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Cain v. Berryhill

United States District Court, N.D. Alabama, Jasper Division

July 21, 2017

RALPH CAIN, Plaintiff,



         Plaintiff Ralph Cain (“Plaintiff” or “Cain”) brings this action pursuant to Sections 205(g) and 1631(c)(3) of the Social Security Act (the “Act”). Plaintiff seeks review of the decision by the Commissioner of the Social Security Administration (“Commissioner”) to deny his claim for disability insurance benefits (“DIB”) and Supplemental Security Income (“SSI”). See 42 U.S.C. §§ 405(g) and 1383(c). Based on the court's review of the record and the briefs submitted by the parties, the court finds that the decision of the Commissioner is due to be affirmed.

         I. Proceedings Below

         Plaintiff filed his applications for DIB and SSI on March 12, 2013, alleging disability beginning August 22, 2012. (Tr. 19, 118). The claim was initially denied on June 24, 2013. (Tr. 19). After his application was denied, Plaintiff filed a written request for hearing pursuant to 20 CFR § 416.1429 et seq. (Tr. 19). On July 9, 2014, Plaintiff received a video hearing before Administrative Law Judge (“ALJ”) George W. Merchant. (Tr. 19, 27). The ALJ determined that Plaintiff was not disabled under Section 1614(a)(3)(A) of the Act. (Tr. 27).

         On May 26, 2016, the Appeals Council denied Plaintiff's request for review of the ALJ decision. (Tr. 1). Following that denial, the final decision of the Commissioner became a proper subject of this court's appellate review. See Chester v. Bowen 792 F.2d 129, 131 (11th Cir. 1986) (finding the ALJ decision final for purposes of judicial review when the Appeals Council denied review).

         Plaintiff Ralph Cain was 54 years old at the time of the hearing. (Tr. 39). He attended school through the tenth grade, but testified that he reads and writes only “very simple words.” (Tr. 38-39, 42, 54, 184). He previously worked for K&H Trucking doing heavy lifting and manual labor, changing oil, changing tires, and generally performing the duties of a mechanic's helper on diesel-type equipment. (Tr. 38-40, 49). He also worked for Southern Energy Homes as a manufactured buildings assembler, a medium exertional job. (Tr. 40, 49, 54-57). Plaintiff alleges that he has not been able work since August 22, 2012 due to injuries in his arms, back, and collarbone, hernias, and high blood pressure. (Tr. 38, 40-46, 152, 183).

         Plaintiff experienced an on-the-job work injury in August 2002[1] from which maintains he continues to have some residual effects. Plaintiff was putting air in a truck tire when the tire exploded and struck him. (Tr. 34, 41, 46, 267, 270). “And it undoubtedly was a defective rim, and it come off, and blowed me about 45 feet in the air from the shock, and I had to be ambulanced out of there …” (Tr. 41). The rim crushed his dominant left hand which now “…stays numb all the time” and makes Plaintiff unable to grip things. (Tr. 41, 319). The doctor report from the day of the incident indicates that Plaintiff had “…taken more of a blow to his left arm.” (Tr. 270). Plaintiff continued to go to the doctor's office and physical therapy as recommended and, on December 16, 2002, the doctor stated that “…he can go to full duty” without any restrictions, but with a 5% whole man impairment.[2] (Tr. 267).

         Other than testimonial assertions, the medical record contains no documentation for ten years, from 2002 until 2012.[3] During that period of time, Plaintiff continued to work despite the nerve damage issues from the on-the-job injury. (Tr. 21, 43, 267). Plaintiff presented to the emergency room at Walker Baptist Medical Center with sudden abdominal pain on August 23, 2012.[4] (Tr. 217-27). Plaintiff had been lifting heavy tires at work and noticed a bulge and pain in the left inguinal[5] region. (Tr. 49, 218). He was diagnosed with a left inguinal hernia and was instructed to make an appointment with surgeon Dr. Matthew Knight. (Tr. 220). Plaintiff was again seen at the same emergency room, for the same left inguinal hernia, on August 27, 2012 because he had run out of pain medication and had not yet seen the surgeon for repair of the hernia. (Tr. 206-16).

         Plaintiff was seen for a consultation with Dr. Billy Richardson on September 27, 2012. (Tr. 232). A CT scan was performed of Plaintiff's abdomen and pelvis, which revealed a probable hernia in the left inguinal area. (Tr. 232, 237). Mild inflammation of Plaintiff's colon, consistent with mild diverticulitis, was noted and Plaintiff was put on antibiotics. (Tr. 232, 237). At this appointment, Plaintiff was encouraged to establish care for high blood pressure. (Tr. 232).

         On October 1, 2012, Plaintiff went to Capstone Rural Health Center to establish care for hypertension. (Tr. 243). Notes from that visit state “Patient states he passed out 1-2 weeks ago. He was told by paramedics he had HTN [hypertension]. hx of high blood pressure. States needs to have hernia surgery but cannot due to elevated blood pressure.” (Tr. 243). Plaintiff was prescribed Lisinopril for high blood pressure. (Tr. 244). Plaintiff returned to Capstone Rural Health Center on October 15, 2012 for a follow-up appointment and stated that he was feeling much better. (Tr. 241). He was again seen on November 13, 2012 for a refill of Lisinopril. (Tr. 240).

         Plaintiff followed up with Dr. Richardson on October 15, 2012 and stated that his abdominal pain was much improved, still with some tenderness and bulging in the left inguinal area. (Tr. 232). On October 23, 2012, Plaintiff had surgery for the recurrent inguinal hernia, which was repaired with extra-large mesh and plug. (Tr. 229-30).

         II. ALJ Decision

         The Act uses a five-step sequential evaluation process to determine a claimant's disability. 20 C.F.R. § 404.1520(a) and 416.920(a). First, the ALJ must determine whether the claimant is engaging in substantial gainful activity. 20 C.F.R. § 404.1520(b) and 416.920(b). Substantial gainful activity is work done for pay or profit that requires significant physical or mental activities. 20 C.F.R. § 404.1572(a-b) and 416.972(a-b). If the claimant has employment earnings above a certain threshold, the ability to engage in substantial gainful activity is generally presumed. 20 C.F.R. § 404.1574, 404.1575, 416.974, and 416.975. If the ALJ finds that the claimant engages in substantial gainful activity, then the claimant cannot claim disability, regardless of a medical condition or age, education, and work experience. 20 C.F.R. § 404.1520(b) and 416.920(b).

         Second, the ALJ must determine whether the claimant has a medically-determinable impairment that significantly limits the claimant's ability to perform basic work activities. 20 C.F.R. § 404.1520(c) and 416.920(a)(4)(ii). Absent such impairment, the claimant may not claim disability. Id. Third, the ALJ must determine whether the claimant's impairment meets or functionally equals an impairment listed in 20 C.F.R. ยง 404, Subpart P, Appendix 1. If the criteria ...

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