Although we cannot second guess the ALJ's reasoning, remand is unnecessary when the record provides substantial and uncontradicted evidence of disability and a remand for further evidentiary proceedings would serve no useful purpose. Podedworny, supra, 745 F.2d at 213.
The evidence presented before the ALJ warrants a finding that the plaintiff was totally disabled due to his diabetes and neurovascular disease. The overwhelming evidence in the record reveals that the plaintiff suffers from uncontrollable diabetes, resulting in frequent diabetic shock episodes and regular hospital admissions. In addition, the medical evidence indicates a general deterioration in the plaintiff's health as demonstrated by his recurrent gastritis, varicosities and diabetic ulcers.
Section 423(d)(5) of the Social Security Act requires the Secretary to consider the plaintiff's subjective complaints of pain or other symptoms when such complaints are substantiated by medical findings demonstrating the existence of an impairment which could be expected to produce the alleged pain or symptoms. 42 U.S.C. 423(d)(5). If the intensity and persistence of pain is of such severity as to preclude the claimant from performing any work, he must be found disabled. Green v. Schweiker, 749 F.2d 1066, 1070 (3d Cir. 1984).
The testimony of the plaintiff reveals that he suffers from severe uncontrollable diabetes, characterized by vomiting, blurry vision, weakness, frequent urination, headaches, dehydration, nausea and dizziness T.41-42, 54. These symptoms occur three to four times a month and often result in hospitalization. Consequently, his activities are severely restricted. He spends most of his day watching television and sitting. T.40. He is unable to stand or walk for extended periods of time because his legs swell and begin to ache. T.44-45. He is unable to lift heavy objects and has difficulty performing housework. Id. We do not believe that these are the activities of someone who has the ability to engage in sustained medium exertional work.
The plaintiff does enjoy a sporadic social life; he occasionally visits his brothers and sister and sees a movie with his mother. T.48-49. However, this lifestyle does not contradict a claim of disabling pain. Smith v. Califano, 616 F.2d 968, 971 (3d Cir. 1980). Moreover, the plaintiff's testimony regarding the existence and effect of his symptoms on his daily activities is entirely consistent with what he told his doctors.
The plaintiff's complaints of disabling symptoms are supported by medical evidence demonstrating the existence of an impairment which could reasonably be expected to produce the symptoms that he experiences. The plaintiff has been hospitalized over twenty times for ketoacidosis, a form of uncontrolled diabetes. It is well documented that the symptoms of ketoacidosis are those associated with the diabetic shock attacks that the plaintiff experiences. The Merck Manual 1042 (R. Berkow, M.D. 14th ed. 1982). Moreover, all of the medical reports list the plaintiff's symptoms as severe abdominal pain, vomiting, blurry vision and dizziness. Finally, the plaintiff's severe varicose veins cause swelling and tenderness in his legs, resulting in his inability to stand or walk for long periods of time.
"Testimony of subjective pain and inability to perform even light work is entitled to great weight when it is supported by competent medical evidence. " Dobrowolsky, supra, 606 F.2d at 409. In the instant case, the plaintiff's complaints of pain were manifested, not only by complaints to his physicians, but by numerous hospitalizations and surgical procedures. While each of the plaintiff's impairments and symptoms, when analyzed in isolation, may not have prevented him from engaging in substantial gainful activity, their cumulative impact certainly had such an effect.
In light of the plaintiff's testimony and supporting medical evidence, we conclude that the plaintiff's impairments seriously affected his ability to engage in his prior work as a security guard. The plaintiff's condition precludes him from standing or walking for any significant length of time. In addition, the uncontradicted medical evidence reveals that the plaintiff has an atypical personality disorder which causes him to uncontrollably explode and which prevents him from handling stressful circumstances. T.377, 381-82. We fail to see how the plaintiff could be a security guard, even one who sits at a monitor all day, the duties of which include being alert, prepared and capable of quickly responding to emergency situations.
In addition, the plaintiff's regular hospitalizations and frequent episodes of diabetic shock seriously hampered his ability to provide an employer with continuous employment. In fact, the plaintiff attempted to work as a security guard in 1987 before applying for disability benefits. He could only work for three weeks before he required hospitalization due to a diabetic ulcer on his right foot. T.39. Since the plaintiff could not have provided an employer with continuous attendance throughout the work week, we find that the plaintiff did not have the capacity to perform any substantial gainful activity. See Dobrowolsky, supra, 606 F.2d at 408.
Since the plaintiff met his burden, the burden of proof shifted to the Secretary to demonstrate that given his age, education and work experience, the plaintiff has the capacity to perform specific jobs that exist in the national economy. Although the Secretary attempted to show this through the use of a vocational expert, as we have discussed above, the hypothetical presented to the expert was seriously defective. In addition, the expert testified that an individual who experienced blurry vision or had to take frequent naps during the day would not be able to perform substantial gainful activity. Thus, the Secretary has failed to meet this burden, as he has failed to produce record evidence which demonstrates that given the plaintiff's condition, including his subjective symptomology, he is capable of performing alternative employment.
The plaintiff's final contention is that the Secretary's decision to deny benefits was implicitly based on the presumption that his diabetes was within his control and thus could not be considered a disabling condition pursuant to 20 C.F.R. 404.1530. This assumption is based on the ALJ's statement that:
Objective medical evidence documented in the record establishes that the claimant's recurrent ketoacidosis is the result of the following two causes: (1) his non-compliance with a prescribed diet; and (2) his non-compliance with the medication regimen (Insulin) prescribed by his physicians. Pursuant to 20 C.F.R. 404.1530 and 416.930, if an individual does not follow prescribed treatment without a good reason, he will not be found 'disabled' within the meaning of the Social Security Act.
The plaintiff's belief is strengthened by the fact that the ALJ, when analyzing the medical evidence in his opinion, repeatedly emphasized the plaintiff's noncompliance with his medical regimen. Moreover, in his motion, the Secretary devotes a considerable amount of time arguing that even if the plaintiff is disabled, he would still not be entitled to receive disability benefits because he has refused to follow medical treatment prescribed by his physicians.
Although the ALJ did not make an express finding that the plaintiff should be denied benefits because of his noncompliance with prescribed medical treatment, it is clear that the ALJ's decision to deny benefits was colored by his express finding that the plaintiff repeatedly refused prescribed medical treatment.
Pursuant to 20 C.F.R. 404.1530, a claimant may be denied disability benefits if the Secretary finds that he unreasonably failed to follow prescribed treatment and that if he had followed the treatment, his ability to work would have been restored. In reviewing whether a claimant's failure to undertake treatment will preclude the recovery of disability benefits, courts have considered four elements: 1) the treatment at issue must be expected to restore the claimant's ability to work; 2) a physician must have prescribed the treatment; 3) the claimant must have refused the treatment; and 4) the claimant's refusal must have been without justifiable excuse. Teter v. Heckler, 775 F.2d 1104, 1107 (10th Cir. 1985); Jones v. Heckler, 702 F.2d 950, 953 (11th Cir. 1983); Cassiday v. Schweiker, 663 F.2d 745, 749 (7th Cir. 1981).
In the instant case, substantial evidence exists to support an affirmative finding on the first three elements. Although one doctor has suggested that the plaintiff's blood sugar levels could not be controlled by insulin, the overwhelming medical evidence indicates that the plaintiff would be able to control his diabetes if he took his prescribed insulin and followed his prescribed diabetic diet. Indeed, on every occasion that the plaintiff was hospitalized for diabetic ketoacidosis, his condition was eventually stabilized following several days of controlled insulin and dietic treatment. In addition, the extensive medical reports document the existence of the plaintiff's severe compliance problem; he injects his insulin into his pillow instead of his arm, and he eats a 3500 calorie "junkfood" diet, instead of a well-balanced 1800 calorie diabetic diet. Many doctors have concluded in their medical reports that the plaintiff's diabetes was out of control due to his refusal to follow his treatment.
However, each doctor also stated that the plaintiff's uncooperativeness was due to a severe underlying personality disorder which prevented him from acting rationally. Dr. Hahn, a psychiatrist, reported that until the plaintiff received psychiatric treatment, his diabetes would remain unstable. T.251. In addition, the doctor concluded that the plaintiff was extremely uncooperative, and that his mental problems complicated effective management of his physical impairment. Id. Similarly, Dr. Helen Thornton drew a link between the plaintiff's underlying personality disorder and his lack of compliance with his medical regimen, noting that the plaintiff's attempts to correct his mental impairment had been unsuccessful. T.384. Finally, Dr. Varma opined that it was unlikely that the plaintiff's compliance problem would ever improve, and therefore, listed his prognosis as guarded. T.561.
Section 404.1530(c) of the regulations permits a claimant to refuse prescribed medical treatment without losing his entitlement to disability benefits, if he has a justifiable reason for refusing treatment. 20 C.F.R. 404.1530(c). Some examples of justifiable cause are: the treatment is contrary to the claimant's religious beliefs; similar surgery was previously unsuccessful; the surgery is very risky; or the surgery involves amputation of an extremity. Id.
Although some courts have used an objective standard when analyzing whether a claimant's refusal of prescribed treatment is reasonable or justifiable, the majority of courts use a more lenient, subjective standard. Johnson v. Secretary of Health and Human Services, 794 F.2d 1106, 1113 (6th Cir. 1986); See also Stone v. Harris, 657 F.2d 210, 215 (8th Cir. 1981) (holding that, "the proper question for the agency is not whether Stone's obesity is in some clinical sense remediable, but whether her obesity is the sole cause of her disabilities, and, if so, whether her obesity is reasonably remediable by her."). Courts are even more likely to employ a subjective test when the claimant has a mental impairment. See Benedict v. Heckler, 593 F. Supp. 755, 761 (E.D. N.Y. 1984) (holding that in cases involving the mentally ill, "justifiable cause" must be given a subjective definition).
We hold that in determining whether a claimant with a mental impairment has reasonably refused treatment, the question is whether he has justifiably refused in light of his psychological, social or other individual circumstances. We believe that this rule makes sense. An individual with a severe mental impairment quite likely lacks the capacity to be "reasonable." In addition, that individual may not have the same capacity to assess the risks and benefits of prescribed treatment as someone who is not affected by such an impairment.
The plaintiff has a long history of noncompliance with medical treatment. However, his mental impairment was diagnosed less than a year after his diabetes was initially diagnosed. Moreover, the medical evidence indicates that although the plaintiff has attempted to correct his personality disorder, his attempts have been unsuccessful and will remain unsuccessful in the future. In 1979, Dr. Hahn indicated that the plaintiff needed long term mental health care, but that his prognosis for recovery was poor. T.252. Six years later, in 1985, the plaintiff voluntarily admitted himself to the hospital for psychological evaluation after assaulting his wife. T.348. The plaintiff's treating physician diagnosed the plaintiff as having a dysthmic disorder and a passive-aggressive personality disorder, and he too listed the plaintiff's prognosis for recovery as poor. T.349. Finally, one year later, after the plaintiff had gone through seven months of therapy, Dr. Coleman, a psychiatrist requested by the Social Security Administration, stated that the plaintiff's prognosis for recovery was poor. T.377
In sum, the uncontradicted medical evidence establishes that the plaintiff suffers from a severe personality disorder which has affected, and will continue to affect, his ability to think and act rationally and to follow his prescribed insulin and diet regimen. Accordingly, justifiable cause exists for the plaintiff's noncompliance.
The Court concludes that there is no substantial evidence to support the ALJ's determination that the plaintiff could perform his past relevant work as a security guard or medium exertional jobs that exist in the national economy. Furthermore, substantial evidence on the record does not exist to support the ALJ's conclusion that the plaintiff's noncompliance with prescribed medical treatment was unreasonable. Accordingly, the Secretary's determination denying benefits is reversed, and we will enter judgment in favor of the plaintiff and award disability benefits beginning August 25, 1979.
An appropriate Order will issue.
AND NOW, to-wit, this 1st day of February, 1989, it is ORDERED, ADJUDGED and DECREED that;
1) the plaintiff's Motion for Summary Judgment be and hereby is GRANTED.
2) the defendant's Motion for Summary Judgment be and hereby is DENIED.
3) Judgment be and hereby is entered for the Plaintiff Robert D. Sharp and against the defendant Otis R. Bowen, Secretary of Health and Human Services.
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