Wooldridge v. Bowen

Decision Date15 April 1987
Docket NumberNo. 86-3084,86-3084
Citation816 F.2d 157
Parties, 22 Fed. R. Evid. Serv. 1578, Unempl.Ins.Rep. CCH 17,271 Wanda L. WOOLDRIDGE, Plaintiff-Appellant, v. Otis R. BOWEN, Secretary, Department of Health and Human Services, Defendant-Appellee.
CourtU.S. Court of Appeals — Fourth Circuit

Roger Daniel Forman, on brief, for appellant.

Dorothea J. Lundelius, Asst. Regional Counsel, Office of the General Counsel, Dept. of Health and Human Services (Beverly Dennis, III, Chief Counsel, Region III, Charlotte Hardnett, Supervisory Asst., Regional Counsel, David A. Faber, U.S. Atty., Gary E. Pullin, Asst. U.S. Atty., on brief, for appellee.

Before HALL and CHAPMAN, Circuit Judges, and SENTELLE, United States District Judge for the Western District of North Carolina, sitting by designation.

K.K. HALL, Circuit Judge:

Wanda L. Wooldridge appeals an order of the district court, affirming the Secretary's denial of her claim for disability insurance benefits under Title II of the Social Security Act. 42 U.S.C. Secs. 416(i) and 423(d). This denial was based upon the determination of an administrative law judge ("ALJ") that Wooldridge has the residual functional capacity to perform light work and was not disabled under the Secretary's medical-vocational guidelines or "grids." The district court affirmed, finding substantial evidence to support the ALJ's decision. We disagree and conclude that the decisions below were deficient in several critical respects. Accordingly, we vacate the judgment of the district court and direct that the case be remanded to the Secretary for further consideration and findings consistent with this opinion.

I.

Wanda Wooldridge was born on August 4, 1931, and was 54 years old at the time of her hearing before the ALJ. She was last insured for disability benefits on December 31, 1982, when she ceased working due to breathing difficulties. Claimant has a ninth grade education and the majority of her past work experience was as a waitress.

Wooldridge applied for social security disability benefits in January, 1984, alleging that she has been disabled since October, 1981, due to emphysema and bleeding from the bowels. Her application was denied initially and on reconsideration.

At the administrative hearing on her claim, Wooldridge testified that she was unable to afford medical treatment for her problems until August 8, 1983, and the record contains no medical evidence concerning claimant's condition prior to the expiration of her insured status on December 31, 1982. According to Wooldridge, she continued to work "part time" or intermittently as a waitress until the end of 1982.

In response to questioning from the ALJ, claimant stated that she had difficulty breathing, sleeping, walking, and as a result of a mastectomy in 1984, moving her right arm. Also in 1984, Wooldridge had several polyps removed from her colon. Wooldridge further complained of low blood count, dizziness, and fainting, as well as chest and back pain. She stated that she was prescribed various medications for these conditions, including pills and inhalers for her breathing impairment. According to claimant, she can walk only twenty feet before being required to rest and can stand only five to ten minutes before becoming dizzy. Wooldridge testified that her husband assists her in getting dressed and brushing her hair and also does the housework and grocery shopping. The medical records from the Cabin Creek Health Association Clinic, where Wooldridge has been a patient since August 8, 1983, confirm the treatment of her ailments.

Subsequent to the hearing, on December 27, 1984, Alan Milliner, M.D., of the Cabin Creek Health Association, wrote in a letter to claimant's counsel that it was apparent that Wooldridge began having significant problems with her breathing about fifteen years ago and for a number of years had used a non-prescription Primatene Mist Inhaler several times a day. According to Dr. Milliner's report, Wooldridge:

experienced dyspnea [difficult or labored breathing] from asthma which was severe enough to cause ... loss of consciousness quite frequently. These exacerbations were precipitated even by activities requiring minimal effort such as walking two blocks to the store. She received no regular medication for her asthma until she established care at Cabin Creek Medical Center.

Dr. Milliner opined that based on claimant's history "she has been severely disabled by her asthma since at least 1980" and that "[e]ven today on maximal medical therapy for her asthma she remains severely dyspneic even at rest." Dr. Milliner's letter was submitted to the ALJ for consideration.

In his decision denying benefits dated March 5, 1985, the ALJ noted that "[c]linical findings in April and June 1984 confirmed that the claimant suffers from chronic obstructive pulmonary disease and should avoid temperature extremes, dust, fumes, humidity and environments where major pulmonary irritants are present." The ALJ further found that Wooldridge's breathing impairment was severe but not of a sufficient degree to meet the Secretary's listing of impairments. Although the ALJ concluded that claimant could not perform her past work as a waitress, he found that she could "perform the physical exertion requirements of work except for lifting more than 20 pounds at a time with occasional lifting or carrying of 10 pounds." Based on this finding, the ALJ determined that Wooldridge retained the residual functional capacity to perform light work. Applying the Secretary's medical-vocational guidelines or "grids," he concluded that she was not disabled.

The Appeals Council denied review and Wooldridge appealed the decision to the district court. The case was referred to a magistrate for a recommended decision. The magistrate found that:

The only evidence of a significant impairment existing before December 31, 1982, is by history ... Also, the plaintiff continued to work until sometime in December, 1982 ... There is no question that after December 31, 1982, the plaintiff suffered from some severe impairments, but not before that date.

The magistrate rejected claimant's argument that, in light of her nonexertional impairment, the ALJ improperly relied upon the "grids," concluding that "the record does not show the presence of a severe non-exertional impairment prior to December 31, 1982."

The district court affirmed the magistrate's decision in Woolridge v. Secretary, 637 F.Supp. 741 (S.D.W.Va.1986). 1 Specifically, the district court concluded that Dr. Milliner's report was not supported by the record and that:

The medical testimony and opinion based thereon taken and rendered by Dr. Milliner were properly given no consideration by the Magistrate, even though they came from a "treating" physician. The evidence in the form offered is pure hearsay and does not satisfy the requirements of admissibility under Rule 803(4), Federal Rules of Evidence. Subsequent history taken by Dr. Milliner was not for the purposes of treatment or diagnosis but rather done to supply a critical evidentiary requirement in support of Plaintiff's claim for benefits under the Act. In other words, it was prepared solely for the purposes of this litigation. Since the doctor's opinion has no evidentiary support in the record and is, in fact, contradicted by the record, it properly was not considered by the Magistrate or Secretary in their conclusions to deny benefits.

Id. at 742.

This appeal followed.

II.

On appeal, Wooldridge contends that the opinion of Dr. Milliner and her post-1982 evidence of disability were improperly disregarded below. Appellant also argues that the ALJ erred in his findings with respect to her capacity to perform light work and to the application of the "grids" in her case. We agree with each of these contentions and conclude that a remand is necessary to reconsider Wooldridge's claim. 2

The ALJ's decision made no mention of Dr. Milliner's opinion that Wooldridge has been disabled since 1980 and the magistrate declined to give Dr. Milliner's opinion any weight. The district court agreed with the magistrate, holding that Dr. Milliner's report was hearsay and was properly given no consideration. Each of these decisions is in error. 3

In Richardson v. Perales, 402 U.S. 389, 91 S.Ct. 1420, 28 L.Ed.2d 842 (1971), the Supreme Court held that Congress intended for social security disability proceedings to be informal and not governed by strict rules of evidence. The Court specifically approved the admission of written medical reports by licensed, examining physicians despite their hearsay character. Id. 402 U.S. at 402, 91 S.Ct. at 1428, 28 L.Ed.2d 842. Thus under Perales, Dr. Milliner's report was entitled to be considered. 4

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