctor so much as suggested she was malingering. The genuineness of her pain, knee buckling and injuries resulting from her falls was obviously genuine. The only question was whether the cause of her condition was orthopedic, neurological or psychiatric. From a disability perspective the cause was irrelevant, because the undisputed condition prevented plaintiff from working at any level.
The post December 31, 1990 evidence both confirms plaintiff's disabling condition and points to a cause, the reason why normally non-disabling conditions resulted in plaintiff's case in disability.
In his quest for answers Dr. Ricciardelli referred plaintiff to Sandra S. Valdez, M.D., a neurologist. Dr. Valdez first saw plaintiff on March 15, 1991. She noted plaintiff's complaints of frequent falls, pain in the neck, back and right hip as well as numbness of the right lower extremity. The doctor's impression was: "This woman had multiple soft and bony injuries to both lower extremities, there is early sensory peripheral polyneuropathy on electrodiagnostic studies; there is no evidence of radiculopathy. Investigations for the polyneuropathy is in order. She was advised to undergo a complete blood profile. We find her permanently totally disabled."
Dr. Valdez conducted neurological follow-ups on six occasions between March and November 1991. She heard the same complaints from plaintiff each time; the complaints seemed to progress in intensity. Dr. Valdez attempted to relieve the knee, leg and head problems with various prescriptions; they provided only moderate relief. In November Dr. Valdez concluded that plaintiff's problems stemmed from causes in addition to organic ones: "We strongly feel that Patty does have organic medical problems, but has superimposed psychological difficulties that probably requires tact and professional psychiatric help."
On November 15, Dr. Ricciardelli requested that the insurance carrier authorize a psychiatric evaluation "since it would appear at this time that this patient has been undergoing so much emotional stress that it is making her rehabilitation extremely difficult, if not impossible."
From November 1991 until May 1992, Dr. Valdez continued to see plaintiff, finding her neurological condition unchanged and urging her to seek psychiatric assistance. In January 1992, Dr. Valdez wrote, "We again strongly suggest that Patty be seen by a psychiatrist, although secondary gains are a good possibility, other psychopathology needs to be uncovered and treated."
In July 1992, Dr. Ricciardelli reported to the New Jersey Department of Labor. He noted that plaintiff was partially confined to a wheelchair because of her inability to ambulate without episodes of recurrent falling. He advised that plaintiff was seeking psychiatric help because of severe mood depression and that "[i]t is unlikely this patient will ever be able to do any type of productive work."
Reporting to the insurance carrier on August 6, 1992 Dr. Ricciardelli stated, "[c]ondition appears to be deteriorating as far as the lower extremities is concerned. She has been experiencing repeated episodes giving way of knees and falling, which I feel is resulting in further deterioration of her patellofemoral joints." He suggested bracing the lower extremities while plaintiff was having psychiatric and neurological treatment.
On August 25, 1992, Dr. Valdez wrote, "[w]e can only hope that the psychiatric intervention will provide some answers and lessen the various somatic complaints."
Plaintiff sought psychiatric assistance and continued with Dr. Ricciardelli and Dr. Valdez. Despite this assistance plaintiff's condition remained totally disabling. Dr. Valdez's September 1, 1994 comment was "We recommend psychiatric consult and treatment. We believe Mrs. DeSantis has multiple Somatization from Major Affective Disorder."
The ALJ's finding that plaintiff was not under a disability at any time through December 31, 1990 and the subsidiary findings leading to that ultimate finding lack support in the evidence. His use of the grid in these circumstances was inappropriate. He failed totally to take into account the evidence establishing plaintiff's psychiatric difficulties. Without any rational basis he rejected the evidence that plaintiff was subject to the pain, knee collapses, falls and resulting injuries and occasional hospitalizations. It is not dispositive that ordinarily organic conditions such as plaintiff's would not result in these manifestations. The undisputed fact is that the disabling manifestations were there, caused in part by organic conditions and in part by psychiatric conditions still not fully understood.
The medical opinions upon which the ALJ relied did not take the psychiatric element into account. As Dr. Mylod testified, he did not "see what would make [plaintiff] totally disabled from a physical point of view. Whether there's a psychological overlay or whatever, I don't know." Since the psychological overlay was what the various treating and examining physicians found critical, Dr. Mylod's opinion was worthless.
CONCLUSION
In light of the medical evidence presented and the accompanying documents in the record, the findings of the ALJ are not supported by substantial evidence. The evidence establishes that Plaintiff was under a disability which arose during her period of insured status and which continues to date. She is unable to perform her previous work, and the Secretary has not established that she has the capacity to perform specific jobs that exist in the national economy. Thus, for the foregoing reasons, the decision of the Commissioner will be reversed. The case will be remanded with directions that an order be entered granting disability insurance benefits and otherwise in accordance with this opinion.