Pratts v. Chater, 1426

• Decision Date: 14 August 1996
• Docket Number: No. 1426,D,1426
• Citation: 94 F.3d 34
• Parties: , Unempl.Ins.Rep. (CCH) P 15638B Edwind F. PRATTS, Plaintiff-Appellant, v. Shirley S. CHATER, Commissioner of Social Security, Defendant-Appellee. ocket 95-6260.
• Court: U.S. Court of Appeals — Second Circuit

Page 34

94 F.3d 34

51 Soc.Sec.Rep.Ser. 549, Unempl.Ins.Rep. (CCH) P 15638B

Edwind F. PRATTS, Plaintiff-Appellant, v. Shirley S. CHATER, Commissioner of Social Security,

Defendant-Appellee.

No. 1426, Docket 95-6260.

United States Court of Appeals, Second Circuit.

Argued June 10, 1996.

Decided Aug. 14, 1996.

Steven Landis, Hauppauge, NY (Robert M. Brigantic, Binder and Binder, of counsel), for Plaintiff-Appellant.

Stanley N. Alpert, Asst. U.S. Atty., Brooklyn, NY (Zachary W. Carter, U.S. Atty., Varuni Nelson, Bruce H. Nims, Asst. U.S. Attys., of counsel), for Defendant-Appellee.

Before OAKES, ALTIMARI and WALKER, Circuit Judges.

OAKES, Senior Circuit Judge:

Appellant Edwin F. Pratts appeals the judgment of the United States District Court for the Eastern District of New York, John F. Gleeson, Judge, entered on September 1, 1995, affirming the decision of the Appellee Commissioner of Social Security's ("Commissioner") that Pratts was not disabled within the meaning of 42 U.S.C. § 423 (1994) at or before the time his eligibility for disability insurance expired. In this appeal, Pratts claims that the Commissioner improperly denied him disability benefits. We find that the denial was based on an incomplete and inadequate record which included several erroneous determinations by the administrative law judge who heard the claim. Accordingly, we vacate the decision of the district court and remand the case to the Commissioner for further development of the evidence and reconsideration of Pratts's application.

BACKGROUND

Pratts filed an application for disability benefits with the Social Security Administration ("SSA") in November 1992, claiming that he was disabled due to the manifestations of an HIV infection. Pratts, who was in his mid-forties at the time, alleged in his application that he had not been able to work since April 1987 as a result of his impairments. Previously, he had worked for roughly fifteen years as an industrial engineer and mechanic, a job requiring significant strength and exertion. Because of his employment history, Pratts met the SSA's disability insured In his application, Pratts stated that he had been treated on an outpatient basis at the Veterans' Administration Hospital (the "VA") in San Juan, Puerto Rico, starting in August 1987. Pratts did not have one treating physician, but was seen primarily by doctors in the VA's Infectious Disease Clinic. The multitude of doctors treating Pratts may explain why his medical records, which are the bulk of the evidence before us, are incomplete and do not reflect a decipherable course of treatment. Rather than recount every detail of these records, then, we instead will briefly summarize their contents.

status requirements through December 31, 1990, and, therefore, was entitled to disability benefits if he could prove that he was disabled on or before that date.

Medical Evidence

After going to the VA once in 1987 with a complaint of poor vision, Pratts began fairly regular visits in the fall of 1988. The inadequacies of his medical records are immediately evident: there is no indication of what prompted the CT scan administered at Pratts's first visit in mid-September 1988, nor any record of his second visit for gastroenteritis in late September 1988, nor any explanation provided for the diagnosis of AIDS made at his third visit in early October 1988. ¹ Pratts's complaints at his 1988 visits included headaches, dizziness, blurred vision, and diarrhea, and he was prescribed ampicillin for sinusitis in November.

Pratts was treated at the VA nine times in 1989. He continued to complain of headaches and blurred vision, and he again reported dizziness toward the end of the year. The records also show he suffered nasal secretions, rashes, and between a ten and twenty pound weight loss during the course of the year. Blood tests were recommended in October, but no results appear in the records. Pratts was diagnosed with maxillary sinusitis in November and was seen by a psychiatrist for anxiety in late December.

In early 1990, Pratts visited the Infectious Disease Clinic, complaining of neck and shoulder pain; he also saw an ophthalmologist for his vision problems. His complaints of dizziness, headaches, and anxiety persisted, and in March he was diagnosed with positional vertigo. Pratts was found to be suffering from anemia at both his April and May visits, and was treated for lower back pain starting in May. In July, Pratts was again evaluated for sinusitis and vertigo: the physician's findings are almost completely illegible, but indicate nasal blockage and positional vertigo. Treatment notes from 1990 show that Pratts remained on AZT and took other medications as well, including Buspar for his anxiety and Motrin for the pain in his back and head. At the end of November, his T-cell count of 211 put him very close to the 200 count used by the Center for Disease Control to identify those people whose HIV infection has developed into AIDS.

Both parties detail Pratts's treatment for the period after his insured status expired on December 31, 1990, until he filed his benefits application. Although such evidence "is not irrelevant" to a disability determination, Arnone v. Bowen, 882 F.2d 34, 39 (2d Cir.1989), we find it unnecessary for the purposes of our discussion here. Suffice it to say that Pratts continued to suffer from a variety of maladies connected to his HIV infection and that his medical records continued to display an unfortunate degree of inexactitude regarding test results, medications, weight loss or gain, symptoms, and follow-up treatment.

Procedural History

The SSA denied Pratts's November 1992 application for benefits in March 1993, and also denied his request for reconsideration in August 1993. Pratts then requested a hearing before an administrative law judge ("ALJ"). The ALJ held the hearing in February 1994; Pratts was represented by counsel and testified on his own behalf. The only other testimony was that of Dr. Edgar Bonilla, a medical expert called by the SSA who based his opinions on his review of Pratts's records from the VA. Unfortunately, the The Secretary of Health & Human Services has promulgated a five-step procedure for evaluating disability claims. 20 C.F.R. § 404.1520 (1995). In this case, the ALJ found that Pratts (1) was not currently working; (2) had a severe impairment that significantly limited his ability to perform work; (3) was not presumptively disabled because his condition did not meet or equal the impairments listed in the regulations; and (4) could not perform his past work. The present dispute concerns the fifth determination--whether there is other work that Pratts could do. The ALJ found that the Commissioner had demonstrated that Pratts retained his exertional capacity for light work. After evaluating all the evidence, the ALJ concluded that Pratts was not under a disability as defined in the Social Security Act, 42 U.S.C. § 423(d) (1994), on or before December 31, 1990. The ALJ based her conclusion on several factors, including Pratts's medical records and the testimony of the Commissioner's medical expert.

hearing tape was mistakenly turned off for a portion of Dr. Bonilla's testimony, leaving a significant gap in the administrative record.

The ALJ issued her decision denying Pratts disability benefits in March 1994. The ALJ's decision became the final decision of the Commissioner when the Appeals Council denied Pratts's pro se request for review on May 17, 1994.

Pratts sought review of the Commissioner's decision in federal court pursuant to 42 U.S.C. § 405(g) (1994). The parties cross-moved for judgment on the pleadings, and the district court, after a brief hearing, granted the Commissioner's motion on the ground that substantial evidence supported the findings of the ALJ. This appeal followed.

DISCUSSION

The standard for our review of Pratts's appeal has been made clear in numerous prior decisions of this court. When considering an appeal of a disability case, "we undertake our own plenary review of the administrative record to determine whether substantial evidence supports the [Commissioner]'s denial of benefits." Havas v. Bowen, 804 F.2d 783, 785 (2d Cir.1986); see also Vargas v. Sullivan, 898 F.2d 293, 296 (2d Cir.1990); Parker v. Harris, 626 F.2d 225, 231 (2d Cir.1980). We therefore focus our attention on the administrative ruling rather than on the decision of the district court. Rivera v. Sullivan, 923 F.2d 964, 967 (2d Cir.1991); Wagner v. Secretary of HHS, 906 F.2d 856, 860 (2d Cir.1990). It is not our function to determine de novo whether Pratts is disabled, Mimms v. Heckler, 750 F.2d 180, 185 (2d Cir.1984), and "we may only set aside a determination which is based upon legal error or not supported by substantial evidence." Berry v. Schweiker, 675 F.2d 464, 467 (2d Cir.1982) (per curiam).

"Substantial evidence" has been defined by the Supreme Court as " 'more than a mere scintilla. It means such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.' " Richardson v. Perales, 402 U.S. 389, 401, 91 S.Ct. 1420, 1427, 28 L.Ed.2d 842 (1971) (quoting Consolidated Edison Co. v. NLRB, 305 U.S. 197, 229, 59 S.Ct. 206, 217, 83 L.Ed. 126 (1938)); see also Diaz v. Shalala, 59 F.3d 307, 314 (2d Cir.1995); Arnone, 882 F.2d at 37.

It is the rule in our circuit that "the ALJ, unlike a judge in a trial, must [her]self affirmatively develop the record" in light of "the essentially non-adversarial nature of a benefits proceeding." Echevarria v. Secretary of HHS, 685 F.2d 751, 755 (2d Cir.1982). This duty arises from the Commissioner's regulatory obligations to develop a complete medical record before making a disability determination, 20 C.F.R. § 404.1512(d)-(f) (1995), and exists even when, as here, the claimant is represented by counsel. Perez v. Chater, 77 F.3d 41, 47 (2d Cir.1996). Based on the administrative record before us, we believe that the...