SSR 68-76a: Sections 216(i) and 223.—Disability—Cessation of Disability
20 CFR 404.1539(a)
The claimant was determined to be under a disability as of December 1, 1963, based on the medical findings indicating arteriosclerotic heart disease, manifested by angina pectoris, and congestive heart failure. In September 1965 objective medical tests revealed no signs suggesting heart failure, no indications of heart block or diagnostic abnormality and that her condition had improved. The examining physician indicated claimant was capable of light work such as clerical work. Claimant's attending physician, while noting that most of the claimant's symptoms were without objective medical support, but were subjective, was of the opinion claimant was unable to work. Claimant performed the usual household functions and drove a car when necessary. A vocational specialist, summarizing the test results conducted by a rehabilitation center, testified that the claimant demonstrated significant clerical skill involving language usage, numerical ability, verbal reasoning, and fluency, and good manual capacity for the fine hand manipulation. Another vocational expert testified that the claimant had highly marketable vocational skills currently in demand, listing types of jobs available in the area in which she lived which she could obtain. Held, on the basis of the medical and vocational evidence as a whole, the claimant's heart condition, as reflected by the medical examination in September 1965, had not significantly improved as to establish that the claimant was then capable of engaging in substantial gainful activity, and thus claimant's disability ceased on September 3, 1965. Accordingly, the claimant's entitlement to a period of disability and disability insurance benefits terminated with the month of November 1965, pursuant to sections 216(i) and 223 of the Act.
This case is before the Appeals Council on the claimant's request for review of the hearing examiner's decision dated October 28, 1966. The hearing examiner held that the claimant's entitlement to a period of disability and disability insurance benefits ended with the close of the last day of November, 1965.
The claimant filed an application for a period of disability and for disability insurance benefits on June 22, 1964 alleging inability to work from December 1, 1963 because of a heart disorder. On the basis of this application, it was determined that the claimant became disabled on December 1, 1963. Subsequently, it was decided that medical evidence established that as of September 1965, the claimant's condition had improved to a degree which would permit her to return to substantial gainful activity within the scope of her vocational training and experience.
STATEMENT OF THE LAW AND ISSUES
Section 404.1539(a) of the Social Security Administration Regulations No. 4 [20 CFR 404.1539(a)] provides that an individual's "disability" shall be found to have ceased in the month in which the impairment, as established by the medical or other evidence, is no longer of such severity as to prevent the individual from engaging in any substantial gainful activity.
Section 216(i) of the Social Security Act, as pertinent herein, provides for the establishment of a period of disability and, in effect, that such period shall end with the close of the last day of the second calendar month following the month in which disability ceases.
Section 223 of the Act, as pertinent herein, provides for the payment of disability insurance benefits and, in effect, that entitlement to such benefits shall end with the close of the second month following the month in which the disability ceases.
The general issues before the Appeals Council are whether the claimant continues to be entitled to disability insurance benefits and/or a period of disability. The specific issues are whether the claimant's disability has ceased, and if so, as of what date. This depends on whether the evidence establishes that the claimant's impairment has improved sufficiently so that it is no longer of such severity as to prevent substantial gainful activity.
SUMMARY OF MEDICAL AND VOCATIONAL EVIDENCE
The medical evidence before the hearing examiner showed that the claimant was admitted to a hospital in April 1964 because of difficulty in breathing. She was treated and was ultimately discharged on May 23, 1964 with a final diagnosis of arteriosclerotic heart disease with cardiac decompensation, and anterior myocardial ischemia.
Shortly after discharge from the hospital, the claimant's attending physician reported that under his care there had been excellent response to medication, and that there were no longer any objective indications of heart disease. He was of the opinion that the claimant would probably become completely symptom-free, but that she should avoid strenuous exertion.
In September 1964 (about 4 months after hospitalization) a specialist in internal medicine examined the claimant and reported that an electrocardiogram gave the impression of: "Myocardial change and/or digitalis effect. First degree block." His diagnoses included arteriosclerotic heart disease, manifested by angina pectoris, and congestive heart failure. However, he recommended re-evaluation of the claimant's medical status in about a year because of the possibility of reversible disease.
Since said internist had suggested the possibility of improvement, the claimant was re-examined by him in September 1965. Medical findings revealed that her chest was clear and free of signs suggesting heart failure. Urinalysis and blood studies were within normal limits; and most significantly, the electrocardiogram, when compared to the tracing of September 1964, no longer demonstrated the previous indications of heart block or other diagnostic abnormality. The internist interpreted this tracing to be a normal electrocardiogram. In conclusion, he stated that although there had been no subjective change, the claimant did not relate a typical history of angina pectoris. Moreover, at the current examination the electrocardiogram had reverted to normal and there was no objective evidence of significant heart disease. Apparently, the paucity of objective medical findings that could be attributed to heart disease prompted him to conclude that "the previous appraisal may have been somewhat in error, or at least the patient's condition has improved significantly despite the fact that she does not think that it has." He was of the opinion that the claimant was now perfectly capable of light work, such as clerical duties not involving heavy labor. He considered her prognosis good with proper orientation and motivation.
The claimant's attending physician, in a medial report dated December 6, 1965 also expressed the opinion that most of her symptoms were without objective medical support but were solely subjective in nature. However, he advised against a job requiring "physical exertion." In another medical report dated July 27, 1966, submitted by the claimant's attending physician, he indicated that subsequent to the sole episode of cardiac decompensation, her objective medical findings returned to normal. Specifically, he stated that her heart has returned to normal size; the claimant's lungs had cleared, her electrocardiograms had reverted to normal, and her blood pressure had remained controlled with medication. However, apparently because of her continued subjective symptoms, he expressed the opinion that she is unable to work.
In view of the contrary medical opinion that light activity was possible, an analysis of the claimant's vocational capabilities and potential was obtained from the state rehabilitation center. Its report indicated that the claimant's daily activities consisted of cooking, washing dishes, dusting, and dry mopping. Also, that she enjoyed sewing, spectator sports, attended her local church, and drove an automobile when necessary. Her full scale I.Q. was calculated to be 108, which placed her within the normal range of intellectual functioning. Her performance scores showed that she achieved average or above average grades in vocational pursuits that required fluency and verbal reasoning, i.e., business correspondence, proofreading, etc. At least an average level of function was achieved in those actions requiring eye and hand coordination, and fine manipulation.
The vocational specialists summarized the test results as meaning that the claimant had demonstrated significant clerical skills involving language usage, numerical ability, verbal reasoning and fluency, as well as good manual capacity (eye-hand coordination) for fine hand manipulation. It was their considered opinion that she was cooperative, but not particularly well motivated. She frequently complained of fatigue, chest pain, dizziness, and numerous other bodily discomforts. They indicated that if these symptoms were present to the degree that she expressed, she could not be expected to secure or maintain a gainful job. Nevertheless, in their opinion she possessed significant work skills, and could be expected to return to gainful employment within the scope of her previous occupational area, if she could be successfully rehabilitated.
To supplement the rehabilitation center's report and to define the claimant's actual employability, a vocational expert was called to testify at the hearing. He stated that he had made a careful review of the claimant's occupational background and experience. On the basis of his evaluation he stated that even if all of her subjective symptoms could be adequately substantiated by objective medical findings, she would still be employable.
In support of this conclusion the expert pointed out that the claimant's clerical work had been sedentary and that the work which she admitted performing at home is heavier and more physically demanding than some clerical work which she could do. After direct discussion with prospective employers located in the general area where the claimant lived, it was the vocational expert's opinion that she was reasonably able to compete for jobs in small commercial establishments, or in various nonprofit organizations. He considered these jobs more or less ideally suited to the claimant's needs because the work pace was slower, and the job pressures much less. The vocational expert determined that the claimant would qualify for such jobs as a cataloguer in a library and a file clerk, and that she had the capacity to perform various clerical duties at the neighboring community college or court house. Also, he indicated that there were sedentary jobs at the local hospital that required the claimant's particular skills. Moreover, the expert was of the opinion that the claimant would make a good receptionist or cashier. Other job opportunities which he found available to the claimant were with local financial institutions and real estate offices, where the hours are relatively short and personal relationships more relaxed. He further testified that the claimant could have her choice of position, and that no job placement problem need be expected. The vocational expert concluded by indicating that it was not necessary to retrain the claimant for other types of work and that the jobs for which she qualified existed in or around the area in which she resided.
Medical evidence in addition to that before the hearing examiner included a more complete clinical record in connection with the single episode of hospitalization in 1964 for treatment of cardiac decompensation and anterior myocardial ischemia. This hospital summary also indicates that the claimant had responded well to treatment and at the time of discharge she was symptom- free.
The other medical statements dated October 12, 1966 and November 1, 1966, indicated that the claimant continued to have symptoms of dyspnea and angina with evidence of cardiac abnormality. Dr. P, who examined the claimant in September and October 1966, recommended continued dietary control along with the avoidance of heavy exertion, exposure to cold or emotional upset. He believed that she would do well to continue at light activity.
EVALUATION OF MEDIAL AND VOCATIONAL EVIDENCE
The question before the Appeals Council is whether the claimant continues to be disabled. In resolving this issue, the Council must decide whether the medical evidence establishes that the claimant has improved to a degree sufficient to permit resumption of substantial gainful activity. In reaching its conclusion, the Appeals Council will consider not only the medical evidence but such factors as the claimant's age, education, training, and occupational background. However, it is essential to bear in mind that mere self-serving allegations of inability to work as a result of impairments causing shortness of breath, lack of bodily functions, etc., must be adequately confirmed by objective evidence, preferably including appropriate clinical and laboratory diagnostic techniques.
The medical evidence clearly established that the claimant had experienced an episode of cardiac decompensation in about May 1964. With appropriate treatment significant improvement is shown to have taken place, and at the time of her discharge from the hospital, her vital functions were operating normally and she was symptom-free. Repeated studies, and findings by the claimant's attending physician over a considerable period of time, consistently indicate the sustained course of the initial improvement. In other words, it has been established that the claimant's heart, with treatment, has remained compensated. Specific studies reported by both the claimant's physician and the specialist in internal medicine revealed that her heart size had returned to normal, her chest had become clear, her electrocardiograms had reverted to normal, her laboratory studies were within normal limits, and her blood pressure remained controlled. Significantly, there were no longer signs of myocardial ischemia (decreased blood supply to the heart muscle). Although the claimant's physician in his last report (in contrast with his previous report), stated that there were definite cardiac abnormalities, he did not describe the type or degree of abnormality present. In any event, on the basis of widely separated examinations, it was found that clinically, the claimant was substantially improved over her condition in 1964. Moreover, the more persuasive medical opinion is to the effect that while it would be inadvisable for the claimant to undertake heavy exertion, or risk undue emotional stress, light activity would be beneficial to her. The specialist in internal medicine specifically stated that the claimant was capable of doing clerical work.
Based upon the medical conclusion that the claimant was capable of at least light activity, an impartial vocational expert testified that she had highly marketable vocational skills currently in demand, and that she had an excellent employment potential. In reaching his conclusion, the vocational expert stated that he had personally investigated the employment possibilities available to the claimant and that no placement problem need be expected.
On the basis of the medical and vocational evidence as a whole, the Appeals Council concludes that the claimant has a medically determinable heart condition for which she received treatment; that this treatment brought about significant improvement, and that as established by medical examination in September 1965, the claimant now is capable of light work activity. The Council further concludes, based on the vocational evidence of record, that there are many suitable jobs in the claimant's labor market for which she can reasonably compete.
FINDINGS OF THE APPEALS COUNCIL
After careful consideration of the entire record, the Appeals Council makes the following findings:
The evidence establishes that the claimant's medical condition had improved by September 3, 1965 to a degree which permitted light work activity.
The claimant has regained the physical capacity to perform substantial gainful activity within the scope of her previous training and vocational experience.
Jobs for which the claimant is qualified are readily available to her in the area in which she resides.
The claimant's inability to engage in substantial gainful activity by reason of her impairment continued from December 1, 1963 to September 3, 1965, but not thereafter.
The claimant was under a "disability" as defined in the Act which commenced on December 1, 1963 and continued to September 3, 1965, but not thereafter.
It is the decision of the Appeals Council that the claimant's disability ceased in September 1965, and that her entitlement to a period of disability and to disability insurance benefits ended effective with the close of November 1965. The decision of the hearing examiner is affirmed. Date: August 1, 1967
See section 404.1510(a) of Social Security Administration Regulations No. 4 [20 CFR 404.1510(a)]. [In effect prior to August 20, 1968, Ed.]