SSR 68-74a: Sections 216(i) and 223.—Disability—Combination of Impairments—Lack of Severity
20 CFR 404.1502, 404.1510
A claimant who had a ninth-grade education and had been employed primarily as a carpenter, filed application in May 1964 for a period of disability and disability insurance benefits, alleging inability to work from November 1963, at age 45, because of a lung condition, stomach ulcers, arthritis, hernia, and a rectal fissure. The clinical diagnostic data as reported by several physicians were not demonstrable of any significant physical impairment or emotional disorder (except for bilateral inguinal herniae which could be corrected by simple surgery) at any time up to September 30, 1966 (when he last met the special earnings requirements). The claimant worked part time as a janitor from May through December 1964, and worked full time on construction work for 5 weeks in 1965. Held, the evidence fails to establish that the claimant was prevented from engaging in any substantial gainful activity by reason of any medically determinable physical or mental impairment which lasted or could have been expected to last for a continuous period of 30, 1966, and therefore, he was not under a disability as defined in the Act, and is not entitled to a period of disability or disability insurance benefits.
This case is before the Appeals Council on the claimant's request for review of the hearing examiner's decision dated November 22, 1965. The hearing examiner held that the claimant was not entitled to a period of disability or to disability insurance benefits under applicable provisions of the Social Security Act.
The claimant filed an application for a period of disability and for disability insurance benefits on May 21, 1964, alleging inability to work from November 12, 1963 because of a lung condition, stomach ulcers, arthritis, hernia and a rectal fissure. In connection with his application, the claimant stated that he was born on November 12, 1918, completed 9 grades of school and was employed as a carpenter. His specific complaints include shortness of breath, stiffness, swelling and pain in multiple joints, chest pain and weakness.
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STATEMENT OF THE LAW AND ISSUES
Section 216(i) of the Social Security Act provides for the establishment of a period of disability, and section 223 provides for the payment of disability insurance benefits. As herein pertinent, both sections prior to the enactment of the Social Security Amendments of 1965 on July 30, 1965, defined "disability" as an inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or to be of long-continued and indefinite duration.
In pertinent part, sections 216(i) and 223 of the Act, as amended, now define "disability" as an inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months.
When a claimant's entitlement is dependent on the amended definition of "disability," disability insurance benefits are not payable for any month prior to September 1965 [section 303(f)(1) of Public Law 89-97]. Entitlement to a period of disability may not be established under an application, if the period would have ended more than 12 months before the date on which such application was filed [section 216(i)(2)(E) of the Act as amended in 1965].
The Amendments of 1965 eliminated the provisions of the Act which limited the prospective life of disability applications. The Act now provides that if a claimant meets all the requirements for entitlement at any time before the Secretary issues a final decision on an application, such application shall be deemed to have been filed in the first month in which all requirements were met.
The general issues before the Appeals Council are whether the claimant is entitled to a period of disability and to disability insurance benefits under sections 216(i) and 223, respectively, of the Social Security Act, as amended. The specific issues are whether the claimant was under a "disability," as defined in the Act either prior to or after the Amendments of 1965, and if so, when such disability commenced and the duration thereof; and whether the special earnings requirements of the Act are met for the purpose of entitlement.
In his decision, the hearing examiner found that the claimant met the special earnings requirements of the Act through March 31, 1966, but not thereafter. Based on a supplementary earnings record, certified April 26, 1967, the Appeals Council finds that the claimant continued to meet the special earnings requirements of the Act through September 30, 1966. Therefore, in order to be entitled to a period of disability or to disability insurance benefits, it is necessary for the claimant to establish that he was under a "disability" from a time on or prior to September 30, 1966.
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SUMMARY OF MEDICAL EVIDENCE
The medical evidence before the hearing examiner showed that the claimant was seen in June 1964 by Dr. [A] for complaints of stomach pain and painful joints. The physician reported arthritic involvement in the hips, fingers, knees, ankles and wrists but did not indicate any limitation of motion. He found the heart and lungs normal. His diagnostic impression was duodenal ulcer, bilateral inguinal hernia and arthritis of multiple joints. He believed the claimant was unable to work at that time.
On June 3, 1964, the claimant was seen by Dr. [B]. This physician reported that the claimant's heart and lungs were normal and that there was no arthritis present. He diagnosed constitutional inadequacy and an inguinal hernia on the right side. The latter condition, he said, was "of no serious threat for disability." It was his opinion that the claimant's "disability stems from poor training and disinterest in what he has been doing."
On July 13, 1964, the claimant was examined, on a consultative basis, by Dr. [C], a full-time specialist in internal medicine. Dr. [C] found no objective evidence of disease other than a questionable tophus-like lesion on the left ear lobe and bilateral inguinal hernia. Although the claimant complained of stiffness, swelling and pain in many joints, the specialist stated there was no redness, or limitation of motion. He said the claimant has a chronic anxiety state with conversion hysteria but suggested further laboratory studies.
On October 1, 1965, the claimant was examined by Dr. [D], who diagnosed osteoarthritis and a right inguinal hernia. He reported moderate tenderness throughout the spinal column and marked limitation of motion in the cervical spine. He said the heart was normal and a neurological examination showed normal reflexes. Additional studies were recommended to determine the presence of other disorders.
In his decision, the hearing examiner found that there was no clinical evidence in the record to establish the diagnosis of arthritis; that an ulcer was not corroborated by objective evaluation; that the inguinal hernia could be remedied by simple surgery; that the claimant had no cardiac or pulmonary disease; and that he had no disabling psychiatric impairment. The hearing examiner also found that the claimant was not prevented from returning to his regular work as a carpenter or as a janitor.
A medical examination was performed on November 17, 1965, by Dr. [E] for the Vocational Rehabilitation Division. At that time the claimant was complaining of stiffness and pain of multiple joints and increasing numbness of both the hands and feet. The physician was unable to elicit any history suggesting endogenous depression or paranoid ideation. On physical examination, there was no cyanosis or pallor. The chest had a normal configuration and expansion. There was no heart enlargement or murmurs. The fingers were not typical of rheumatoid arthritis. There was a bilateral loss of pin prick sensation below the knees. His diagnoses included generalized arthritis, etiology undetermined; peripheral neuritis, etiology uncertain; rectal bleeding, etiology to be determined; and a possible head injury, incurred in 1961. The physician stated that the claimant's memory loss may be due to this injury or other cause. He considered the claimant completely disabled because of his generalized rheumatic condition. He said there was not sufficient evidence to corroborate the possible diagnosis of arteriosclerotic heart disease with anginal syndrome. He suggested additional diagnostic studies.
On April 14, 1966, the claimant was examined, on a consultative basis, by Dr. [F], a full-time specialist in internal medicine. Dr. [F] noted that the claimant had had to change a tire on his car on the way to his office but did not complain of any particular difficulties resulting from this incident. He described the claimant as a healthy appearing individual with good color. There were no abnormal precordial pulsations, and the heart sounds were of normal quality with no murmurs. The lungs were clear and the liver and spleen not enlarged. The hands and feet were cool but there were normal peripheral pulses and no edema.
A chest X-ray revealed a normal heart size and configuration. An electrocardiogram was unremarkable. A double Masters Test was performed without any difficulty of any sort, including locomotion, and interpreted as negative. The claimant showed no evidence of shortness of breath after completion of the test and made no complaints. The specialist observed that the claimant was able to dress, including buttoning his shirt, with no evidence of any dysco-ordination or apparent impairment of manual dexterity. The claimant also appeared to be able to freely move his joints. His memory and mentation seemed normal. Dr. [F] concluded that he could find no evidence of organic heart disease and no findings to indicate inability to perform light to medium sustained exertion.
On June 20, 1966, the claimant was admitted to [X] Hospital for evaluation under the State special project. His chief complaint was pain and stiffness in every joint in his body. On physical examination he gave a superficial appearance of good health although his actual development was normal for a man of his stature. He held himself very stiffly with his shoulders hunched forward and moved with a studied slowness. There was a marked dorsal kyphosis and apparent tenderness of the muscles to palpation. There was no demonstrable deformity or limitation of the joints and no muscular atrophy. The remainder of the examination was thoroughly unremarkable except for a circumscribed hernia. An electrocardiogram was normal. X=rays of the cervical spine showed some hypertrophic arthritic changes of the vertebrae which were interpreted as minimal and well within normal limits for an individual of the claimant's age.
During the course of the hospitalization, the claimant was seen to move about much less stiffly when not under observation. He spent one session in the physiotherapy department where he performed well without any restriction of motion and with apparent good muscle strength. It was believed that the claimant did not have rheumatoid arthritis. The sedimentation rate, rheumatoid arthritis test and other blood work showed no abnormalities even suggesting early active disease. It was also believed that the claimant's allegation of complete amnesia from a head injury appeared very questionable in the course of interviewing and history taking. A psychiatric consultation resulted in an impression of an inadequate personality with many neurasthenic and functional trends. Because of the claimant's inadequate personality, the prognosis for rehabilitation was termed poor. The claimant was discharged on June 23, 1966, and advised to continued under the care of his osteopathic physician.
An X-ray was performed on September 20, 1966, to study the claimant's colon. The results were interpreted as showing functional colitis of the descending and sigmoid colon.
EVALUATION OF MEDICAL EVIDENCE
At the time the claimant filed his application for disability benefits, he related his alleged inability to work to several physical disorders. He identified those impairments as a lung condition, stomach ulcers, arthritis, hernia and a rectal fissure.
Although the claimant has, on occasion, complained of shortness of breath, the record is completely devoid of any objective findings  consistent with or attributable to pulmonary pathology. Two of the claimant's attending physicians reported in June 1964 that his lungs were normal. A specialist in internal medicine, after examining the claimant in July 1964, was unable to find any evidence of a respiratory disorder. A chest X-ray at that time was negative and pulmonary function studies demonstrated no true loss of pulmonary function. The more recent specialist's examination in April 1966 failed to disclose any pulmonary abnormalities. Significantly, the claimant was able to perform a double Masters Test without showing any evidence of shortness of breath. It seems quite clear, therefore, that the claimant's allegation of a lung condition is not substantiated by any of the reporting physicians of record.
Dr. [E], after examining the claimant in November 1965, raised the possibility of arteriosclerotic heart disease with anginal syndrome. Even though all of the prior medical reports, including an examination by a specialist in internal medicine in July 1964, contained no mention of heart disease, the Appeals Council authorized a comprehensive examination by another specialist in internal medicine to thoroughly explore this possibility. This examination, performed in April 1966, conclusively ruled out the presence of any organic heart disease.
Pertinent laboratory studies such as a chest X-ray and electrocardiogram disclosed no evidence of cardiac irregularities. Accordingly, the Appeals Council concludes that the claimant has no impairment affecting the cardiovascular system.
The record does support the claimant's allegations concerning the presence of bilateral inguinal herniae. However, the record also shows that the herniae can be remedied by simple surgery. It appears that the only reason the claimant has not yet elected to have surgery is because the condition has not caused him any significant difficulties.
The claimant's allegations of stomach ulcers and a rectal fissure find little support in the record. Although one physician diagnosed a duodenal ulcer in 1964, of 10 years' duration, and prescribed ulcer medication, his report contained no objective findings to support the diagnosis. Subsequent examinations, including that of the internist in April 1966, did not even result in a diagnosis of duodenal ulcer. Additionally, in April 1966, the claimant was described as "healthy looking," a strong indication that his nutritional status has not been adversely affected. In the absence of appreciable loss of weight, loss of muscle strength, significant neurological changes, severe pain, anemia or ascites, the Appeals Council must conclude that there is no active ulcer present and no significant impairment of the digestive system. Although the record does mention occasional rectal bleeding and X-ray evidence of functional colitis, there is nothing to show that these disorders were anything but minor irritants, causing some discomfort but imposing no discernible functional limitations.
The claimant's major complaints are pain, stiffness, and swelling of multiple joints, allegedly due to an arthritic disorder. Again, however, the Appeals Council is unable to find sufficient objective manifestations of a musculoskeletal impairment that would be compatible with the claimant's allegations. The preponderance of credible medical evidence convincingly shows no significant arthritic impairment. One physician who diagnosed arthritis of multiple joints in June 1964, did not indicate any limitation of motion. Another attending physician expressly stated in June 1964, that the claimant did not have arthritis. The internist who examined the claimant in July 1964, found no swelling, redness or limitation of motion.
It is true that Dr. [D], in October 1965, did report moderate tenderness throughout the spinal column and marked limitation of motion in the cervical dorsal area. Apparently, however, the physician reported these findings based on the subjective complaints of the claimant. His report does not contain an X-ray interpretation or other studies to support his diagnosis of osteoarthritis. Neither does the report submitted by Dr. [E] carry any objective corroboration for his diagnosis of generalized arthritis or of his conclusion that the claimant was completely disabled because of his condition.
On the other hand, Dr. [F], a few months later, was able to report no gross limitation of physical function, no apparent impairment of manual dexterity and no difficulty in locomotion during the performance of a double Masters Test. Moreover, in June 1966, X-rays of the cervical spine showed only minimal hypertrophic changes, well within normal limits for an individual of the claimant's age. Additionally, at that time there was no demonstrable deformity or limitation of the joints and no muscular atrophy. The Appeals Council therefore, finds that the claimant's arthritic disorder represents a slight impairment unaccompanied by significant physical limitations.
The remainder of the claimant's many physical complaints are of little consequence and, in any event, not clearly related to any pathology. A small tophus-like lesion of the left ear lobe, reported in July 1964, is not mentioned in any of the subsequent medical reports. Some peripheral neuritis of the lower extremities was reported by Dr. [E] in November of 1965. However, he was unable to establish any etiology for the symptomatology and again, subsequent examination found no evidence of the condition.
Some of the medical reports have suggested the presence of an emotional disorder. One of the claimant's attending physicians described him as constitutionally inadequate. Another reporting physician diagnosed a chronic anxiety state with conversion hysteria. Dr. [E] mentions the possibility of a head injury, occurring in 1961, affecting the claimant's memory. Significantly, however, none of the physicians furnished findings that would be compatible with a serious emotional disorder. Dr. [F], in April 1966, specifically stated that the claimant's memory and mentation seemed normal. During the claimant's hospitalization in June 1966, a psychiatric consultation resulted in a diagnosis of inadequate personality with many neurasthenic and functional trends. It was the opinion of two of the hospital physicians that the claimant's allegation of amnesia appeared very questionable. Although he was considered a poor candidate for rehabilitation at that time, the opinion was not based on the presence of any significant psychiatric disorder but rather on the claimant's inadequate personality.
The Appeals Council, therefore, believes that the claimant's apparent self-concern over his alleged aches and pains has not deepened into a preoccupation causing severe social, personal and occupational regression. The Appeals Council finds that the claimant's mental status would not significantly restrict his capacity to cope with the mental demands which ordinarily would be encountered in day-to-day work situations. The conclusion is inescapable that whatever degree of emotional impairment is present, it is mild and of no consequence.
SUMMARY AND EVALUATION OF VOCATIONAL DATA
The claimant has a ninth grade education and has worked as a carpenter most of his life. He has done finish work and rough work. He operated bench saws, planers, band saws, and all of the machinery normally used in connection with this trade. He has sometimes been a foreman, laying out work, supervising men and keeping them occupied on a project. Several years ago he completed a 6-month course in electronics, attending one night a week.
In May 1964, the claimant began working in the [Y] Department Store as a janitor. Actually, he was employed by a contractor who would send a crew of five individuals, including the claimant, to the department store. He worked an hour and a half a day or 9 hours a week. His duties included dry mopping and washing the floors, waxing and buffing them. He earned $1.25 an hour. In August 1964, the contractor left the area to look after his other enterprises, and left the claimant in charge of his business. Thereafter, until December 1964, the claimant not only continued to perform his regular cleaning duties but was also responsible for the equipment used for the various jobs and for assigning work to the other employees. This employment was terminated in December 1964, when the business closed down. A supplementary earnings record shows that $706.44 was paid to the claimant for the three month period ending September 30, 1964.
In the summer of 1965, the claimant returned to his regular construction work. He worked for 5 weeks at $1.25 an hour, earning an average of $50 a week on a variety of jobs.
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Although the amount of wages earned by the claimant during his employment in 1964 is relatively small and the work was performed on a part-time basis, the Appeals Council believes it demonstrated an ability to engage in substantial gainful activity. The claimant's work activity in the summer of 1965, although short-lived, also indicated an ability to engage in substantial gainful activity. In fact, the claimant's work effort, over a sustained period of time, is consistent with the essentially unremarkable objective medical findings during the period at issue and confirms the absence of significant functional limitations.
* * * The Appeals Council finds that the claimant is physically and mentally capable of performing the duties associated with his usual jobs as a carpenter or with his more recent job as a janitor.
FINDINGS OF THE APPEALS COUNCIL
* * * The Appeals Council makes the following additional findings:
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The claimant last met the special earnings requirements of the Act, for disability purposes, on September 30, 1966.
The claimant had a mild arthritic disorder causing no significant physical limitation and no discernible anatomical changes on and before September 30, 1966.
The claimant had no cardiac or pulmonary disease on or before September 30, 1966.
The claimant's bilateral inguinal herniae were remedial by simple surgery on and before September 30, 1966.
The claimant had no significant impairment of the digestive system on and before September 30, 1966.
The claimant had no significant emotional disorder on or before September 30, 1966.
The claimant was physically and mentally capable of performing his usual work on and before September 30, 1966.
The evidence of record fails to establish that the claimant was prevented from engaging in substantial gainful activity for any continuous period beginning on or prior to September 30, 1966, which has lasted or could have been expected to last at least 12 months.
The claimant was not under a "disability," as defined in the Act either prior to or after the Social Security Amendments of 1965, at any time on or before September 30, 1966.
It is the decision of the Appeals Council that the claimant, based on his application filed on May 21, 1964, is not entitled to a period of disability or to disability insurance benefits under the provision of section 216(i) and 223, respectively, of the Social Security Act, in effect prior to the Social Security Amendments of 1965 or as amended thereby. The hearing examiner's decision, as herein supplemented, is affirmed.
The phrase "objective findings" in this context means findings of a medically discernible condition. (See CFR 404.1501(c), 33 F.R. 11750, Aug. 20, 1968).