Schweers v. Nancy A. Berryhill

Background

Theodore W. Schweers, represented by counsel, sought judicial review under 42 U.S.C. §§ 405(g) and 1383(c)(3) of the Commissioner of Social Security’s decision denying him disability insurance benefits. The claimed disability period ran from March 21, 2015, through December 31, 2016, the date Schweers was last insured. After an administrative hearing, the administrative law judge (ALJ) found that Schweers had severe impairments involving migraines, affective disorder, and anxiety disorder, but concluded that he could perform medium, unskilled work with limits on exposure to irritants, job stress, decision-making, workplace changes, and interaction with others. The ALJ found that Schweers could not return to his past work as a plumber or plumber supervisor but could perform jobs such as dining-room attendant, kitchen helper, and stock handler.

Schweers and the Commissioner filed cross-motions for judgment on the pleadings. Schweers argued that the ALJ improperly excluded additional medical evidence, made contradictory findings about his mental impairments, failed to consider medication side effects, improperly determined his residual functional capacity (RFC), misapplied the Medical-Vocational Guidelines, and inadequately evaluated his reported symptoms.

Record-Development Error

The court held that the ALJ failed to develop the administrative record adequately. Although Schweers was represented by counsel, the ALJ still had an affirmative duty in this non-adversarial benefits proceeding to obtain necessary medical evidence. In particular, the ALJ did not obtain or attempt to obtain a medical source statement from Schweers’s treating psychiatrist, Dr. Howard Isaacs. A medical source statement addresses what a claimant can still do despite an impairment, including work-related physical or mental abilities.

The court found this omission material because Dr. Isaacs had treated Schweers for mental-health conditions over time, while the consulting mental-health professionals relied on by the ALJ had either examined Schweers only once or had never examined him. Dr. Isaacs’s records ended in June 2015, only three months into the relevant period, and the record did not show that Schweers had stopped treatment or that the ALJ had sought additional records. The ALJ instead gave little weight to an October 2014 note stating that Schweers was unable to work. The court explained that this note was not the type of detailed functional assessment needed for the benefits decision and that the ALJ should have sought a proper statement covering the relevant period.

Excluded Medical Evidence

The court also held that the ALJ erred by excluding additional medical records from Montefiore Medical Group. Schweers informed the ALJ about those records six business days before the hearing and explained why they were needed. The ALJ incorrectly stated that Schweers had not complied with the five-business-day rule, cited a regulatory provision concerning supplemental security income rather than disability insurance benefits, and incorrectly stated that Schweers had not explained the records’ importance.

The court determined that at least some of the excluded records could be relevant to the disability period. In particular, November 2016 records documented an emergency-room visit after Schweers had a panic attack, struck his rib on a doorway, and fractured two ribs. The court rejected the argument that this event was merely cumulative. It also stated that records from outside the relevant period may be considered when they shed light on the claimant’s condition during that period. The court noted uncertainty about whether other “outstanding records from Dr. Isaacs” had been excluded and directed the ALJ to obtain and consider any such records on remand.

Other Arguments

The court found no inherent contradiction in the ALJ’s finding that Schweers’s mental impairments were severe while also finding mild or no limitations in some functional areas. The ALJ had found moderate limitations in two other functional areas, and the regulations allow an impairment to be severe even when some individual functional ratings are mild or absent. The court directed the ALJ to reconsider the severity findings if new relevant information changed the record.

The court rejected Schweers’s argument that the ALJ failed to consider medication side effects, finding that the ALJ expressly addressed reported fatigue, insomnia, memory problems, panic attacks, blurry vision, and weight gain. The court said the ALJ should revisit the issue after developing the record further. The court did not decide Schweers’s challenges to the RFC determination or application of the Medical-Vocational Guidelines because the additional evidence could affect those issues. It found that the ALJ had generally addressed Schweers’s reported activities and symptoms but had not clearly considered his claimed susceptibility to illness and antibiotic limitations; those matters also had to be reconsidered on remand.

Disposition

Pursuant to sentence four of 42 U.S.C. § 405(g), Judge Robert W. Lehrburger granted Schweers’s motion for judgment on the pleadings, denied the Commissioner’s cross-motion, and remanded the case to the Commissioner for further consideration consistent with the decision. The ruling required further administrative review but did not determine that Schweers was disabled or direct an award of benefits.