Filed: Jul. 05, 2006
Latest Update: Feb. 21, 2020
Summary: F I L E D United States Court of Appeals Tenth Circuit UNITED STATES CO URT O F APPEALS July 5, 2006 FO R TH E TENTH CIRCUIT Elisabeth A. Shumaker Clerk of Court RO BERT H . M IRA CLE, Plaintiff-Appellant, v. No. 05-6308 (D.C. No. CIV-04-769-W ) JO A NN E B. BA RN HA RT, (W .D. Okla.) Commissioner of Social Security Administration, Defendant-Appellee. OR D ER AND JUDGM ENT * Before H E N RY, BR ISC OE, and M U RPH Y, Circuit Judges. Robert H. M iracle appeals from an order of the district court
Summary: F I L E D United States Court of Appeals Tenth Circuit UNITED STATES CO URT O F APPEALS July 5, 2006 FO R TH E TENTH CIRCUIT Elisabeth A. Shumaker Clerk of Court RO BERT H . M IRA CLE, Plaintiff-Appellant, v. No. 05-6308 (D.C. No. CIV-04-769-W ) JO A NN E B. BA RN HA RT, (W .D. Okla.) Commissioner of Social Security Administration, Defendant-Appellee. OR D ER AND JUDGM ENT * Before H E N RY, BR ISC OE, and M U RPH Y, Circuit Judges. Robert H. M iracle appeals from an order of the district court a..
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F I L E D
United States Court of Appeals
Tenth Circuit
UNITED STATES CO URT O F APPEALS
July 5, 2006
FO R TH E TENTH CIRCUIT Elisabeth A. Shumaker
Clerk of Court
RO BERT H . M IRA CLE,
Plaintiff-Appellant,
v. No. 05-6308
(D.C. No. CIV-04-769-W )
JO A NN E B. BA RN HA RT, (W .D. Okla.)
Commissioner of Social Security
Administration,
Defendant-Appellee.
OR D ER AND JUDGM ENT *
Before H E N RY, BR ISC OE, and M U RPH Y, Circuit Judges.
Robert H. M iracle appeals from an order of the district court affirming the
Commissioner’s decision denying his application for Social Security disability
and Disabled Adult Child’s benefits, which had a protective filing date of M ay 4,
*
After examining the briefs and appellate record, this panel has determined
unanimously to grant the parties’ request for a decision on the briefs without oral
argument. See Fed. R. App. P. 34(f); 10th Cir. R. 34.1(G). The case is therefore
ordered submitted without oral argument. This order and judgment is not binding
precedent, except under the doctrines of law of the case, res judicata, and
collateral estoppel. The court generally disfavors the citation of orders and
judgments; nevertheless, an order and judgment may be cited under the terms and
conditions of 10th Cir. R. 36.3.
2001. 1 He alleged disability based on bipolar disorder with an onset date of April
1, 1999, when he was nineteen years old. An administrative law judge (ALJ)
determined that he could return to his past relevant work as a stocker.
In this appeal, M r. M iracle raises four issues. He argues that the ALJ failed
to correctly assess the “longitudinal” nature of his mental impairment. He
contends that there is substantial evidence to support his allegations of a disabling
mental impairment. He argues that his mental impairment precludes him from
performing his past relevant work. Finally, he contends that the district court
improperly failed to make a de novo review of the magistrate judge’s report and
recommendation in his case. Because the ALJ failed to give proper consideration
to all the evidence and the record and to make proper findings concerning the
interaction between M r. M iracle’s RFC and his past relevant work, and because
he inadequately developed the record concerning M r. M iracle’s impairments and
his ability to return to his past relevant work, we must reverse and remand.
FACTS
M r. M iracle was born on September 14, 1979. On February 17, 1997, when
he w as seventeen, his mother brought M r. M iracle to see his family doctor,
1
M r. M iracle applied for Disabled Adult Child’s benefits based on the
earnings record of his father, Roger Dale M iracle, who died fully insured on
January 30, 2000. To obtain the benefits, M r. M iracle needed to demonstrate,
among other things, that he had a disability before attaining age 22 and that this
disability continued without interruption through the date of his application.
See 42 U.S.C. § 402(d).
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Dr. Pope. M r. M iracle reported having problems staying in school and had
trouble “defining reality.” A plt. App. at 159. He had done drugs and engaged in
binge drinking. He reported a fear that he might hurt somebody. Dr. Pope
thought he showed “some almost delusional thinking at times with very decreased
concentration” and that a “[p]ersonality disorder is probable.”
Id. at 158.
Dr. Pope recommended that M r. M iracle obtain psychological counseling.
By September 11, 1997, things were much w orse. M r. M iracle had dropped
out of school, and was experiencing trouble sleeping. He had gained twenty-three
pounds, had stopped seeing his friends, and hardly ever left the house. Dr. Pope
observed that M r. M iracle had “pressured speech, flight of ideas, and has a very
low attention span” and that he “comes up with off the wall comments and
completely changes the subject.”
Id. at 154. M r. M iracle w as hospitalized in
mid-September 1997, at Bethany Pavilion Hospital at which time he was initially
diagnosed with Psychosis, NOS (not otherwise specified), and later with paranoid
schizophrenia. After his discharge from the hospital, he received follow-up
treatment from a psychiatrist, Dr. M cNeil, from September 25, 1997, to
November 17, 2000. Dr. M cNeil diagnosed him with schizoaffective disorder and
treated him with a mood stabilizer and anti-psychotic medication. 2 The record
2
The ALJ found that M r. M iracle has a “mental health impairment.” A plt.
App. at 53. M r. M iracle identified his condition as bipolar disorder on documents
filed with the agency. See, e.g.,
id. at 116. The medical records contain many
(continued...)
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does not contain any medical records from the 1997 hospitalization nor any
treatment or progress notes from M r. M iracle’s three years of treatment with
Dr. M cNeil. 3 It does contain a letter from Dr. M cNeil, dated January 7, 2002,
summarizing his diagnosis and treatment of M r. M iracle.
Records from the family doctor, Dr. Pope, during the period of October 31,
1997, to January 31, 2001, show sporadic visits for ear infections and hearing
problem s, with occasional notations that M r. M iracle continued on his psychiatric
medications. The next significant medical record pertaining to M r. M iracle’s
mental status is dated April 2, 2001, six months after he stopped seeing
Dr. M cNeil and a month before he filed his application for benefits. Dr. Pope
noted on that occasion:
Patient comes in reporting he has been having some pain in his low
back, thinks that he has had a kidney stone in the past, he reports it
was “delirious pain.” Patient reports he was screaming, he went
outside to try and cool off, but took a blanket w ith no clothes.
Patient reports also fever and chills. . . . He did have 2 beers
yesterday. . . . As well he did some marijuana over the weekend.
Denies any . . . suicidal/homicidal ideation. . . .
Patient is unshowered, wearing polo shirt, briefs, and flip-flops.
Patient very suggestable, having trouble continuing with individual
topics. To grass is always greener on the other side of the fence he
2
(...continued)
different mental diagnoses, some of which note the existence of bipolar-type
symptoms. Following his own assertions, we have referred to his condition
generically as “bipolar disorder.”
3
It appears that M r. M iracle’s representative attempted to obtain these
records but was unable to do so. Aplt. A pp. at 131.
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wrote my grass is better. To every cloud has a s[il]ver lining he
wrote clouds have lots of different linings. To people that live in
glass houses should not throw stones he reports “lots of stones.”
Patient was completely oriented to date and time.
Id. at 144.
Dr. Pope diagnosed M r. M iracle w ith a psychotic episode, talked to him
about receiving inpatient treatment and to get back on his medications, and
contacted the mental health authority in Norman, Oklahoma, and made
arrangements for M r. M iracle to go there that afternoon. There is nothing in the
record to indicate whether M r. M iracle kept his appointment with the mental
health authority, or if so, what sort of diagnosis or treatment he received there.
The next evidence in the record concerning M r. M iracle’s mental health is a
disability evaluation report conducted by agency consultant Dr. Chakraburtty
three months later, on July 21, 2001. Dr. Chakraburtty noted that M r. M iracle
“reports that he is not having any psychiatric treatment at the present time.”
Id. at 163. He diagnosed him with “Psychosis, NOS,” “History of Bipolar
Disorder,” and “Personality Disorder, NOS, with dependent traits.”
Id. at 165.
Less than a month later, in August 2001, M r. M iracle obtained a
comprehensive treatment plan and began receiving mental health services from
Chisholm Trail Counseling Services. He was diagnosed at Chisholm Trail with
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schizoaffective disorder, bipolar type. 4 It was noted that he was living with his
mother.
The agency denied his applications initially and on reconsideration. On
August 19, 2002, M r. M iracle received a de novo hearing before an ALJ. The
ALJ determined that Mr. Miracle had severe impairments, namely “mental health
impairment and some hearing difficulty.” Aplt. App. at 53. He further
determined that Mr. Miracle retained the residual functional capacity (RFC) to
perform “the physical demands of a full range of physical activities. However, he
should not be expected to understand, remember, and carry out detailed or
complex job instructions; work closely with the general public; or perform tasks
requiring ability to hear with the left ear.”
Id. at 56.
4
The Chisholm Trail records before the A LJ covered the period from August
7, 2001, through February 6, 2002. See Aplt. App. at 206-47. Curiously, in his
brief, M r. M iracle also cites to Chisholm Trail records from M ay 29, 2002,
through July 26, 2003. He even supplies a purported record reference to these
documents. See Aplt. Br. at 22-23 (citing Aplt. App. at 211-47). These medical
records are not contained in either copy of the appendix filed with this court,
however. Neither, it appears, w ere they before the ALJ or the Appeals Council.
The ALJ apparently received exhibits at the hearing, including exhibits 5F
and 6F, records provided by Chisholm Trail on February 13, 2002, covering the
time period we have noted, but nothing later than this. See Aplt. App. at 34, 247,
265. The ALJ did not hold the record open, see
id. at 266, 275, and nothing in the
record indicates that M r. M iracle attempted to supplement the record before the
Appeals Council w ith anything but a brief,
id. at 36. W e conclude that the
records cited on pages 22 and 23 of M r. M iracle’s brief are not part of the record
on appeal, and we will not consider them.
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STANDARD OF REVIEW
The ALJ found that M r. M iracle could return to his past relevant work as a
stocker, and was therefore not disabled. See Williams v. Bowen,
844 F.2d 748,
750-52 (10th Cir. 1988) (outlining five-step test for disability). The Appeals
Council denied review, making the ALJ’s decision the Commissioner’s final
decision. We review the Commissioner’s decision to determine whether the
factual findings are supported by substantial evidence in the record and whether
the correct legal standards were applied. See Andrade v. Sec’y of Health &
Human Servs.,
985 F.2d 1045, 1047 (10th Cir. 1993). Substantial evidence is
“such relevant evidence as a reasonable mind might accept as adequate to
support a conclusion.” Fowler v. Bowen,
876 F.2d 1451, 1453 (10th Cir. 1989)
(quotations omitted).
ANALYSIS
1. Failure to develop the record
The Commissioner follows a five-step sequential evaluation process
to determine whether a claimant is disabled. See
Williams, 844 F.2d at 750-52.
The ALJ decided this case at step four, finding that Mr. Miracle could return to
his past relevant work. The claimant bears the burden of establishing
a prima facie case of disability at steps one through four. See
id. at 751 n.2.
Although M r. M iracle bore the burden of establishing his disability, “unlike
the typical judicial proceeding, a social security disability hearing is
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nonadversarial, with the ALJ responsible in every case to ensure that an adequate
record is developed during the disability hearing consistent with the issues
raised.” Hawkins v. Chater,
113 F.3d 1162, 1164 (10th Cir. 1997) (citation and
quotation omitted). The duty is particularly acute where the claimant is
unrepresented at the hearing, Henrie v. United States Dep’t of Health & Human
Servs.,
13 F.3d 359, 361 (10th Cir. 1993), or (as here) is represented by a
non-attorney. In addition to developing the record at the hearing through careful
questioning, and by obtaining the services of a consultative examiner when
necessary, the ALJ “has the duty to develop the record by obtaining pertinent,
available medical records which come to his attention during the course of the
hearing.” Carter v. Chater,
73 F.3d 1019, 1022 (10th Cir. 1996).
The most striking thing about the administrative record is the absence of
known medical records directly relevant to significant issues surrounding
M r. Miracle’s mental disability. As noted, the record does not contain any
medical records from his 1997 hospitalization at Bethany Pavilion Psychiatric
Hospital nor any treatment or progress notes from M r. M iracle’s three years of
treatment with Dr. M cNeil, from 1997 to 2000. Records also appear to be
missing from any follow-up treatment he obtained through a hospitalization
recommended by his family doctor after a psychotic episode in April 2001.
The government contends that M r. M iracle w aived any objection as to this
woefully under-developed state of the record by failing to raise this issue in
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district court until he filed his objections to the magistrate judge’s report and
recommendation. These vast gaps in the record, however, are directly relevant to
the other issues that he did properly preserve, and cannot be simply swept under
the rug by a narrow application of the waiver rule.
2. “Longitudinal nature” of mental impairment
The ALJ made only passing reference to the three years of mental health
treatment M r. M iracle received from Dr. M cNeil prior to the time he applied for
benefits. W hile an ALJ need not discuss every piece of evidence in the record,
the A LJ appears to have affirmatively and selectively misread the record
concerning M r. M iracle’s impairment. At several times in his decision, the ALJ
relied on the fact that M r. M iracle was not receiving mental health care at the
time he filed his application for benefits. See Aplt. App. at 53 (“After filing his
applications for benefits, the claimant sought mental health counseling. . . .
Although the claimant obtained psychological counseling after filing for benefits,
he w as not receiving mental health care as of the time of his application.”);
id. at 55 (“The claimant testified . . . that he had recently started mental health
treatment . . . .”). This reading of the record, which ignored M r. M iracle’s
long-standing treatment history, reflected the kind of misleading selective inquiry
courts have decried on numerous occasions. See, e.g., Sisco v. United States
Dep’t of Health & H um an Servs.,
10 F.3d 739, 743 (10th Cir. 1993). M oreover,
the ALJ’s failure to develop the record by obtaining the records pertaining to this
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treatment facilitated his failure to consider the medical evidence showing a
long-standing record of impairment.
3. Nature of impairment and past relevant w ork
A key issue in this case involved whether M r. M iracle was capable of
sustained work, given his spotty employment record and his frequent job changes,
many of which were attributed by himself and his treating physician to his mental
impairment. A disability report prepared by his representative informed the ALJ
that, “Robert has had frequent job changes due to an inability to stay focused,
complete tasks, Has been fired, has had trouble relating to others at work, and
has had to quit because of too much pressure at w ork.” Aplt. A pp. at 116.
Dr. M cNeil explained that M r. M iracle “had several different jobs, all of which he
had quit for various reasons. W hat seemed to be clear from his reports is that he
had difficulties with interpersonal relations, both with co-workers and in service
related jobs.”
Id. at 167. The VE testified that his w ork record was quite “scant”
and that it “seem[ed] like work attempts to me.”
Id. at 272.
Even if we assume that M r. M iracle’s previous work attempts, only a
few of which lasted more than a month, represented “past relevant w ork,”
see 20 C.F.R. § 404.1560(b)(1) (defining past relevant work), given the issues
developed prior to the hearing, the ALJ needed to build an adequate record and
make proper findings concerning M r. M iracle’s ability to work with others on a
sustained basis, and the demands of his past relevant work in terms of relating to
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co-w orkers and the general public. See SSR 96-8p, 1996 W L 374184, at *5
(stating that ALJ must consider work attempts and lay evidence in determining
RFC).
M r. M iracle’s representative asked him one question about the problems he
had had with employment. He responded that he had experienced the “[f]eeling
of being paranoid, like people were out to get me, and like somebody was going
to do something bad to me.”
Id. at 267. He stated, “I couldn’t work right because
I thought I would hear things that weren’t present to others.”
Id. M r. M iracle
further testified that he did not have any friends and did not do things w ith people
outside his family.
Id. at 269. The ALJ only asked M r. M iracle one question at
the hearing, concerning w hether he had obtained a GED.
The A LJ asked the V E about the specific tasks involved in being a stocker,
the kind of work M r. M iracle had previously performed. W hile he asked whether
the jobs would require significant interaction with the general public (to which
the VE responded no), he did not ask any questions concerning what sort of
interaction was required with M r. M iracle’s co-workers. As mentioned,
Dr. M cNeil stated that M r. M iracle had quit many of his prior jobs and had
“difficulties with interpersonal relations, both with co-workers and with
customers in service related jobs.”
Id. at 167 (emphasis added). He also opined
that “[d]uring the time that I treated [M r. M iracle], he consistently showed mental
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status signs and symptoms which would make employment difficult in . . . jobs
which require significant amounts of interpersonal contact.”
Id. at 168.
Dr. M cNeil did not distinguish between difficulties M r. M iracle w ould
experience in dealing with co-workers and with the general public. The ALJ
concluded in his decision, however, giving no reason for ignoring Dr. M cN eil’s
opinion concerning jobs involving interpersonal contact, that M r. M iracle “is able
to interact appropriately with others on a superficial level [but] . . . should not be
expected to . . . work closely with the general public.”
Id. at 55. As noted, there
was no testimony about the demands of M r. M iracle’s past relevant work when it
came to relating to his co-workers. M oreover, the ALJ asked the VE only one
hypothetical question, concerning M r. M iracle’s ability to perform work
activities, and that question contained no indication of any interpersonal
difficulties, either with the public or with co-workers. Aplt. App. at 274-75. 5
“[T]estimony elicited by hypothetical questions that do not relate with precision
5
The ALJ asked:
Now let’s assume I have an individual that could work but that
– and taking only the jobs that he’s had in the past, I’m not looking
at anything else at the present time. Let’s assume I had an individual
that could w ork, but let’s assume also that he w ould – and let’s
assume he would be a very good employee, but he’s going to have to
have more time off than the average employee would have to have.
At what point in time would he no longer have a job?
Aplt. A pp. at 274-75.
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all of a claimant’s impairments cannot constitute substantial evidence to support
the [Commissioner’s] decision.” Hargis v. Sullivan,
945 F.2d 1482, 1492
(10th Cir. 1991) (first alteration in original). W e conclude that the ALJ failed
to follow the appropriate legal standards in reaching his conclusions
about M r. M iracle’s ability to work and his past relevant work, and failed to
adequately develop the record concerning these issues.
4. De novo review of magistrate judge’s recommendation
As we are reversing the district court’s decision affirming the agency’s
determination, it is unnecessary to determine whether the district court properly
reviewed the magistrate judge’s report and recommendation.
This case is REVERSED and REM ANDED to the district court, with
instructions to remand to the agency for further proceedings in accordance with
this order and judgment.
Entered for the Court
Robert H. Henry
Circuit Judge
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