George D. D. L. v. Saul

Background

George D. D. L. applied for disability insurance benefits, alleging disability beginning February 1, 2012. He was insured through September 30, 2015. After a hearing at which he testified with counsel and a vocational expert also testified, the administrative law judge found severe impairments involving degenerative joint disease in both shoulders and neck pain.

The administrative law judge determined that George D. D. L. had the residual functional capacity—the most he could do despite his limitations—to perform medium work, except that he could not reach overhead with either arm. The administrative law judge found that he could perform his past work as a material handler as he had performed it, and could also perform work as a courtesy clerk, sandwich maker, or hospital cleaner. The Commissioner relied on that decision in opposing the plaintiff’s motion.

George D. D. L. argued that the administrative law judge improperly evaluated medical opinions, failed to support the finding that he could lift up to 50 pounds as required for medium work, and improperly discounted his testimony about his symptoms.

Medical Evidence

The court found several errors in the evaluation of the medical evidence. The administrative law judge incorrectly summarized Dr. Craig M. Wiseman’s examination as showing no atrophy or deformity and full strength, despite findings that included mild painful weakness and positive shoulder tests. The administrative law judge also failed to address Wiseman’s stated limitations on heavy labor and high-impact activity.

The administrative law judge similarly misstated Dr. James D. Kelly II’s findings by describing the plaintiff as having no atrophy or deformity and full strength. Kelly had documented atrophy, reduced strength, positive shoulder tests, and a massive rotator-cuff tear. Although Kelly did not provide specific weight restrictions, the court found that the administrative law judge’s description of his findings was inaccurate.

The court also found that the administrative law judge improperly failed to consider the substance of opinions from Dr. John D. Warbritton and Dr. Matthew J. Johnson. Warbritton found restrictions against forceful repetitive work at or above shoulder level and against working with the arms extended away from the body. Johnson identified restrictions involving overhead activity and forceful pushing, pulling, twisting, gripping, lifting, and carrying with the right arm.

The court held that the record was unclear about whether George D. D. L. could lift up to 50 pounds and whether the jobs identified by the administrative law judge required working with the arms extended away from the body. Because the evidence was ambiguous or inadequate, the administrative law judge had a duty to further develop the record, even though the plaintiff was represented by counsel.

Plaintiff’s Testimony

The court found that the administrative law judge also failed to adequately evaluate George D. D. L.’s testimony. The administrative law judge stated that the plaintiff’s allegations about the intensity and effects of his symptoms were not entirely consistent with the evidence but did not identify which testimony was disbelieved or explain specifically why.

The court further found that the administrative law judge mischaracterized the plaintiff’s treatment as conservative despite surgeries on both shoulders and his efforts to obtain another right-shoulder surgery. The administrative law judge also relied improperly on daily activities and a report mentioning weight training without adequately considering the plaintiff’s statements that activities caused discomfort and that he could carry only light weight at the relevant time.

The court concluded that these errors were not harmless. The vocational expert testified that the plaintiff could not perform the identified medium-work jobs if he could not work with his right arm extended away from his body. The vocational expert also testified that the plaintiff could not perform his material-handler job as he described it if he was restricted from overhead reaching.

Ruling and Remedy

Judge Sallie Kim granted George D. D. L.’s motion for summary judgment and denied the Commissioner’s cross-motion for summary judgment. The court remanded the matter for further proceedings rather than awarding benefits because additional issues remained and it was not clear that proper evaluation of the evidence would require a finding of disability.

On remand, the administrative law judge must further develop and evaluate the plaintiff’s lifting and carrying restrictions, including weight limits and whether he can work with his arms extended or close to his body. The administrative law judge must also clarify whether the plaintiff can perform his past material-handler work in light of his reaching limitations and the vocational expert’s testimony.