C.L. v. Berryhill

Background

C.L. applied for supplemental security income under Title XVI of the Social Security Act, alleging disability beginning August 12, 2015, because of stage III colon cancer and a heart condition. The agency denied the application initially and on reconsideration. After a December 19, 2017 hearing, an administrative law judge denied the application on March 29, 2018. The Appeals Council denied review on February 8, 2019, making the administrative law judge’s decision the Commissioner’s final decision.

The record contained medical treatment notes through February 8, 2016. Those records showed surgery for a perforated bowel and colon cancer, followed by chemotherapy. An undated note indicated that chemotherapy was expected to end by March 23, 2016, and that C.L. would be disabled until April 15, 2016. The record did not contain later treatment records. C.L. had also written that his cancer had worsened and testified that he had a second colon surgery in June 2016.

At the hearing, C.L. was not represented by counsel and used a Vietnamese interpreter. His testimony about whether the cancer had returned or was in remission was unclear. The medical expert appeared to understand C.L.’s answers as showing that the cancer had resolved, while C.L. testified that the cancer was always present. C.L. also gave unclear testimony about a growing tumor, continuing medical treatment, the second surgery, travel to Vietnam, his work, and medication related to chemotherapy.

Administrative Decision

The administrative law judge found that C.L.’s work after the application date did not amount to substantial gainful activity. At the next step, the judge found stage III colon cancer to be a severe impairment, but found that C.L.’s impairments did not meet or equal a listed impairment. The judge assessed a residual functional capacity for medium work with additional lifting, standing, climbing, and environmental restrictions. The judge then found that C.L. could perform his past relevant work and was not disabled from the application date through March 29, 2018.

Court’s Analysis

The court explained that although the claimant generally must provide evidence proving disability, an administrative law judge has a special duty to fully and fairly develop the record. That duty is especially important when the claimant is unrepresented. Ambiguous evidence or an inadequate record requires an appropriate inquiry, which may include obtaining records, questioning medical providers, continuing the hearing, or keeping the record open for additional evidence.

The court held that the administrative law judge failed to meet that duty. The judge relied on the February 2016 treatment information to conclude that C.L. had fully recovered by April 2016, but did not seek records from after February 8, 2016. The judge also did not investigate how the reported June 2016 surgery could be reconciled with the medical expert’s conclusion that C.L. had recovered earlier.

The court identified additional unresolved issues. The administrative law judge did not clarify C.L.’s testimony about recurrence or remission, his report that a tumor was still growing, how long he stayed in a nursing home after the second surgery, when he traveled to Vietnam, his work duties and possible accommodations, his daily activities, his physical limitations, or medication side effects. The judge also did not ask why C.L. was apparently taking medication connected to chemotherapy nearly two years after the last treatment records.

Disposition

The court granted C.L.’s motion for summary judgment, denied the Commissioner’s motion for summary judgment, reversed the Commissioner’s decision, and remanded the case to the Social Security Administration for further proceedings. The court stated that further record development should include obtaining updated medical records for the period after February 8, 2016. The opinion did not award benefits.