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Berghauser v. Commissioner of Social Security Administration

United States District Court, E.D. Oklahoma

September 3, 2019

COMMISSIONER of the Social Security Administration, Defendant.



         The claimant David Allen Berghauser requests judicial review of a denial of benefits by the Commissioner of the Social Security Administration pursuant to 42 U.S.C. § 405(g). He appeals the Commissioner's decision and asserts the Administrative Law Judge (“ALJ”) erred in determining he was not disabled. For the reasons set forth below, the Commissioner's decision should be REVERSED and the case REMANDED for further proceedings.

         Social Security Law and Standard of Review

         Disability under the Social Security Act is defined as the “inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment[.]” 42 U.S.C. § 423(d)(1)(A). A claimant is disabled under the Social Security Act “only if his physical or mental impairment or impairments are of such severity that he is not only unable to do his previous work but cannot, considering his age, education, and work experience, engage in any other kind of substantial gainful work which exists in the national economy[.]” Id. § 423 (d)(2)(A). Social security regulations implement a five-step sequential process to evaluate a disability claim. See 20 C.F.R. §§ 404.1520, 416.920.[1]Section 405(g) limits the scope of judicial review of the Commissioner's decision to two inquiries: whether the decision was supported by substantial evidence and whether correct legal standards were applied. See Hawkins v. Chater, 113 F.3d 1162, 1164 (10th Cir. 1997). Substantial evidence is “‘more than a mere scintilla. It means such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.'” Richardson v. Perales, 402 U.S. 389, 401 (1971), quoting Consolidated Edison Co. v. NLRB, 305 U.S. 197, 229 (1938); see also Clifton v. Chater, 79 F.3d 1007, 1009 (10th Cir. 1996). The Court may not reweigh the evidence or substitute its discretion for the Commissioner's. See Casias v. Secretary of Health & Human Services, 933 F.2d 799, 800 (10th Cir. 1991). But the Court must review the record as a whole, and “[t]he substantiality of evidence must take into account whatever in the record fairly detracts from its weight.” Universal Camera Corp. v. NLRB, 340 U.S. 474, 488 (1951); see also Casias, 933 F.2d at 800-01.

         Claimant's Background

         The claimant was forty-two years old at the time of the administrative hearing (Tr. 38, 178). He completed the twelfth grade while attending special education classes and has worked as a parking enforcement officer and janitor (Tr. 30, 209). The claimant alleges that he has been unable to work since September 7, 2015, due to results of heat stroke, sensitivity to heat, diabetes, dyslexia, learning trouble, petit mal seizures, sleep apnea, depression, gout, and arthritis (Tr. 208).

         Procedural History

         On October 22, 2015, the claimant applied for disability insurance benefits under Title II of the Social Security Act, 42 U.S.C. §§ 401-434. His application was denied. ALJ Kevin Batik held an administrative hearing and determined that the claimant was not disabled in a written opinion dated March 24, 2017 (Tr. 21-32). The Appeals Council denied review, so the ALJ's written opinion is the Commissioner's final decision for purposes of this appeal. See 20 C.F.R. § 404.981.

         Decision of the Administrative Law Judge

         The ALJ made his decision at step five of the sequential evaluation. He found that the claimant had the residual functional capacity (RFC) to perform sedentary work as defined in 20 C.F.R. § 404.1567(a), but that he had the additional limitations of being unable to climb ladders, ropes, and scaffolds, or work at unprotected heights, around moving mechanical parts, drive as part of most jobs, or be exposed to extreme heat. The ALJ further found that the claimant could understand, remember, and carry out simple tasks and instructions, but that he was precluded from interaction with the general public and limited to occasional interaction with co-workers and supervisors (Tr. 27). The ALJ concluded that although the claimant could not return to his past relevant work, he was nevertheless not disabled because there was work he could perform, i. e., patcher, table worker, or bonder (Tr. 30-31).


         The claimant contends that the ALJ erred by: (i) failing to account for all his impairments in formulating the RFC, specifically with regard to his visual impairments, (ii) failing to properly evaluate his counselor's other source opinion, and (iii) failing to properly evaluate his subjective statements. The undersigned Magistrate Judge agrees with the claimant's contention that the ALJ failed to properly assess his RFC, and the decision of the Commissioner should therefore be reversed, and the case remanded for further proceedings.

         The ALJ found that the claimant had the severe impairments of diabetes mellitus, epilepsy, hypertension, major depressive disorder, and autism (Tr. 23). The relevant medical evidence as to the claimant's eyes reveals that he experienced a decline or change in vision in September 2015 and was assessed with corneal pannus of the left eye, as well as bilateral iris nevus, diabetic cataracts, and diabetes mellitus type II with ophthalmic complications, non-proliferative diabetic retinopathy, retinal hemorrhage, myopia, and astigmatism (Tr. 321). Further treatment notes describe the eye condition as an almost 3D myopic shift secondary to high sugar levels (Tr. 321). That same month, another treatment note indicates that the claimant's acuity was still grossly impaired (Tr. 367). The “Discussion Notes, ” refer to a period of heat exhaustion that had previously hospitalized the claimant, as well as the sudden death of his wife and lack of diet and weight control that sent his blood sugars so high he was almost in ketoacidosis and had to be intubated during a stay in the ICU (Tr. 368). The note continues, that “He has had little to no tolerance at work to physical [conditioning] type environment. Couple with his limited mental ability to understand the consequences of his disease processes has got him to the point that his vision is now severely affected. He will have to live with family for the long foreseeable future in my view” (Tr. 368). The following month, his vision condition was described as stabilized following updated glasses for his refractive state (Tr. 325). In February 2016, treatment notes again reflected the claimant's acuity was impaired, and that his vision was still grossly impaired (Tr. 566). June 2016 and February 2017 treatment notes again refer to the claimant's acuity as impaired (Tr. 699, 747). In August 2016, the claimant again sought treatment for his eyes, reporting blurred vision at distance and near, noting that varied visual tasks were impaired, and that his eyes fatigued easily (Tr. 719). The claimant was to monitor the condition and report any changes immediately (Tr. 721).

         The claimant additionally struggled to manage hypertension and presented to the emergency room on January 9, 2016 with blood pressure of 177/114 but was discharged that same day following blood pressure readings of 151/87, 136/65, and 154/67 (Tr. 536-538). The claimant was also treated for, inter alia, generalized epilepsy and a Chiari I brain malformation both of which were diagnosed in 2013 (Tr. 675, 679). Medical treatment notes also ...

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