Trujillo, Jr. v. Nancy A. Berryhill

Background

Gilbert Trujillo, Jr. sought disability insurance benefits under Title II of the Social Security Act for the period from January 2, 2009, through December 31, 2009. After a hearing, the administrative law judge (ALJ) found that Trujillo had diabetes, hypertension, stasis dermatitis of the right leg, neuropathy, a prior left great-toe amputation, and obesity. The ALJ determined that Trujillo could perform light work, subject to standing and walking for no more than four hours total during a workday, and found that he was not disabled because he could perform jobs including cashier, assembler of electrical accessories, and arcade attendant.

After the Social Security Appeals Council denied review, the parties filed cross-motions for summary judgment. Trujillo argued that the ALJ improperly discounted the opinions of his treating physicians, Dr. Tomas Valdez and Dr. Jan Lin; improperly evaluated his testimony; and failed to support the work-related finding at the final step of the disability analysis.

Medical opinions and development of the record

The court upheld the ALJ’s decision to give little weight to Dr. Valdez’s February 2016 medical-source statement. Dr. Valdez identified March 11, 2010, as the date of his first appointment with Trujillo, and the record contained no references to Dr. Valdez before 2010. The court concluded that the ALJ gave specific and legitimate reasons, supported by substantial evidence, for discounting that opinion as evidence of Trujillo’s limitations during the 2009 insured period.

The court reached a different conclusion regarding Dr. Lin. Dr. Lin’s April 2016 statement identified June 3, 2009, as her first appointment with Trujillo, which fell within the claimed disability period. The record contained no medical records from Dr. Lin for that period, and the ALJ did not acknowledge that Dr. Lin said she began treating Trujillo in June 2009. Because the ALJ placed importance on the overall lack of treatment records through the end of the insured period, the court found that the record was incomplete and ambiguous and that the ALJ had a duty to develop it further.

The court directed the ALJ to investigate whether medical records existed concerning Dr. Lin’s treatment during the relevant period and, if records existed, to evaluate them under the applicable legal standards.

Testimony and work assessment

The court found that the ALJ’s evaluation of Trujillo’s testimony was tied to the ALJ’s evaluation of the medical evidence. Because that medical evaluation was incomplete regarding Dr. Lin, the ALJ was required to reassess Trujillo’s testimony after properly evaluating any additional medical records.

The court also required the ALJ to reevaluate the final-step work analysis. The vocational expert’s hypothetical questions had to reflect all limitations supported by substantial evidence. Because a proper evaluation of the medical evidence could result in additional residual-functional-capacity limits, the court held that the work analysis also had to be reconsidered.

Disposition

The court concluded that it was not clear that Trujillo would necessarily be found disabled if all medical evidence were properly evaluated. It therefore determined that further administrative proceedings, rather than an immediate award of benefits, were appropriate. The court granted Plaintiff’s motion for summary judgment, denied the Commissioner’s cross-motion for summary judgment, and remanded the matter for further administrative proceedings.