Summary
In Hollis v. Massanari, 2002 WL 500780 (N.D. Cal. Mar. 25, 2002), the administrative law judge "never obtained" the agency's records of an earlier application, id. at *4, a fact which easily distinguishes that case from the one before this court.
Summary of this case from Duckworth-Bubar v. BarnhartOpinion
No C-O0-04633 VRW
March 25, 2002
ORDER
Plaintiff Linus Hollis filed this action under 42 U.S.C. § 405(g) seeking judicial review of defendant's administrative decision denying his application for Supplemental Security Income (SSI). See Compl (Doc # 1). Plaintiff moves for summary judgment, requesting that the court remand the action for further proceedings before an administrative law judge. See Doc # 10. Defendant opposes this motion and moves for summary judgment as well. See Doc # 12. For the reasons that follow, the court DENIES defendant's motion (Doc # 12), GRANTS plaintiff's motion (Doc # 10) and REMANDS this case for further proceedings consistent with this order.
I
The factual background in this case is somewhat limited. Most of the factual record is based on plaintiff's testimony; unfortunately, plaintiff was not clear and often rambled during his testimony. Plaintiff testified that he received SSI disability benefits from approximately 1977 until about 1993. See Tr (Doc # 9) at 28. When plaintiff married in 1990, due to his wife's income, plaintiff was no longer eligible for benefits and his SSI benefits were terminated. See id. Plaintiff's marriage was annulled in 1993. See id at 28-29. Plaintiff applied for SSI benefits again in 1998, alleging asthma, emphysema, arthritis in his left knee, migraines and organic memory dysfunction. See id at 79, 85. The Social Security Administration denied plaintiff's initial application for benefits and denied his application on reconsideration. See id at 57-59, 64-66. Plaintiff requested a hearing before an Administrative Law Judge (ALJ). See id at 55. At the hearing, plaintiff waived attorney representation and testified on his own behalf. See id at 23. A medical expert, a psychiatrist who had reviewed plaintiff's medical records, gave the only other testimony. See id at 23. In addition, medical records from several doctors who had examined plaintiff were entered into the record as exhibits. The ALJ found plaintiff's impairment non- severe and held that plaintiff did not qualify for disability benefits. See id at 13-20. The Appeals Council declined review and the ALJ's determination became final. See id at 6-7.
Plaintiff was 47 years old at the time of the ALJ's decision. See Tr (Doc # 9) at 23. Plaintiff graduated high school and completed some college. See id at 24. Plaintiff worked briefly for the postal service and as a wine consultant. See id at 24-26. Plaintiff has been unemployed since 1988. See id at 25-26. Plaintiff has been homeless since about 1990. See id at 29. He supports himself by collecting bottles and cans and singing for change. See id at 27, 29. Plaintiff also receives general assistance. See id at 27.
Plaintiff saw Dr Malin in January 1997 and February 1998 for his asthma and other conditions. See Tr (Doc #9) at 110-11. Dr Malin documented wheezes in plaintiff's lungs. See id at 118. Dr Malin also reported arthritis in plaintiff's left knee. See id at 110-11. Dr Malin concluded plaintiff's impairment was severe and that plaintiff was permanently disabled. See id at 118. At the ALJ's request, a different doctor, Dr Gozan, performed a physical examination of plaintiff in April 1998. See id at 119- 122. The results of respiratory examination and a pulmonary function test performed in May 1998 were normal. See id at 123. Dr Gozan stated he "doubted [plaintiff's knee] would limit him to gainful employ," but that "[plaintiff] should have at least an x- ray of his knee with orthopedic evaluation." Id at 122. No x-ray was taken. Plaintiff did not receive an orthopedic evaluation.
The ALJ also requested cognitive testing. Psychologist Dr Taylor determined plaintiff had a genius IQ and showed no signs of memory dysfunction. See Tr (Doc # 9) at 134-139. Dr Taylor revealed "[plaintiff] did not present or report any mental disorder that would impede his ability to sustain a consistent work effort." Id at 138. Dr Taylor could not say whether or not plaintiff had a personality disorder and recommended that the ALJ consider additional information available about the patient such as past treatment records and further psychiatric testing. See id at 138- 139. Dr Taylor noted the evaluation of plaintiff could "only be based on how the [plaintiff] presented the day of this evaluation." Id at 139.
At the hearing, psychiatrist Dr Shapiro testified he could not form a medical opinion regarding plaintiff's medical status. Dr Shapiro stated that plaintiff's psychiatric records from his treatment during the late 1970s were "[t]he main psychological document[s]," upon which diagnosis should be based and were missing from the record. Tr (Doc # 9) at 37. In addition, Dr Shapiro stated that further psychological testing would be useful. See id at 38. The ALJ did not obtain these earlier records or order further psychological testing.
After the hearing, the ALJ arranged for plaintiff to undergo neurological testing to investigate plaintiff's complaint of migraine headaches. See Ans (Doc #9), Tr at 154-56. The neurologist, Dr Hill, found no evidence of nervous system disease or dysfunction to explain symptoms reported by plaintiff. See id at 154-56. From these reports, the ALJ determined that plaintiff's impairment was not severe and denied his SSI application. See id at 13-20. Plaintiff now seeks judicial review of the ALJ's decision that plaintiff is not disabled.
II
The ALJ's decision to deny disability benefits will not be disturbed unless (1) the findings of fact are not supported by substantial evidence on the record or (2) the decision is based on a legal error. SeeMagallanes v Bowen, 881 F.2d 747, 750 (9th Cir 1989). Substantial evidence means "more than a mere scintilla, but less than a preponderance; it is such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Andrews v Shalala, 53 F.3d 1035, 1039 (9th Cir 1995). The reviewing court must consider the record as a whole and review evidence both supporting and undermining the ALJ's decision. See Desrosiers v Secretary of Health Human Serv, 846 F.2d 573, 576 (9th Cir 1988). It is the ALJ's role to make credibility determinations and to resolve conflicts in medical testimony. Andrews, 53 F.3d at 1039. If the evidence is susceptible to more than one rational interpretation, the court will uphold the decision of the ALJ. Id at 1040. Nevertheless, a decision supported by substantial evidence must be set aside if improper legal standards were applied in reaching the decision. See Brawner v Secretary of Health and Human Serv, 839 F.2d 432, 433 (9th Cir 1987).
Plaintiff asserts that the ALJ committed legal error because the ALJ did not fully develop the factual record before making his determination. In addition, plaintiff contends that there is insufficient evidence to support the ALJ's decision in the record. Defendant responds that the ALJ fully developed the record and that there is substantial evidence to support the ALJ's decision. Because the court agrees that the ALJ failed to develop the record fully, it does not consider whether substantial evidence exists in the record as it currently stands to support the ALJ's decision.
The ALJ has an independent duty fully to develop the record. See Smolen v Chater, 80 F.3d 1273, 1288 (9th Cir 1996). This duty exists regardless of whether plaintiff is represented by I counsel. The duty is heightened, however, when plaintiff is not represented. See Vidal v Harris, 637 F.2d 710, 713 (9th Cir 1981). In that case, courts describe the ALJ's duty as a duty to probe into, inquire of and explore for all relevant facts scrupulously and conscientiously. See id. The ALJ must be especially diligent in ensuring that favorable as well as unfavorable facts and circumstances are elicited. See id. In addition, if the claimant is impaired by mental illness, the ALJ's duty is further heightened. See DeLorme v Sullivan, 924 F.2d 821, 849 (9th Cir 1991).
Here, plaintiff was unrepresented at the administrative hearing. See Tr (Doc # 9) at 23. Plaintiff has a history of chronic homelessness. See id at 29, 30. Plaintiff also has a history of mental illness and mental health treatment. See id at 31, 38-39. Dr Taylor reported that plaintiff may have a personality disorder. See id at 138. Plaintiff's testimony is rambling and inconsistent. See id at 23-42. These facts indicated possible mental impairment at the time of the administrative hearing. Therefore, the ALJ was under a heightened duty to develop the record fully.
In order to demonstrate that the ALJ did not fulfill this duty, plaintiff must point to relevant evidence that the ALJ neglected to obtain. See Tonapetyan v Halter, 242 F.3d 1144, 1150 (9th Cir 2001). Plaintiff points to three omissions by the ALJ which were relevant to the determination of plaintiff's disability. First, plaintiff contends that further psychological testing to discovery any personality disorder was necessary. Second, plaintiff contends that his psychiatric records from the late 1970s were relevant. Third, plaintiff asserts that the records from the previous determinations of disability in plaintiff's case are relevant to the current determination of disability.
A
Dr Shapiro, the independent medical expert, stated that psychological testing was necessary to diagnose any mental disorder that plaintiff might have. The record only contains results from cognitive and neurological testing. See Tr (Doc # 9) at 134-39; 154-56. In addition, Dr Taylor stated that his diagnosis was "only based on how the [plaintiff] presented the day of [his] evaluation." See id at 139. Dr Taylor suggested that plaintiff might have a personality disorder and that further psychological testing was warranted. See id. The ALJ does not discuss this recommendation in his decision or make any reference to during the hearing. Whether the plaintiff has a personality disorder sufficiently severe to be disabling is relevant to the ALJ's determination. The ALJ's decision to refrain from psychological testing was therefore error.
B
Dr Taylor recommended review of plaintiff's past mental health treatment records; the ALJ dismissed this recommendation. See Tr (Doc #9) at 139, 16, 37-40. At the hearing the ALJ relied on Dr Shapiro's testimony that mental health treatment records from 1977-1979 would not be helpful if plaintiff had been using drugs during treatment. See id at 40. When asked by the ALJ, plaintiff first testified that he stopped using drugs around 1980. See id at 40. A moment later, plaintiff revised estimate, stating that he stopped using drugs even earlier. See id. In addition, plaintiff told Dr Taylor that he has not used drugs since the early 1970s. See id at 135. The ALJ relied upon plaintiff's testimony that he stopped using drugs in 1980 to support his decision that review of Dr Chapel's records would not be helpful. See id at 40. But Dr Chapel's records are relevant if plaintiff was not using drugs while in treatment. See id at 37-39. Given plaintiff's conflicting answers regarding whether he was using drugs during his psychological treatment, the ALJ should not have dismissed those records as irrelevant. Dr Shapiro makes clear that those records are the main documents necessary for diagnosis. See id at 37. The ALJ erred in not obtaining and considering these records.
C
Finally, plaintiff asserts that the ALJ failed to obtain records from plaintiff's earlier period receiving disability benefits. Plaintiff received benefits from approximately 1977 to 1993. See Tr (Doc # 9) at 28. Plaintiff asserts that because res judicata applies to administrative decisions, albeit in a less formalistic way, these records are relevant to a determination of plaintiff's disability. See Taylor v Heckler, 765 F.2d 872 (9th Cir 1985). Defendant asserts that any benefit from res judicata would be in defendant's favor, as the most recent previous decision denied plaintiff SSI benefits in 1996. See Def Opp (Doc # 12) at 3. As the ALJ never obtained the records from this 1996 application either, the court cannot infer that benefits were denied based on the same disabilities plaintiff currently alleges. Because both plaintiff and defendant are entitled to rely to some degree on the res judicata effects of previous determinations, the ALJ had a duty to obtain these records.
III
In sum, the ALJ erred by not fully developing the factual record in this case. The court therefore GRANTS plaintiff's motion (Doc # 10) and DENIES defendant's motion for summary judgment (Doc # 12). The judgment of the ALJ is reversed and the action is remanded for further proceedings consistent with this order.
As the prevailing party, plaintiff may be eligible for attorney fees and costs under the Equal Access to Justice Act. Plaintiff must submit a petition for fees and costs to the court no more than thirty days after the period for appeal has expired.
IT IS SO ORDERED.