Connecticut Court Reverses Social Security Disability Case For Failure to Develop the Record - Bathrick v. Astrue

July 14,2009
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In Bathrick v. Astrue, the District Court for the District of Connecticut reminds the ALJ’s once again that they cannot make a decision on a disability benefits claim without referring to evidence in the record that is sufficient to support it.
Sarah Bathrick filed a Social Security Disability benefits claim, asserting that she’s unable to work as a result of a number of mental impairments as well as nerve damage in her right leg that resulted from a spider bite. The Social Security Administration (SSA) denied the claim and Ms. Bathrick then appeared before an SSA Administrative Law Judge (ALJ) in an administrative hearing. The ALJ determined that Plaintiff was not disabled because she retained the residual functional capacity (RFC) to perform “medium work, limited to jobs involving simple, routine, repetitive tasks with short simple instructions and few workplace changes.”
On appeal, the District Court remanded the case to the ALJ for further proceedings because the ALJ failed to properly develop the record. SSA regulations define “medium work” as lifting no more than 50 pounds at a time with frequent lifting or carrying of objects weighing up to 25 pounds. The evidence in the record, according to the court, was insufficient to determine Plaintiff’s ability to lift 50 pounds.
“The ALJ rendered the RFC finding without reference to a medical opinion that specifically described Bathrick’s physical limitations,” the court ruled. Nor did the evidence of Plaintiff’s daily activities – including grocery shopping and housework – indicate that she could lift up to 50 pounds at a time.
An ALJ’s decision on a disability claim must be based on substantial evidence. In this case, the evidence regarding Plaintiff’s physical ability to perform medium work was not only not supported by substantial evidence, it was not supported by any evidence at all. “Without further evidence specifically relating to Bathrick’s physical limitations, it is impossible to make an accurate RFC determination,” the court concluded.
As a result, the court determined that it was appropriate to remand the case for further proceedings. Specifically, the ALJ should have re-contacted Plaintiff’s treating physicians, obtained a consultative examination or requested the opinion of a medical expert on the issue of lifting and carrying. On remand, the court instructed the ALJ “to obtain the necessary medical opinions regarding Bathrick’s physical limitations, including her abilities to perform the tasks required by medium level jobs.”

While the court made it clear that the ALJ had the responsibility to adequately develop the medical record in this case, a person seeking Social Security Disability benefits can significantly strengthen his or her claim by presenting a full range of medical evidence along with the claim. A case should never be taken to federal court without objective evidence to support a claimant’s complaints.
An experienced Social Security disability attorney can provide invaluable assistance to a claimant by gathering the necessary objective medical evidence and treating source opinions regarding RFC and presenting it in a clear and concise manner. The disability lawyer can also point out and explain any inconsistencies in the record, rather than expecting the SSA or an ALJ to sift through the evidence. In the event that the SSA nevertheless finds that the client is not disabled, the lawyer can also pursue the matter in federal court, assuming there are significant errors of law.
Related blog posts:
New York Court Requires Social Security Judge to Clarify Medical Record in Disability Benefits Case – Stokes v. Commissioner of Social Security

Submitting “New” Evidence on Appeal in Social Security Disability Cases – Hood v. Commissioner of Social Security
Court: Judge Reviewing Social Security Disability Benefits Claim Must Consider Each of the Claimant’s Alleged Impairments – Black v. Astrue