Schaffer v. Califano

• Decision Date: 13 May 1977
• Docket Number: Civ. A. No. Y-76-58.
• Citation: 433 F. Supp. 1218
• Parties: Russell Thomas SCHAFFER v. Joseph A. CALIFANO, Jr., Secretary, Department of Health, Education and Welfare.
• Court: U.S. District Court — District of Maryland

433 F. Supp. 1218

Russell Thomas SCHAFFER v. Joseph A. CALIFANO, Jr.,¹ Secretary, Department of Health, Education and Welfare.

Civ. A. No. Y-76-58.

United States District Court, D. Maryland.

May 13, 1977.

Francis N. Iglehart, Towson, Md., for plaintiff.

John W. Sheldon, Asst. U. S. Atty., Baltimore, Md., for defendant.

MEMORANDUM AND ORDER

JOSEPH H. YOUNG, District Judge.

The plaintiff, Russell Thomas Schaffer, instituted this action on January 13, 1976 to obtain judicial review of the final decision of the Secretary of Health, Education and Welfare which denied his claim for benefits under the Social Security Act, 42 U.S.C. § 301 (1970), et seq.

On January 31, 1975, Mr. Schaffer filed his original application for disability insurance benefits and for supplemental security income benefits alleging disability due to extensive head and face injuries and injuries to his left eye resulting from an automobile accident occurring on December 20, 1974. (Tr. 48, 54).² Mr. Schaffer's claims for benefits were denied on March 5, 1975 by the Division of Initial Claims. (Tr. 52). The plaintiff's request for reconsideration filed March 12, 1975 met with a similar denial on March 27th of that year. (Tr. 58-59).

On May 6, 1975, plaintiff requested a hearing before an Administrative Law Judge. His claimed entitlements to disability insurance benefits and supplemental security income were consolidated and heard before Administrative Law Judge Leonard N. Lawrence on September 16, 1975. (Tr. 20-47). Mr. Schaffer appeared and testified under oath before the Administrative Law Judge. Although he is now represented by counsel, he was not so represented throughout the administrative process.

On September 25, 1975, the Administrative Law Judge issued his written hearing decision in which he found that the claimant retained the residual capacity to return to several of the forms of work in which he had previously engaged and that, therefore, he was not disabled within the meaning of the Social Security Act. (Tr. 6-12).

Being dissatisfied with that determination, the plaintiff requested a review of that hearing decision before the Appeals Council on September 26, 1975. (Tr. 4). On November 14, 1975, the Appeals Council affirmed the finding of the Administrative Law Judge and denied the claimant benefits. (Tr. 3). That decision became the final decision of the Secretary of Health, Education and Welfare for purposes of review in this court. 20 C.F.R. § 404.951.

PLAINTIFF'S MEDICAL HISTORY

Russell Thomas Schaffer was born on January 6, 1949 and is 28 years of age at the present time. He is 5'10½" tall, unmarried, and is buying his own home. (Tr. 28-29). At the time of the accident, out of which this claim arises, Mr. Schaffer had completed approximately two years of college and was then one semester away from obtaining an Associate of Arts Degree in Correctional Services. (Tr. 31). Prior to his accident, plaintiff worked for the Department of Corrections as a correctional officer, and has also worked for different periods as an assemblyline worker in a ski plant and as a retail salesman. (Tr. 32, 40). In addition, he worked for a short period one summer with the Board of Education as a custodian which involved the use of scrubbing and waxing machines and cleaning up school facilities. (Tr. 40).

An admission summary from the University of Maryland Hospital, dated December 20, 1974, reveals that Mr. Schaffer was an emergency admission and that he suffered acute head trauma, multiple facial fractures, and facial lacerations as a result of an apparent automobile accident. It appears that the noted head trauma resulted in an acute epidural hematoma. The patient was taken to the neurosurgical operating room where the treating physicians performed an evacuation of the acute epidural hematoma. During this procedure it was noted that he had suffered a large left supraorbital laceration, a left mid-face laceration, nasal fractures, comminuted, and an inner periorbital laceration, and left frontal sinus fracture. A left infraorbital rim fracture and anterior maxillary sinus fracture were also found.

It is not necessary for purposes of this review to review in detail the injuries suffered and the emergency surgical procedures performed. It suffices to say that Mr. Schaffer suffered acute and massive injuries to his head in the region of the left eye. (Tr. 76-77).

On December 23, 1974, a surgical procedure was undertaken to continue repair and reconstruction of the area around the eye including the eyelids. This procedure was tolerated well and no complications arose. (Tr. 78).

A neurosurgery note from the Outpatient Department of the University of Maryland Hospital, dated February 5, 1975, notes that the plaintiff was "fully recovered neurologically except diplopia". (Tr. 79). Diplopia is a condition in which two images of a single object are perceived.

A history record from the University of Maryland Hospital directed "To Whom It May Concern" relates that Mr. Schaffer was hospitalized from December 20, 1974 to January 9, 1975 for significant injuries sustained in an auto accident. It also revealed that he was at that time recovering from a severe head injury which "will prevent him from returning to work". (Tr. 83). Unfortunately, other than indicating that it was made in 1975 the illegibility of the date entry precludes consideration of this report in terms of relevant time periods. (Tr. 83-84).

On May 1, 1975, Dr. J. Parran, a resident in opthamology at the University Hospital, reported that Mr. Schaffer had received multiple facial fractures, lid and canalicular system injury, and impairment of extraocular muscle function in his left eye with resultant diplopia. Dr. Parran noted that the plaintiff would continue to be followed until spring or summer of 1975 as an outpatient, at which time plastic reconstructive surgery, perhaps followed by extraocular muscle surgery, would be undertaken with recuperation from these procedures taking approximately five to six months. (Tr. 86).

On May 7, 1975, Dr. Pratt, the chief resident in neurosurgery at the University of Maryland Hospital, reported that Mr. Schaffer had been unable to work or drive a car since December 20, 1974, and that it was expected that his recovery would take approximately eight additional months before he would be able to return to work. (Tr. 87).

On September 16, 1975, Dr. Joel J. Feldman, a chief resident in plastic surgery at the Johns Hopkins Hospital, reported that Mr. Schaffer had undergone a craniofacial reconstruction for deformities resulting from the automobile accident. This procedure was performed on August 19, 1975. Dr. Feldman noted that a second stage procedure would be required in approximately six to eight weeks from the date of the report, and that it was anticipated that the plaintiff would not be able to return to work until approximately one or two months after completion of that procedure. (Tr. 91).

Also on September 16, 1975, Dr. Neil R. Miller, chief resident in ophthalmology at the Wilmer Ophthalmological Institute of the Johns Hopkins Hospital, reported that Mr. Schaffer had undergone multiple reparative operations and that at that time he was suffering from double vision and that he could, therefore, not use both eyes together. Dr. Miller further stated that "this is not helped by, nor have we suggested, patching of the left eye. He is to have further surgery in the near future by the Division of Plastic Surgery. Following this it is hoped that his double vision will ultimately be improved. Until this time I have instructed him not to wear any patch over the eye." (Tr. 92).

On September 16, 1975, Dr. Miller was contacted by either the Administrative Law Judge or a member of his staff for clarification of Dr. Miller's report of the same date. This report of contact states as follows: "Doctor stated unequivocally that claimant may do light and sedentary work. A patch worn over the eye would not prove harmful in any way. The doctor was under the impression claimant's work as a correctional officer involved the use of a gun and on this basis could not return to that type work. He can read and write without restriction." (Tr. 95).

Dr. Feldman's report of September 16, 1975 was similarly clarified by contact from the Administrative Law Judge or his staff on that date. That report of contact states as follows: "Dr. Feldman stated claimant could do light and sedentary work so long as he is not affected adversely. He stated diplopia does not affect straight ahead vision, only peripheral. He stated the purpose for waiting for surgery is for allowing time for fluid in the area between the eye and the brain to disperse. This would not affect his current ability to engage in light and sedentary activities." (Tr. 96).

On September 17, 1975, Mr. Schaffer was informed of the existence of these reports of contact of the previous day by the Administrative Law Judge and his comments were solicited. (Tr. 97).

On September 20, 1975, the claimant responded stating two objections to the reports. As to the report from Dr. Miller, he noted that the clarification statement was in direct conflict with Dr. Miller's earlier statement concerning the advisibility of wearing a patch over the left eye. Mr. Schaffer noted that Dr. Miller's observation that "he can read and write without restriction" was essentially true but incomplete due to irritation to the eye which results from reading over a short period of time. With regard to the clarification of Dr. Feldman's report, the claimant took issue with the characterization of his diplopia as "only peripheral". He stated that it is true that it does not affect straight ahead vision, but it does affect the upward, downward, and leftward gazes." (Tr. 98). Mr. Schaffer concluded his letter to the Administrative Law Judge as follows: "I have been rendered incapable of doing heavy labor for the present by the fact...