Claussen v. Chater

• Decision Date: 29 October 1996
• Docket Number: Civil Action No. 95-5214 (AJL).
• Citation: 950 F.Supp. 1287
• Parties: Francine CLAUSSEN, Plaintiff, v. Shirley CHATER, Commissioner of Social Security, Defendant.
• Court: U.S. District Court — District of New Jersey

950 F.Supp. 1287

Francine CLAUSSEN, Plaintiff, v. Shirley CHATER, Commissioner of Social Security, Defendant.

Civil Action No. 95-5214 (AJL).

United States District Court, D. New Jersey.

October 29, 1996.

Anna P. Navatta, Bergen County Legal Services, Hackensack, NJ, for Plaintiff.

Faith S. Hochberg, United States Attorney, Peter G. O'Malley, SAUSA, United States Department of Justice, Newark, NJ, for Defendant.

OPINION

LECHNER, District Judge.

This is an action brought under sections 205(g) and 1631(c)(3) of the Social Security Act¹ (the "Act"), as amended, 42 U.S.C. §§ 405(g) and 1383(c)(3), to appeal the final determination of the Commissioner of Social Security (the "Commissioner") denying the application of plaintiff Francine Claussen ("Claussen") for disability insurance benefits and supplemental security income benefits.² Jurisdiction is alleged pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3). For the reasons set forth below, the instant matter is remanded to the Commissioner for further findings.

Procedural History

On 18 February 1993, Claussen submitted an application (the "Application") for disability insurance benefits and supplemental security income benefits under the Social Security Act, alleging disability, since 23 December 1992, due to multiple sclerosis. Tr. at 74-78. The Commissioner initially denied the Application on 27 April 1993, id. at 63-67, and subsequently denied Claussen's request for reconsideration on 5 August 1993, id. at 71-72.

On 13 September 1993, Claussen filed a request for review of the Application by an administrative law judge ("ALJ"). Tr. at 74. ALJ Quintin Morales-Ramirez ("ALJ Morales-Ramirez") held a hearing (the "Hearing") on 13 June 1994. Id. at 12. On 21 September 1994, ALJ Morales-Ramirez rendered his decision (the "Decision"), determining Claussen was not under a disability because, although Claussen "had a severe impairment," she retained the "residual functional capacity to perform the full range of sedentary work." Id. at 13, 19.

On 15 November 1994, Claussen requested that the Appeals Council of the Social Security Administration's Office of Hearings and Appeals (the "Appeals Council") review the Decision. Tr. at 7. In a notice, dated 18 August 1995, the Appeals Council denied review. Id. at 4-5. Accordingly, the Decision became the final determination of the Commissioner. Id. at 4; see 20 C.F.R. §§ 404.981, 416.1481.

Claussen seeks judicial review of the Commissioner's determination. Claussen timely filed a complaint (the "Complaint") with the Clerk of the court, on 16 October 1995. See 42 U.S.C. § 405(g). Thereafter, the parties filed their submissions.

Facts

A. Hearing Testimony

1. Testimony of Claussen

Claussen, who was born on 11 November 1959, is unmarried and lives in an apartment with her young son in Elmwood Park, New Jersey. Tr. at 33, 51-52. Claussen testified her daily activities included making breakfast for her son, watching television and resting on her bed or couch. Tr. at 38-39. In addition, Claussen testified she occasionally drove to her doctors, the grocery store and the laundromat "when [she had] to." Id. at 34. While driving she testified she had difficulty with "double vision." Id.

Claussen testified a state-provided home health aide (the "Health Aide") assisted her by performing household tasks. Tr. at 38. The Health Aide also took care of Claussen's son: "She bathes him, she feeds him, she clothes him, she's the one that takes him outside. I don't have the energy to do it, so she does it." Id. at 39. Claussen testified that after the Health Aide leaves, her mother often assists her by cooking "or whatever." Id.

In a series of answers to questions from ALJ Morales-Ramirez, Claussen testified she is able to bend down, kneel down, reach up, reach down and pick up objects weighing five pounds. Tr. at 36. She confirmed she does not need assistance to feed or dress herself. Id. at 38. Claussen testified, however, when she walks she gets tired within a couple of blocks and her "legs start to cramp." Id. at 35-36. She further testified she can only sit for about fifteen minutes at a time because her "legs start stiffening up," id. at 36, and cannot stand for long without experiencing discomfort. Id.

Claussen testified she attended school up to the ninth grade. Tr. at 34. Thereafter, she worked as a waitress until the seventh month of her pregnancy in December 1992. Id. at 34-35. Claussen testified she is prevented from working because she is "too tired all the time." Id. at 35.

Claussen testified her multiple sclerosis caused "very bad" fatigue after about twenty to thirty minutes of activity. Tr. at 39-40. This fatigue caused her to get overtired, and, in turn: "My blurry vision gets worse, my mood swings are worse, my legs go — everything gets worse if I get too overtired or fatigued." Id. As a result, she spent about fifty to seventy-five percent of the day lying down. Id. at 40. Furthermore, Claussen testified her memory and concentration were deteriorating. Id.

Claussen testified she visits her doctor at the Bernard Gimbel Multiple Sclerosis Center (the "Gimbel Center") about "once a year" unless she has an exacerbation. Tr. at 35. Claussen testified her treatment included taking the prescription drugs Prozac and Laorso and her doctor had advised her "to get a little exercise." Id. at 35, 37.

B. Medical Records Before ALJ Morales-Ramirez

ALJ Morales-Ramirez examined several medical reports submitted by physicians who treated or examined Claussen. These included a medical record from Said Shanawani, M.D. ("Dr. Shanawani"), dated 5 April 1993 (the "Shanawani Report"), Tr. at 95-98, a record from the Gimbel Center, dated 22 April 1993 (the "Gimbel Report"), id. at 99, a medical record from Maryann Picone, M.D. ("Dr. Picone"), Claussen's neurologist, dated 11 June 1993 (the "First Picone Report"), id. at 100-102, a medical record from Dr. Picone, dated 15 June 1993 (the "Second Picone Report"), id. at 103, a medical record from Dr. Picone, dated 29 June 1993 (the "Third Picone Report"), id. at 104, a medical record from Dr. Picone, dated 26 July 1993 (the "Fourth Picone Report"), id. at 105, progress notes from the Gimbel Center, dated March 1987 through November 1993 (the "Progress Notes"), id. at 109-129, a one page questionnaire, dated 9 June 1994, filled out by Dr. Picone for the Social Security Administration (the "Picone Evaluation"), id. at 143, an eight-page report, dated 22 April 1993, evaluating Claussen's physical limitations (the "Residual Physical Functional Capacity Assessment"), id. at 55-62, and a one page report from the Social Security Administration evaluating Claussen's employment capacity, dated 27 April 1993 (the "Social Security Notice"), id. at 67.

1. The Shanawani Report

The Shanawani Report indicates Dr. Shanawani first treated Claussen on 17 March 1987. Tr. at 97. Dr. Shanawani diagnosed Claussen with multiple sclerosis "characterized by slow and dyskinetic tongue motion." Id. In reaching his diagnosis, Dr. Shanawani noted Claussen exhibited a sudden onset of numbness in her face, arms and legs. Id. He also noted other instances of specific physical findings: on 17 March 1987, Claussen suffered from overwhelming fatigue, "sleeping in late" and blurry vision; on 15 September 1987, she exhibited pain in her extremities; on 11 March 1992, she had difficulty lifting her right foot; on 16 September 1992, she suffered numbness in both hands; and on 19 February 1993, ataxia³ was noted. Id. Dr. Shanawani also reported a modified barium swallow exam, conducted on 9 February 1993, indicated a "mild oral stage dysfunction." Id.

2. The Gimbel Report

The Gimbel Report recorded information Claussen conveyed on her 16 April 1993 visit to the Gimbel Center. Tr. at 99. The Gimbel Report indicated Claussen suffered numbness in her arms, had ataxia and intermittently used a cane, but that she had no problems with her hands. Id.

3. The First Picone Report

The First Picone Report records Claussen's condition as of 11 June 1993. Tr. at 102. It indicated Claussen was losing her balance, feeling "dizzy," having "blurry vision," undergoing "mood swings," experiencing weakness in her left wrist and was becoming forgetful. Id.

4. The Second Picone Report

The Second Picone Report is a report of a phone conversation between Dr. Picone and Claussen on 18 June 1993. Tr. at 103. Dr. Picone reported: "[Claussen's] condition is basically the same — she was seen yesterday having another exacerbation" and the "same symptoms [were] flaring up." Tr. at 103.

5. The Third Picone Report

The Third Picone Report is a one-page report to the Division of Disability Determinations. Tr. at 104. Dr. Picone reported Claussen's condition, as of 29 June 1993, was essentially the same as reported in a Second Picone Report. Id. Dr. Picone observed Claussen continues to have "flare-ups." Id.

6. The Fourth Picone Report

The Fourth Picone Report is a one-page medical report describing Claussen's condition as of 26 July 1996. Tr. at 105. Dr. Picone noted: "downgoing toes", reflexes "2 + /4" and "difficulty with tandem" in Claussen's gait. Id. Additionally, Dr. Picone noted: "MS Exacerbation not responding to steroids orally." Id.

7. The Progress Notes

The Progress Notes are twenty-one pages of notes from the Gimbel Center, dated March 1987 through November 1993. Tr. at 109-29. Because Claussen alleges disability starting 23 December 1992, the Progress Notes during this period are the ones most relevant. The Progress Notes prior to this period, however, serve as a basis for comparison. For example, a Progress Note, dated 16 September 1992, a time when Claussen was working full time as a waitress and was four months pregnant, records occasional dizziness and pain in addition to numbness in her arms. Id. at 122. There was no mention of fatigue and under the section "Incapacity Status," Claussen received a score of "0," indicating no...