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McFall v. Colvin

United States District Court, D. New Hampshire

March 9, 2016

Nancy Keith McFall,
Carolyn W. Colvin, Acting Commissioner, U.S. Social Security Administration. Opinion No. 2016 DNH 049


          PAUL BARBADORO, District Judge.

         In June 2012, Nancy Keith McFall applied for disability insurance benefits ("DIB"), alleging disability as of April 30, 1989. The SSA initially denied McFall's claim in August 2012, and denied her claim again upon reconsideration in November 2012. Thereafter, a hearing was held before an Administrative Law Judge ("ALJ"), where McFall, represented by counsel, appeared and testified. The ALJ then issued a written decision finding that McFall had failed to show that she suffered from a severe impairment before her March 31, 1997 date last insured, or through the date of the ALJ's decision. The ALJ therefore concluded that McFall was not disabled. McFall now challenges the Social Security Administration's decision to deny her claim. The Social Security Commissioner, in turn, seeks to have the ruling affirmed.

         I. BACKGROUND

         A. Medical Evidence and Hearing Testimony

         McFall applied for DIB on June 15, 2012, alleging disability as of April 30, 1989. Tr. at 19 (Doc. No. 7). McFall last met the Social Security Act's insured status requirement on March 31, 1997, and there are no medical records predating her March 31, 1997 date last insured ("DLI"). Rather, the first treatment notes in the record were from June 1997 (several months after her DLI), when McFall was admitted to Pembroke Hospital due to bipolar affective disorders, psychiatric disorders not otherwise specified, polysubstance abuse, increased anxiety, difficulty sleeping and suicidal ideation. Tr. at 22, 161, 164. Before that admission, McFall had undergone no psychiatric treatment. Tr. at 161.

         At the hospital, McFall reported that she had suffered a head injury as a teenager, and that, for several years before June 1997, she had engaged in substance abuse and experienced paranoid ideation. Tr. at 159. McFall was diagnosed with bipolar disorder and polysubstance abuse and placed on a fourteen-day treatment plan. Tr. at 159, 162. Upon discharge, she was described as alert, partially cooperative, with continued paranoid ideas, irritable mood, and fair judgment. Tr. at 159. McFall was referred to Northeast Psychological Associates for further treatment, but there are no records indicating that she followed through with that referral. Tr. at 22, 159-60.

         At her October 13, 2013 hearing before the ALJ, McFall described the circumstances surrounding her June 1997 treatment at Pembroke Hospital. She testified that she had had problems sleeping since she was involved in a car accident as a teenager, and continued to have problems sleeping as of the date of her hearing. Tr. at 39-41. She stated that she was diagnosed with bipolar disorder in 1997 (presumably at Pembroke Hospital), and testified that the condition significantly affected her ability to function on a daily basis. Tr. at 53. She also told the ALJ that, at around that same time she was hospitalized, she had increased her alcohol consumption. Tr. at 53. When asked about the suicidal ideations, depression and anxiety mentioned in the Pembroke Hospital notes, McFall said that she "went through that for a short period, " and that she "couldn't do anything" while affected. Tr. at 54.

         Based on the evidence before the ALJ, there were no additional treatment records until May 2012, about one month before McFall applied for DIB.[1] In May 2012, McFall sought treatment for abdominal swelling and discomfort and chronic diarrhea. Tr. at 258. McFall was diagnosed with hepatic failure due to alcohol use. Tr. 263. In July 2012, McFall was again treated for abdominal pain and distention. Tr. 252-53. At her October 2013 hearing, McFall testified that these abdominal symptoms have since been resolved, and stated that she no longer drinks alcohol. Tr. at 35, 50.

         B. ALJ's Decision

         In his decision, the ALJ evaluated McFall's claim under the five step sequential process described in 20 C.F.R. § 404.1520(a)(4). At step one, the ALJ found that McFall had not engaged in substantial gainful activity during the period from her alleged onset date through her DLI. Tr. at 21. The ALJ then resolved the case at step two, determining that McFall had not established that she suffered from a severe medically determinable impairment at any time from her alleged onset date through her DLI.

         To support this conclusion, the ALJ explained that McFall had "experienced an acute episode in June 1997, " at which time she "had medically determinable impairments that could reasonably produce work-related functional limitations." Tr. at 23. The ALJ also noted that, in June 1997, McFall described "symptoms of paranoia and substance abuse dating back one to two years" and "being unable to work for the previous three years." Tr. at 22. The ALJ concluded, however, that this evidence was inadequate to establish a medically determinable impairment because "there is no evidence to support this degree of symptomology or limitations prior to the date last insured, " and because the record contained no evidence of follow-up treatment after McFall's hospitalization. Tr. at 23. According to the ALJ, that lack of follow-up "suggests that [McFall's] symptoms had largely resolved." Tr. at 23.

         With respect to McFall's history of substance abuse, the ALJ noted that McFall "did admit that she was abusing substances during the period of her hospitalization in June 1997, as well as subsequently, " and that she was diagnosed with alcoholic hepatitis and portal hypertension in June 2012. Tr. at 23. The ALJ thus found "sufficient support in the limited evidence of record that [McFall] does have some issues with substance abuse." Tr. at 23. Nonetheless, in light of the limited record evidence, and the absence of "evidence documenting higher functioning absent substance abuse and a significant deterioration with such abuse, " the ALJ concluded that there was insufficient support to find that McFall's alcohol abuse was material to the finding of disability, "or that it produces any specific work-related functional limitations throughout the period under review." Tr. at 23.

         The ALJ further concluded that, even if there was sufficient evidence that McFall was disabled before her DLI, McFall's claim nonetheless failed because McFall did not "have disability continuing to the present date or ending within the 12-month period in which she applied, " as required by 20 C.F.R. § 404.315. Tr. at 23. According to the ALJ, "the record contains no evidence whatsoever for fifteen years prior to the application date. Even as of the application date, the record contains only a few brief notes from May 2012 to July 2012, which fail to support any specific work-related functional limitations." Tr. at 23. The ALJ was therefore "unable to find [McFall] disabled." Tr. at 23.

         In January 2014, McFall asked the Appeals Council to review the ALJ's decision. Tr. at 12-15. The Appeals Council denied McFall's request. Tr. at 1-4. As such, the ALJ's decision constitutes the ...

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