A woman suffered pain and headaches resulting from various neck and back conditions, including a tumor near her cervical spine, disc herniation, degenerative disc conditions, and a broad-based disc bulge. The medical providers tracked the woman’s degenerative disc changes for about nineteen years, when she underwent back surgery following a seizure. The woman had suffered from mild tingling in her left hand. After surgery, she experienced great difficulty gripping and grasping items with her left hand. She applied for social security disability benefits as she could not perform her work as a receptionist and a manicurist.
The administrative law judge (ALJ) discredited the woman’s testimony to the extent that it conflicted with the residual functional capacity. The ALJ also rejected the contrary conclusions of the woman's primary care doctor. The woman’s treating physician, found that the woman experienced headaches on a regular basis that seriously affected her ability to function. All other treating and examining doctors concluded that the woman could perform medium exertion work with only minor limitations. The ALJ adopted the consensus view and rejected the woman’s treating physician's view. The ALJ gave two reasons for rejecting the woman’s treating physician's assessment. The ALJ reasoned that the doctor's opinions were conclusory, providing little explanation of the evidence relied on in forming that opinion. The ALJ also opined that the doctor's conclusions were contrary to the medical evidence and to the doctor’s own treatment notes. The ALJ concluded that the woman was not disabled because she can perform her past relevant work as a receptionist and a manicurist.
The woman sought review by the Appeals Council. As part of that review, she submitted additional medical evidence. The Appeals Council denied review. The woman filed an action in federal court. The United States District Court for the District of Arizona affirmed the denial of the woman’s application for disability insurance benefits.
The Ninth Circuit United States Court of Appeals reversed and remanded. The court held that substantial evidence did not support the ALJ's adverse determination of the woman's credibility based on inconsistencies between the woman's testimony and her reported daily activities, conflicts between the woman’s testimony and the medical record, and secondary gain from the disability claim; the ALJ did not give specific and legitimate reasons supported by substantial evidence for rejecting the medical assessment by the woman's treating physician; and instead of remanding for an award of benefits, further proceedings on an open record were warranted given the court's serious doubt as to whether the woman was in fact disabled.
Substantial evidence did not support the ALJ's adverse determination of the woman's credibility based on inconsistencies between the woman's testimony and her reported daily activities, conflicts between the woman’s testimony and the medical record, and secondary gain from claiming to be disabled. The court held that where a claimant presented evidence of an underlying impairment and the government did not argue that there was evidence of malingering, the courts review the ALJ's rejection of the claimant’s testimony for specific, clear and convincing reasons. The ALJ's written decision provided no reasons for the credibility determination. The ALJ did not elaborate on which daily activities conflicted with which part of the claimant's testimony. The court found that substantial evidence did not support the ALJ's determination that there was a conflict concerning the woman's ability to vacuum. The court reasoned that the woman consistently reported to the physical therapist that she had trouble vacuuming, which was entirely consistent with her testimony at the hearing that stretching and pulling, which were required to vacuum, caused her pain. The woman did not testify that she never could vacuum; she stated that vacuuming was difficult for her. Although the ALJ made findings concerning the woman's treatment for headaches, he never stated that he rested his adverse credibility determination on those findings. The ALJ overlooked significant medical records when assessing whether the medical record conflicted with the woman’s testimony. The court found that the ALJ did not make a specific finding linking a lack of medical records to the woman's testimony about the intensity of her back, neck, and head pain and, in any event, the record did not support the ALJ's findings. As to the issue of secondary gain, the ALJ read one of the woman’s treating physician’s notes as questioning whether the woman was exaggerating her symptoms in order to miss work that she disliked. The court questioned the ALJ’s reading and then reasoned that even if the court did read the note the same way, it was a weak reason and insufficient to meet the specific, clear and convincing standard. The woman’s treating physician treated her for several years, and this was the only statement of its type. Moreover, the woman’s treating physician merely suggested that perhaps there was an issue of secondary gain—he did not affirmatively find that the woman was exaggerating or malingering. Because the ALJ's three reasons for discrediting the woman’s testimony were not supported by substantial evidence, the court concluded that the ALJ erred in discrediting her testimony.
The ALJ did not give specific and legitimate reasons supported by substantial evidence for rejecting the medical assessment by the woman's treating physician. Because the woman’s treating physician's opinion was contradicted, the court reviewed the ALJ's rejection of the woman’s treating physician's opinion for specific and legitimate reasons that are supported by substantial evidence. The court found that the record supported the treating physician's opinions because they were consistent both with the woman's testimony at the hearing and with the treating physician's own extensive treatment notes. The court found that the ALJ clearly erred in his assessment of the medical evidence, overlooking nearly a dozen reports related to head, neck, and back pain.
Instead of remanding for an award of benefits, further proceedings on an open record were warranted given the court's “serious doubt” as to whether the woman was in fact disabled. The court may remand on an open record for further proceedings when the record as a whole creates serious doubt as to whether the claimant is, in fact, disabled within the meaning of the Social Security Act. The court found evidence in this record not discussed by the ALJ that suggested that the woman may not be credible. For example, her testimony at the hearing concerning her ability to knit appeared to contradict the medical record. Similarly, the record suggested that the woman's headaches were secondary to her neck problems, but her neck problems improved, both objectively and subjectively, after surgery. Viewing the record as a whole, the court concluded that the woman may be disabled. But, because the record also contained cause for serious doubt, the court remanded with instructions that the district court remand to the ALJ for further proceedings on an open record.
The Ninth Circuit United States Court of Appeals reversed the district court’s affirmation of the Commissioner of Social Security’s denial of the woman’s application for disability insurance benefits.
See: Burrell v. Colvin, 2014 WL 7398892 (C.A.9 (Ariz.), December 31, 2014) (not designated for publication).
See also Medical Law Perspectives, October 2014 Report: Backaches and Court Battles: When Chronic Back Pain Leads to Litigation
See also Medical Law Perspectives, June 2013 Report: Independent Medical Evaluations: Legal Risks and Responsibilities