ROBERT E. BLACKBURN, District Judge.
The matter before me is plaintiff's
Plaintiff alleges that he is disabled as a result of residuals of a closed head injury, fused left elbow, double vision, and poor balance.
The ALJ found that plaintiff was not disabled between his alleged date of onset through June 30, 1989, his date last insured, and, therefore, not entitled to disability insurance benefits. The judge concluded that plaintiff had failed to show the existence of a medically determinable impairment during the period of his alleged disability. She, therefore, found plaintiff not disabled at step two of the sequential evaluation.
Plaintiff appealed this decision to the Appeals Council. The Council affirmed. Plaintiff then filed this action in federal court.
A person is disabled within the meaning of the Social Security Act only if his physical and/or mental impairments preclude him from performing both his previous work and any other "substantial gainful work which exists in the national economy." 42 U.S.C. § 423(d)(2). "When a claimant has one or more severe impairments the Social Security [Act] requires the [Commissioner] to consider the combined effects of the impairments in making a disability determination."
The Commissioner has established a five-step sequential evaluation process for determining whether a claimant is disabled:
20 C.F.R. § 404.1520(b)-(f).
Review of the Commissioner's disability decision is limited to determining whether the ALJ applied the correct legal standard and whether the decision is supported by substantial evidence.
Plaintiff alleges that the ALJ erred in concluding that he did not suffer from any medically determinable impairment between his alleged date of onset and his date last insured. I agree with him on this account. Nevertheless, because nothing in the record suggests that plaintiff's medically determinable impairments were severe, as that term is defined by applicable regulations, I conclude that any error in this regard clearly was harmless and that remand is unwarranted.
Under the Commissioner's regulations, a claimant can be found disabled only if he is "unable to do 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." 20 C.F.R. § 404.1527(a)(1). A medically determinable impairment is a "anatomical, physiological, or psychological abnormalit[y] which can be shown by medically acceptable clinical and laboratory diagnostic techniques." 20 C.F.R. § 404.1508. The existence of a medically determinable impairment must be established by "medical evidence consisting of signs, symptoms, and laboratory findings, not only by [the claimant's] statement of symptoms."
There can be little doubt that plaintiff suffered from medically determinable impairments within the meaning of these regulations. Plaintiff was severely injured in June, 1980, after he was struck by a car while riding his motorcycle. He suffered a closed head injury, a dislocated left elbow fracture, a compact distal right radius fracture, a fracture through the shaft of the left distal radius, a ruptured spleen, a liver laceration, and a contused kidney. (Tr. 368.) Even after he recovered from these acute injuries, plaintiff developed calcifications around his left elbow that resulted in a frozen joint. Although he subsequently had surgery on the elbow some time in 1983, it was noted that he would "never attain normal use of the left arm" due to "severe limitation of elbow flexion and extension." (Tr. 361.) It is also beyond dispute that he suffered from problems with memory, balance, and double vision.
The existence of these impairments is documented by medical signs and findings on examination of various medical providers in 1983 through 1985. Although outside the period of disability, such evidence should be considered in determining whether plaintiff was disabled as of his alleged date of onset.
Nevertheless, I am compelled to consider whether the error in this regard was harmless.
In this case, the medical records in this case do not support a conclusion that plaintiff's impairments were severe under even this lenient standard. Concerning plaintiff's impairments of memory, balance, and vision, in May, 1983, plaintiff reported to Dr. Rudolf Taubner that he "had a resolution of almost all of his deficits," despite "occasional double vision on lateral gaze" and a "little incoordination if he runs." Overall, however, he "denie[d] any major problems" and reported that he attended college that year and passed his courses, "including his math course." (Tr. 357.) Although Dr. Taubner concluded that plaintiff had permanent neurological residuals from his accident, these were "slight" and "subtle." (Tr. 358.)
Medical records from the fall of 1984 show a similar theme of progress toward more normal neuropsychological functioning. In early October, 1984, Dr. Donald Trahan found that plaintiff "has recovered well and most of his cognitive deficits have resolved." (Tr. 342.) Indeed, plaintiff reported that "his cognitive abilities seem reasonably normal except for decreased attentional ability and mild memory problems," as well as occasional problems with balance. (Tr. 343.) Dr. Trahan concluded that there was "no evidence of neuropsychological impairment of sufficient severity to preclude his return to AD [active duty] status," although his physical limitations merited further evaluation. (Tr. 336.) Later that month, plaintiff reported to Dr. Carlos Palacios that despite some continuing deficits, "his memory and higher cortical functions ha[d] improved." (Tr. 337.) At a followup examination in May, 1985, plaintiff gave similar reports to Dr. Frank Franco. He denied headaches and dizzy spells and reported double vision only when excessively fatigued. His balance problems were described as occasional but infrequent. (Tr. 225.)
The same reports of mild and non-severe limitation were echoed with respect to plaintiff's left arm and elbow impairments. Although Dr. Foth found in May, 1983, that plaintiff would "never attain normal use of the left arm because of severe limitation of elbow flexion and extension" (Tr. 361), in September, 1984, plaintiff told Dr. Thomas Shepler that his left elbow was "without difficulties" and that he was "satisfied with his elbow in this particular position" (Tr. 344). Dr. Shepler noted that plaintiff had "fairly good pronation and supination" and had converted to right-handedness to compensate. (Tr. 344.) Although the left elbow bothered him when the weather changed, he took no medication and had "no essential complaints." (Tr. 345.)
Likewise, plaintiff reportedly denied "any major complaints regarding the left arm and hand" when examined by Dr. Palacios in October, 1984. (Tr. 337.) His physical examination was "unremarkable," and he had "no difficulty with sensory system, gait, or station." (Tr. 338.) Similar findings were reported by Dr. Franco following his May, 1985, examination. Although plaintiff had some immobility with his left elbow which was reportedly affected his work in an unspecified way, he reported pain "only when the weather changes" and took no medication at those times. Dr. Franco found no local pain or tenderness over the elbow and noted that plaintiff "takes no medications [nor] does he seek any medical care at this time." (Tr. 225.)
In short, the medical evidence of record does not support a conclusion that plaintiff's determinable impairments were sufficiently severe in the period prior to his alleged date of onset to overcome plaintiff's burden at step two. Coupled with the facts that plaintiff was performing substantial gainful activity during a significant portion of this same time period,
Granted, the Air Force did conclude in October, 1985 that plaintiff was 90 percent disabled and unemployable from December 1, 1981 through December 31, 1985. (Tr. 220-222;
Nevertheless, any error in this regard was undoubtedly harmless also, for the reasons already discussed. The medical record from the final VA examination and disability determination shows that although plaintiff reported experiencing "double vision at time of excessive fatigue" but that he had "no double vision at [that] time." Once again, his occasional balance problems that were described as "infrequent," and his gait and heel and toe walking were normal at the time of the examination. Moreover, plaintiff stated that "he has no problems with the right or left forearm and denies any pain of difficulty in motion." (Tr. 220.) The ALJ herself noted plaintiff's limited complaints and complete lack of medical care during the relevant time period, despite the availability of care through the Veterans Administration, in finding that his impairments did not withstand step two scrutiny. (Tr. 17-18.) Finding no reversible error in that determination, I affirm.
20 C.F.R. § 404.1528.