Reefer v. Barnhart, 02-2510.

• Decision Date: 14 April 2003
• Docket Number: No. 02-2510.,02-2510.
• Citation: 326 F.3d 376
• Parties: Laurel REEFER v. *Joanne B. BARNHART, Commissioner of Social Security. Laurel M. Reefer, Appellant. *(Pursuant to F.R.A.P. 43(c))
• Court: U.S. Court of Appeals — Third Circuit

326 F.3d 376

Laurel REEFER v. *Joanne B. BARNHART, Commissioner of Social Security.

Laurel M. Reefer, Appellant. *(Pursuant to F.R.A.P. 43(c))

No. 02-2510.

United States Court of Appeals, Third Circuit.

Argued November 20, 2002.

April 14, 2003.

John G. Burt (Argued), Pittsburgh, PA, for Appellant.

David F. Chermol (Argued), James A. Winn, Mary Beth Buchanan, Paul E. Skirtich, Social Security Administration OGC/Region III, Philadelphia, PA, for Appellee.

Before BARRY and AMBRO, Circuit Judges, ACKERMAN,^** District Judge.

OPINION OF THE COURT

AMBRO, Circuit Judge.

Laurel Reefer appeals a decision discontinuing her Social Security benefits. Because that decision was not supported by substantial evidence, we reverse and remand.

I. Background

In 1989, Reefer began receiving Social Security Supplemental Security Income ("SSI") benefits because she suffered disabling hypertension. In March 1997, the Social Security Administration ("SSA") reviewed Reefer's case and issued a notice of disability cessation on the ground that her medical condition had improved to the point that her disability had ceased.¹ Her benefits were discontinued as of May 31, 1997.

Reefer requested reconsideration of the SSA's denial of benefits, alleging continuing disability due to hypertension, anxiety, tiredness, muscle spasms and pain in her left leg, shoulder, arm and hand, chest pains, neck pains and headaches. On reconsideration, the SSA again denied Reefer benefits. She then sought an administrative hearing, which was held on September 10, 1998 before an administrative law judge (the "ALJ"). Reefer appeared pro se at the hearing, which lasted only twenty minutes. She testified that she suffered a stroke in 1997 and provided the ALJ with the names of her two treating physicians — Dr. Tuchinda, a cardiologist, and Dr. Tabas, her primary-care physician. She also testified that she was having seizures, for which her neurologist ordered video monitoring. At the conclusion of the hearing, the ALJ said that he would obtain additional medical records and, if necessary, would call for another hearing. The ALJ did obtain some of Reefer's medical records. However, he issued his opinion without the benefit of a second hearing and without requesting testimony from either of Reefer's treating physicians. The record before the ALJ contained no medical report concerning the 1997 stroke.

Between the date of the hearing and the ALJ's decision, Reefer underwent elective surgery in 1999 to remove pressure from her brainstem. Following this surgery, she suffered a second stroke. However, because the ALJ did not request medical records detailing these events, they also were not before him at the time of his decision. Reefer submitted those records both to the District Court and to this Court on appeal.²

In his May 26, 1999 decision, the ALJ found that Reefer was not entitled to SSI. First, the ALJ found that Reefer does not suffer from any of the impairments described in 20 C.F.R., Pt. 404, Subpt. P, App. 1, which would make her per se disabled. He said that her "hypertension[,] though severe, is well-controlled ... with only situational episodic elevation," and that no medical evidence supported her alleged mental and neurological impairments. He also found that Reefer's "activities of daily living are ... not consistent with an individual experiencing total[] disability," and that her "statements concerning her impairments and their impact on her ability to work are not entirely credible." In so finding, the ALJ noted that "[i]n her Daily Activities Questionnaire, the claimant indicated that she can independently care for her personal needs. She cooks, does dishes, dusts, vacuums, and does other housework." The ALJ went on to find that "[a]lthough she indicated on her Fatigue and Pain Questionnaires that both pain and fatigue interfere substantially with her daily activities, this is not supported by her own statements, nor by the objective medical evidence in record." Finally, the ALJ stated that "the claimant retains the residual functional capacity to perform the exertional demands of at least light work, or work which requires maximum lifting of 20 pounds and frequent lifting of up to 10 pounds.... The evidence supports a finding that she is able to lift and carry 20 pounds. The claimant has no significant non-exertional limitations which narrow the range of work she can perform, as demonstrated by the objective medical evidence."

In this context, the ALJ concluded that Reefer was capable of returning to her past relevant work as a cleaner. The ALJ also noted that application of Reefer's residual functional capacity to the Medical-Vocational Guidelines set out in 20 C.F.R., Pt. 404, Subpt. P, App. 2, confirmed that there are jobs in the economy she can perform.

Reefer filed a request for review, which the Appeals Council denied. She then filed a complaint in the District Court, which granted summary judgment in favor of the Commissioner. At issue here is whether the ALJ's determinations that Reefer is no longer disabled and can find work in the economy are supported by substantial evidence. Reefer asks that we either (1) reverse the District Court's decision and grant her SSI benefits or (2) remand the claim to the ALJ for additional testimony and related proceedings.

II. Jurisdiction and Standard of Review

We have subject matter jurisdiction pursuant to 42 U.S.C. § 405(g). Appellate jurisdiction exists under 28 U.S.C. § 1291.

We examine the record to determine whether substantial evidence supported the ALJ's findings. Smith v. Califano, 637 F.2d 968, 970 (3d Cir.1981). "`Substantial evidence' has been defined as `more than a mere scintilla. It means such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.'" Id. (quoting Richardson v. Perales, 402 U.S. 389, 401, 91 S.Ct. 1420, 28 L.Ed.2d 842 (1971)). Stated differently, this standard is met if there is sufficient evidence "to justify, if the trial were to a jury, a refusal to direct a verdict." Universal Camera Corp. v. NLRB, 340 U.S. 474, 477, 71 S.Ct. 456, 95 L.Ed. 456 (1951).

The "substantial evidence" standard of review requires that we review the whole record. Smith, 637 F.2d at 970 ("Despite the deference to administrative decisions implied by this standard, appellate courts retain a responsibility to scrutinize the entire record and to reverse or remand if the Secretary's decision is not supported by substantial evidence."). Further, in evaluating whether substantial evidence supports the ALJ's findings, we are mindful that "leniency [should] be shown in establishing the claimant's disability, and that the Secretary's responsibility to rebut it [should] be strictly construed.... [D]ue regard for the beneficent purposes of the legislation requires that a more tolerant standard be used in this administrative proceeding than is applicable in a typical suit in a court of record where the adversary system prevails." Dobrowolsky v. Califano, 606 F.2d 403, 407 (3d Cir.1979) (internal quotation marks omitted) (quoting Hess v. Sec'y of Health, Educ. & Welfare, 497 F.2d 837, 840 (3d Cir.1974)).

III. Discussion

We reverse for two reasons. First, the ALJ did not adequately develop the record, a duty he owed Reefer because she appeared pro se. Second, he neglected to explain why he credited some record evidence but rejected other evidence. In this context, we find that substantial evidence does not support the ALJ's opinion.

A. The ALJ failed adequately to develop the record.

An ALJ owes a duty to a pro se claimant to help him or her develop the administrative record. "When a claimant appears at a hearing without counsel, the ALJ must `scrupulously and conscientiously probe into, inquire of, and explore for all the relevant facts.'" Key v. Heckler, 754 F.2d 1545, 1551 (9th Cir.1985) (quoting Cox v. Califano, 587 F.2d 988, 991 (9th Cir.1978)); Dobrowolsky, 606 F.2d at 407 (noting that an ALJ must "assume a more active role when the claimant is unrepresented"). See generally Ventura v. Shalala, 55 F.3d 900, 902 (3d Cir.1995) ("ALJs have a duty to develop a full and fair record in social security cases.").

While we do not prescribe any particular procedures that an ALJ must follow, see Vt. Yankee Nuclear Power Corp. v. Natural Res. Def. Council, Inc., 435 U.S. 519, 524-25, 98 S.Ct. 1197, 55 L.Ed.2d 460 (1978), we believe that the procedures the ALJ did follow were insufficient to develop the record in this case. See Miranda v. Sec'y of Health, Educ. & Welfare, 514 F.2d 996, 998 (1st Cir.1975) (ALJ's investigation must be "not wholly inadequate under the circumstances."); see also Lashley v. Sec'y of Health & Human Servs., 708 F.2d 1048, 1052 (6th Cir.1983) (courts determine the adequacy of an ALJ's investigation on a case-by-case basis). The ALJ did not follow up on Reefer's testimony about her 1997 stroke, an occurrence of obvious relevance to this disability determination. Upon finding that the medical records before him did not refer to this stroke, the ALJ had a duty to investigate further. See Dobrowolsky, 606 F.2d at 407. For example, he could have requested additional medical records or held another hearing to receive testimony from Reefer's treating physicians about the stroke. The ALJ did not do this and did not even mention Reefer's 1997 stroke in his opinion. While the record is over 700 pages, that it lacks detail about Reefer's stroke makes it "inadequate under the circumstances." Miranda, 514 F.2d at 998.

Second, while the ALJ found Reefer's "statements concerning her impairments and their impact on her ability to work ... not entirely credible," he had an insufficient basis to make this conclusion. We would ordinarily defer to an ALJ's credibility determination because he or she has the opportunity at a hearing to assess a witness's demeanor. See, e.g., Atl. Limousine, Inc. v. NLRB, 243 F.3d 711, 718 (3d Cir.2001). However, the ALJ...