Hall v. Harris

• Decision Date: 04 September 1981
• Docket Number: No. 80-1739,80-1739
• Parties: Alva M. HALL, Appellant, v. Patricia R. HARRIS, Secretary of Health and Human Services, Appellee.
• Court: U.S. Court of Appeals — Fourth Circuit

Page 260

658 F.2d 260

Alva M. HALL, Appellant, v. Patricia R. HARRIS, Secretary of Health and Human Services, Appellee.

No. 80-1739.

United States Court of Appeals, Fourth Circuit.

Argued April 8, 1981.

Decided Sept. 4, 1981.

C. Frank Goldsmith, Jr., Marion, N. C., for appellant.

Max O. Cogburn, Jr., Asst. U. S. Atty., Asheville, N. C. (Harold M. Edwards, U. S. Atty., Asheville, N. C., on brief), for appellee.

Before BRYAN, Senior Circuit Judge, and PHILLIPS and SPROUSE, Circuit Judges.

JAMES DICKSON PHILLIPS, Circuit Judge:

Alva M. Hall appeals from a judgment of the U.S. District Court for the Western District of North Carolina, which affirmed a final decision of the Secretary of Health and Human Services denying Hall's application for social security disability insurance benefits. Concluding that the administrative record upon which the Secretary's decision was based is deficient in several critical areas, we vacate the judgment and remand for further proceedings.

I

Mrs. Hall filed an application in September 1978 for disability insurance benefits under Title II of the Social Security Act. Her claim was denied initially and on reconsideration by the Social Security Administration. Hall then requested a hearing before an administrative law judge (ALJ), which was held in May 1979.

At the hearing, Mrs. Hall testified that she had eight years of education and had last worked in September 1977, that her husband was employed, and that they had no dependent children. She described her past work experience. From 1974 to September 1977, she worked for Baxter Laboratories making a liquid medium and putting it in test tubes for later use in testing an intravenous solution. This job involved sitting, standing, walking, and lifting 25-30 pound packs of tubes. From 1971 to 1974, she worked as a furniture preassembler with Marimont Furniture using an automatic nailing machine and lifting pieces weighing 10-15 pounds each; from 1966 to 1971 she worked as a cabinet preassembler with Drexel Furniture Company and lifted tabletops weighing about 25 pounds each; and from 1958-1966, she worked for Washington Mills inspecting cut garment pieces and packing and loading them into trucks to be sent to the sewing room. These latter three jobs required Mrs. Hall to stand throughout the day. Finally, she worked for three months as a yarn winder at Cross Cotton Mill, a job which involved bending and lifting 7- to 18-pound tubes. Mrs. Hall also attempted to learn crocheting at a technical school in 1978, but dropped the course because she could not sit through the class and could not use her arms to that extent. She stated that she knew of no jobs that she could perform.

Mrs. Hall testified that she could not bend over and reach past her knees, remain in one position for long periods of time, raise her arms more than halfway, lift large pots, walk farther at one time than two doors down the street, walk up an incline or steps without help, or garden. Finally, she testified that she could do only limited housework for example, that it took her about a half hour to make the bed because she had difficulty pulling the covers, and that her husband did the shopping and helped her to dress.

Mr. Hall corroborated his wife's testimony. Letters from neighbors and friends also supported Mrs. Hall's allegations of limited physical capacities.

Medical records in evidence showed that since 1977, Mrs. Hall has been in the hospital frequently. Dr. David Cappiello, her treating orthopedic surgeon, first hospitalized Mrs. Hall from November 10 to December 3, 1977, for work-up and treatment because of her history of severe back and right leg pain. At that time, she underwent a lumbar myelogram, which indicated a defect on the right at the level of L4-5. This finding indicated a possible herniated disc. After conservative treatment with bed rest, analgesics, muscle relaxants, hydrocullator packs, and traction, Mrs. Hall was found practically asymptomatic and discharged. She was rehospitalized from January 24 to February 11, 1978 for low back pain of unknown etiology. An epidural venogram and another lumbar myelogram indicated a left-sided herniation. A consulting physician, Dr. Durham, however, thought Mrs. Hall might have a herniated nucleus pulposus. She was treated as before and also with an epidural block. Upon discharge, Mrs. Hall was not appreciably improved.

Based on the diagnosis of a herniated nucleus pulposus and the failure of conservative treatment, Mrs. Hall was again hospitalized from March 30 to April 8, 1978. This time she underwent surgery consisting of a hemilaminectomy, L4-5, right, and excision of the L4-5 disc. On April 29, 1979, Mrs. Hall was readmitted for acute lumbar strain and received conservative treatment. When discharged on May 20, 1979, Mrs. Hall was minimally symptomatic. Dr. Cappiello suggested that she return to work if her employer had any light work that she could do. When Dr. Cappiello last saw Mrs. Hall on September 13, 1978, she had been unable to work because Baxter Laboratories had no light work. Dr. Cappiello was insistent that Mrs. Hall should not lift heavy objects at that time. Mrs. Hall also testified that in late 1978 or early 1979, Dr. Cappiello stopped her from doing even housework. No medical reports, however, were introduced to support this assertion.

Mrs. Hall also was admitted to the hospital in 1978-79 for other problems not asserted in support of her disability claim. From June 2 to July 4, 1978, she was hospitalized by Dr. Yates Palmer, a general surgeon, and underwent a total abdominal hysterectomy, a left salpingo-oophorectomy, an appendectomy, and repair of cystocele and rectocele. She was discharged as improved. Three days later Mrs. Hall was rehospitalized for gastritis and traumatic arthritis of the right knee from an injury. She was discharged on July 16, 1978, as improved.

Based on these medical records, a physician for the state agency made a physical capacities evaluation of Mrs. Hall on October 16, 1978, that was made part of the record. He never examined Mrs. Hall, but concluded that she could lift 50 pounds occasionally and 25 pounds frequently, could stand and walk 6 or more hours during a normal work day, could sit and work 6 out of 8 hours, and had the capacity to perform the following functions frequently: pushing and pulling movements, climbing stairs or ladders, gross manipulation (grasping, twisting, and handling), fine manipulation, bending and/or stooping, and reaching. This report indicated that Mrs. Hall could do medium work as defined in the Social Security Administration regulations. 20 C.F.R. § 404.1510(d) (1980).

Mrs. Hall also underwent sinus surgery in November 1978 and April 1979. At the time of the hearing, she was taking muscle relaxants and nerve pills prescribed by Dr. Cappiello, hormones and vitamins prescribed by Dr. Palmer, and pain pills (Fiorinol) prescribed by the family physician.

The ALJ gave Mrs. Hall an extension of time to submit additional reports from Dr. Cappiello. When she was unable to contact him, Mrs. Hall saw another orthopedic surgeon, Dr. Larry Anderson. Dr. Anderson completed a physical capacities evaluation of Mrs. Hall and found that she could lift 10 pounds or less frequently; could stand and walk only 2 hours during a normal work day; could not sit and work 6 out of 8 hours; could only occasionally make pushing, pulling, grasping, twisting, handling, and reaching movements; and could neither climb stairs or ladders nor bend and/or stoop. Dr. Anderson concluded that Mrs. Hall was relatively disabled and doubted that she could do work requiring substantial lifting, prolonged standing, or bending.

Based on the above evidence, the ALJ found Mrs. Hall met the Social Security Act's special earnings requirements, but that she was not totally disabled. The ALJ first found that Mrs. Hall was not then working and that the medical evidence did not indicate that she was suffering from a "listed impairment" or the medical equivalent, so that she was not automatically deemed disabled under the regulations. Id. §§ 404.1503(d), .1504(a)(2), .1516(b), .1517, App. 1. The ALJ then found that Mrs. Hall was unable to do work involving substantial lifting, prolonged standing, or bending and, therefore, could not perform her past relevant work; that she had the residual functional capacity for at least sedentary work, id. § 404.1510(b); was a younger individual who can easily adapt to new work situations; and was semi-skilled with transferable skills. Consequently, he applied 20 C.F.R. § 404.1513 and App. 2, Table No. 1, Rule 201.20, which directed the conclusion that Mrs. Hall was not disabled.

The Appeals Council denied Mrs. Hall's request for review and the ALJ's decision became the Secretary's final determination. Mrs. Hall then brought this action for judicial review. 42 U.S.C. § 405(g). Acting on cross-motions for judgment on the pleadings and on Mrs. Hall's alternative motion for summary judgment, the district court affirmed the Secretary's decision as supported by substantial evidence. The district court noted that upon discharge after her back surgery and treatment, Mrs. Hall was minimally symptomatic and that there was neither neurological nor apparent physical evidence, such as significant weight loss, to support her allegations of severe pain. This appeal followed.

II

A claimant for disability benefits bears the burden of proving a disability, 42 U.S.C. § 423(d)(5); 20 C.F.R. § 404.1502 (1980); Blalock v. Richardson, 483 F.2d 773, 775 (4th Cir. 1972), which is defined by statute 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)(1)(A). Once the claimant makes a prima facie showing...