United States District Court, D. Nebraska
TRUDY K. LEAPALDT, Plaintiff,
CAROLYN W. COLVIN, Acting Commissioner of the Social Security Administration, Defendant
For Carolyn W. Colvin, Acting Commissioner of the Social Security Administration, Defendant: Robert L. Homan, LEAD ATTORNEY, U.S. ATTORNEY'S OFFICE - OMAHA, Omaha, NE.
For Office of General Counsel Social Security Administration, Interested Party: Office of General Counsel Social Security Administ, LEAD ATTORNEY, SOCIAL SECURITY ADMINISTRATION - KANSAS CITY, Kansas City, MO.
MEMORANDUM AND ORDER
John M. Gerrard, United States District Judge.
This matter is before the Court on the denial, initially and upon reconsideration, of plaintiff Trudy K. Leapaldt's application for disability insurance benefits under Title II of the Social Security Act, 42 U.S.C. § 401 et seq. The Court has considered the parties' filings and the administrative record. Finding the Commissioner's development of the record inadequate, the
Court reverses and remands for further proceedings.
Leapaldt applied for disability insurance benefits in February 2010. T11, 118, 142. Her claim was denied initially and on reconsideration. T67-72, 76-79. Leapaldt appealed the decision and requested a hearing from an administrative law judge (ALJ). The ALJ held a hearing on November 30, 2011 and a supplemental hearing on January 13, 2012. T27-57, 58-66. In a decision dated March 23, 2012, the ALJ found that Leapaldt was not disabled as defined under 42 U.S.C. § § 416(i) or 423(d), and therefore not entitled to benefits. T8-26.
To determine whether a claimant is entitled to disability benefits, the ALJ performs a five-step sequential analysis. 20 C.F.R. § 404.1520(a)(4). At step one, the claimant has the burden to establish that she has not engaged in substantial gainful activity since her alleged disability onset date. Id. ; Gonzales v. Barnhart, 465 F.3d 890, 894 (8th Cir. 2006). If the claimant has engaged in substantial gainful activity, she will be found not to be disabled; otherwise, at step two, she has the burden to prove she has a medically determinable physical or mental impairment or combination of impairments that significantly limits her physical or mental ability to perform basic work activities. Gonzales, 465 F.3d at 894.
At step three, if the claimant shows that her impairment meets or equals a presumptively disabling impairment listed in the regulations, she is automatically found disabled and is entitled to benefits. Id. Otherwise, the analysis proceeds to step four, but first, the ALJ must determine the claimant's residual functional capacity (RFC), which is used at steps four and five. 20 C.F.R. § 404.1520(a)(4). A claimant's RFC is what she can do despite the limitations caused by any mental or physical impairments. Travis v. Astrue, 477 F.3d 1037, 1041 (8th Cir. 2007). At step four, the claimant has the burden to prove she lacks the RFC to perform her past relevant work. Gonzales, 465 F.3d at 894. If the claimant can still do her past relevant work, she will be found not to be disabled; otherwise, at step five, the burden shifts to the Commissioner to prove, considering the claimant's RFC, age, education, and work experience, that there are other jobs in the national economy the claimant can perform. Id.
Leapaldt alleged disability primarily as a result of visual impairments caused by Duane syndrome and cataracts, and the headaches caused by those conditions, as well as asthma, chronic obstructive pulmonary disease, and depression. T14, 16, 35-36, 146. Leapaldt alleged a disability onset date of December 14, 2009. T142. On March 23, 2012, the date of the ALJ's
decision, Leapaldt was 56 years old. T27, 118, 142.
In this case, at step one, the ALJ found that Leapaldt had not engaged in substantial gainful activity since her alleged onset date. T14. At step two, the ALJ found that Leapaldt had two severe impairments: Duane syndrome and a history of asthma. T14-15. Next, at step three, the ALJ found that Leapaldt's impairments, considered singly and in combination, did not meet or medically equal a listed impairment. T15.
The ALJ found that Leapaldt had the RFC to perform light work, as defined in 20 C.F.R. § 404.1567(b), although Leapaldt was further limited to work " involving lifting 25 pounds occasionally and 15 pounds frequently and never climbing ladders, ropes, or scaffolds." T15. The ALJ further found that Leapaldt " should avoid concentrated exposure to extremes of fumes, odors, dusts, gases, poor ventilation, and hazards such as unprotected heights or dangerous machinery" and that she could not work in a job which required her to drive. T15.
At step four, the ALJ found, based on the testimony of a vocational expert, that Leapaldt was able to perform her past relevant work. T19, T47-56, 60-65. In the alternative, the ALJ proceeded to step five, where he found that Leapaldt could perform other jobs that existed in significant numbers in the national economy. T19-20. So, the ALJ found that Leapaldt was not disabled. T21.
On November 30, 2012, the Appeals Council of the Social Security Administration denied Leapaldt's request for review. T1-4. Leapaldt's complaint (filing 1) seeks review of the ALJ's decision as the final decision of the Commissioner under sentence four of 42 U.S.C. § 405(g).
I. Pre-Onset Date Medical and Work History
As noted above, Leapaldt has Duane syndrome. She can move her eyes up and down, but cannot move them laterally, so she has to turn her head rather than simply move her eyes. T36, 295, 350-51. This is a congenital disorder which Leapaldt has experienced since childhood. T36, 295.
Briefly stated, Leapaldt claims that as she has aged, her vision has continued to decline. She claims that during the period of disability, she could only read, use a computer, or watch television for a short time before her vision would become too blurry to continue. And Leapaldt maintains that as a result of straining to see, she would often suffer debilitating headaches.
However, for much of her life, these symptoms were not present or not as severe, and did not prevent Leapaldt from working. From 1976 until the late 1980s she worked as a patient account manager, and from 1994 to 2000 she worked as an invoice clerk. T157, 233, 295. From 2000 to 2001 Leapaldt worked in billing or collections for various companies. T233. And from 2002 to June 2007 she owned and operated a sleep center with her husband, where she worked as an office manager. T157, 232, 276. Most of her jobs were fulltime and involved working on a computer. T158-161, 232-233. From 2007 to 2008 she also worked part-time at a coffee shop. T232.
In July 2007, Leapaldt and her husband sold the sleep center. She stayed on as a manager and helped train the new employees. T41, 157, 232, 276. Leapaldt was eventually laid off in March 2008. T41, 276.
Leapaldt returned to work, very briefly, in December 2009. On December 8, she began working at a job that required her to use a computer to work with spreadsheets. T42, 232, 276. Leapaldt claims she developed a severe headache and could not see well enough to drive, and her husband had to pick her up. She did not return to the job. T42, 232.
II. Medical and Disability Records: 2009-2011
In September 2009, Leapaldt met with ophthalmologist Marianne Diego-Wright, M.D. T241. Leapaldt complained of double vision in her right eye. T241. Diego-Wright apparently performed the standard visual acuity tests, but the Court cannot tell what conclusion Diego-Wright reached regarding Leapaldt's visual acuity. The Commissioner reads the chart as stating that Diego-Wright measured Leapaldt's vision as " 20/50 and 20/40." Filing 17 at 2. Although this is not apparent from the Court's reading of the chart, Leapaldt has not objected to this characterization of the record. In any event, Diego-Wright provided Leapaldt a new prescription for glasses. T241.
Diego-Wright also assessed Leapaldt with nuclear sclerosis in her left eye (" NS OS" ). T241 This is an age-related change to the eyes, " caused primarily by the hardening and yellowing of the lens over time. 'Nuclear' refers to the gradual clouding of the central portion of the lens, called the nucleus; 'sclerotic' refers to the hardening, or sclerosis, of the lens nucleus." Tina D. Turner, FamilyConnect, Are There Different Types of Cataracts?, http://www.familyconnect.org/parentsite.aspx?FolderID=6& SectionID=112& Docum entID=5676 (last visited January 22, 2014). A nuclear sclerotic cataract is a common, age-related cataract. Id. Diego-Wright's assessment was " obs[erve] cataract for now." T241. Previously, in 2007, Leapaldt underwent surgery to extract a cataract in her right eye. She later reported that the surgery was not that helpful. T243, 297, 316.
Leapaldt saw Diego-Wright again on December 15, 2009 (7 days after her unsuccessful attempt to return to work). T240. Leapaldt reported that she could not see well after using a computer for a couple of hours. T240. Diego-Wright observed no change in Leapaldt's visual acuity. T240. (" MR [manifest refraction] no D." ) She noted that Leapaldt " can't read well binocular." T240. Diego-Wright referred Leapaldt to another doctor, but it is not clear if Leapaldt ever visited that doctor, and the record contains no notes from him.
In March 2010, Leapaldt responded to several questionnaires from the Social Security Administration. Her husband completed most (if not all) of the reports she submitted. See, e.g., T146, 164, 172, 196. Leapaldt described her daily activities:
she cleaned, cooked, and baked (but she could not read recipes), shopped and did laundry, took care of her pets, and went to church on a regular basis. T165-69. Leapaldt took care of her mother, and cooked and cleaned for her, although Leapaldt's husband and daughter also helped with this. T166. Leapaldt stated that she could not " work on any computer[-]related activity or any activity that requires long[-]term viewing." T153. She watched " some" television, but could not watch for any length of time. T169. Nor could she read for any length of time. T169. Leapaldt could drive by herself, but not at dark, and could not use her computer to pay bills online. T166-68. Leapaldt's husband submitted two reports in March 2010 that contained similar information. T173-188. He stated that Leapaldt would read or watch television for a total of 1 to 2 hours a day, but could not do so for very long. T185. Shortly after these reports, Leapaldt submitted an updated report, stating, among other things, that it was " very seldom now" that she read or watched television. T193.
On May 11, 2010, Leapaldt underwent a consultative psychological exam with psychologist Carroll D. Roland, Ph.D. T273. Leapaldt's psychological status is not at issue in this appeal, and Roland's conclusions need not be discussed. However, during the consultation, Leapaldt made several statements regarding her visual impairments. Leapaldt reported that she could not use the computer for more than 15 minutes, after which she " can't see." And she claimed she would suffer from " severe" headaches if she watched television for more than 30 minutes or attempted to read. T274-75. Leapaldt stated these could last for 2 or more days. T276. She claimed that she had told her doctors about her headaches but none had identified a clear cause. T275. And, for the first time, Leapaldt stated that while she had a driver's license, she did not drive. T276.
Then on June 3, 2010, Leapaldt met with Timothy Lowry, M.D., for a consultative physical examination. T294. Leapaldt explained that she had glasses, but did not wear them because they did not help and caused headaches. T295. She claimed she could read large print but not fine print, such as a newspaper, and that reading for long gave her a headache. T295-96. Although Leapaldt had told Roland she did not drive, she told Lowry that she had a driver's license but did not drive at night. T296. Lowry noted that, with her vision, he did not believe Leapaldt would qualify for a license. T296.
Leapaldt also told Lowry she had suffered from chronic headaches or migraines since she was a young adult. She had never had an MRI scan or been evaluated by a neurologist. Leapaldt claimed that over-the-counter medication did not offer relief, nor did tramadol or Vicodin (stronger, prescription pain medications). T296. Leapaldt reported that her headaches might be " a little bit worse" and that sometimes she ...