RULING AND ORDER
On July 29, 2008, Plaintiff Terry E. Cobb sought judicial review under 42 U.S.C. § 405(g) of Defendant Commissioner of Social Security’s denial of his application for supplemental security income (“SSI”) benefits. On February 26, 2009, United States Magistrate Judge William Garfinkel issued a Recommended Ruling on Mr. Cobb’s Motion for Summary Judgment [doc. # 16] and Defendant’s Motion to Affirm [doc. # 18], in which Judge Garfinkel recommended that the Commissioner’s decision be affirmed because the Administrative Law Judge’s (“ALJ”) decision was supported by substantial evidence. See Recommended Ruling on Pending Motions [doc. # 21] [hereinafter Rec. Ruling].
On March 9, 2009, Mr. Cobb timely filed a number of objections to the Recommended Ruling, to which the Commissioner then replied.
See generally
Pl.’s Objections to Rec. Ruling on Pending Motions [doc. # 22]; Def.’s Resp. to Pl.’s Objection to Rec. Ruling on Pending Motions [doc. #23]. In particular, Mr. Cobb contends that the record does not support the ALJ’s decision because: (1) the ALJ failed to obtain a consultative examination regarding any possible mental impairment that he may have suffered on account of his
The Court assumes the parties’ familiarity with the facts of this case, and refers the reader to Judge Garfinkel’s Recommended Ruling, which contains a thorough and comprehensive recitation of the record evidence and the underlying administrative decisions. See Rec. Ruling [doc. #21] at 3-20. The Court has benefitted greatly from Judge Garfmkel’s extensive analysis of the record evidence. After reviewing the record in connection with Mr. Cobb’s objections, the Court agrees with Judge Garfinkel’s Recommended Ruling in almost all respects and departs only in its ultimate legal conclusion that the ALJ’s failure to address Mr. Cobb’s urinary frequency when rendering a decision deprived the Commissioner of substantial evidence necessary to support the denial of Mr. Cobb’s claim. 1 Thus, the Court adopts the Recommended Ruling insofar as it rejects Mr. Cobb’s arguments that (1) the ALJ failed to order consultative examinations regarding his alleged speech and mental impairments and (2) the ALJ failed to support her findings as to his residual functional capacity (“RFC”). However, as the Court explains in detail later, the Court grants Mr. Cobb’s objection that the ALJ erred in failing to address his increased urinary needs before denying his claim.
For the reasons that follow, the Recommended Ruling [doc. # 21] is ACCEPTED in part and REJECTED in part, Mr. Cobb’s Motion for Summary Judgment [doc. # 16] is GRANTED in part and DENIED in part, and the Commissioner’s Motion to Affirm [doc. # 18] is DENIED.
I.
Where a party objects to a magistrate judge’s recommendation in accordance with 28 U.S.C. § 636(b)(1), the Court must make a “de novo determination of those portions of the report or specified proposed findings or recommendations to which objection is made. ' A judge of the court may hccept, reject, or modify, in whole or in part, the findings or recommendations made by the magistrate judge.” § 636(b)(1). That said, when conducting this review, the Court is limited to determining whether there is substantial evidence to support the Commissioner’s decision and whether the Commissioner applied the correct legal standard.
See Lamay v. Comm’r of Social Sec.,
Mr. Cobb first complains that the ALJ was required to obtain an evaluation of his mental status before rendering a decision on his benefits application. The parties agree that Social Security Ruling 96-7p, which states as follows, applies; “The adjudicator must develop evidence regarding the possibility of a medically determihable mental impairment when the record contains information to suggest that such an impairment exists, and the individual alleges pain or other symptoms, but the medical signs and laboratory finds do not substantiate any physical impairment(s) capable of producing the pain or other symptoms.” SSR 96-7p, Evaluation of Symptoms in Disability Claims,
The Magistrate Judge has already addressed the merits of Mr. Cobb’s argument in detail. See Rec. Ruling [doc. # 21] at 27-30. The Court adopts Judge Garfinkel’s findings and conclusions in their entirety as to this issue, and writes only to respond to Mr. Cobb’s additional citation to the record, which he says lends further support to his position. The Court disagrees with Mr. Cobb. Although his August 25, 2005 neurological evaluation does state that he had “trouble getting words out,” this note is listed under the “Communication” field of the evaluation, not the “Cognition/Behavior/Percéptual” field of the evaluation. See Record [doc. # 13] at 186, 219. Thus, read in context, this note corresponds to the speech difficulties that Mr. Cobb undisputedly faced immediately following his four strokes, and not to any mental impairment that Mr. Cobb now claims he suffered. This interpretation is consistent with a subsequent neurological evaluation by the Tully Health Center only a day later on August 26, 2005, in which no complaints were noted under “Cognition/Behavior/Perceptual,” while “dysarthric, slightly slurred” was noted under “Communication.” See Record [doc. # 13] at 190, 223.
Moreover, and as Judge Garfinkel correctly noted in his Recommended Ruling, Mr. Cobb never complained of any possible mental impairment during his regular doctors’ visits (nor was any such impairment ever noted in the objective medical evidence). Further, he did not mention any adverse mental effects from his strokes when the ALJ specifically asked him whether any mental problems affected his ability to work.
See
Record [doc. # 13] at 20-21. “[W]here there are no obvious gaps in the administrative record, and where the ALJ already possesses a complete medical history, the ALJ is under no obligation to seek additional information in advance of rejecting a benefits claim.”
Rosa v. Callahan,
Mr. Cobb next argues that the ALJ impermissibly ignored his statements regarding his frequent urinary needs as well as the vocational expert’s response concerning how this might affect his ability to engage in substantial gainful activity for purposes of a disability determination. Unlike Mr. Cobb’s argument regarding his possible mental impairment, the Court believes this issue presents a closer question that implicates the ALJ’s assessment of Mr. Cobb’s credibility and ultimately, her finding of his residual functional capacity and prospect for gainful employment. In his Recommended Ruling, Judge Garfinkel expressed misgivings about the ALJ’s treatment of this issue, but nonetheless concluded that the ALJ did not err in failing to credit Mr. Cobb’s statements concerning the side effects of his hypertension medication. See generally Rec. Ruling [doc. # 21] at 30-34. In doing so, the Judge Garfinkel relied on the ALJ’s general assessment of Mr. Cobb’s credibility as well as Mr. Cobb’s inconsistent answers to two questionnaires and his ample opportunity at the administrative hearing to discuss the impact of his increased urination on his ability to work. See id. Although the Court agrees with Judge Garfinkel’s discussion of Mr. Cobb’s urinary needs, the Court reaches a different legal conclusion based on the particular facts presented in this case.
The Court’s review of the record indicates that there were five references to Mr. Cobb’s increased urinary frequency, which he attributed to a prescribed diuretic called hydrochlorothiazide that he takes for hypertension. Three undated Disability Reports list a side effect from Mr. Cobb’s treatment with hydrochlorothiazide as making him “urinate a lot.” See Record [doc. # 13] at 136 (undated “Disability Report”); id. at 154 (undated “Disability Report”); id. at 175 (undated “Disability Report”). In addition, Mr. Cobb indicates in two questionnaires that this medication causes him to urinate “very often — about every hour for a few seconds” and “about ten times a day as [a] result of the medication. Some times it takes seconds and other times 5 to ten minutes due to water intake.” See id. at 165 (“Questionnaire on Side Effects of Medications” dated 11/17/06); id. at 167 (undated “Questionnaire on Side Effects of Medications”).
That said, the Recommended Ruling accurately reflects that the objective medical evidence is devoid of any discussion of Mr. Cobb’s increased urinary frequency as a result of taking hydrochlorothiazide.
See
Rec. Ruling [doc. #21] at 32 (“Although the medical records contain numerous references to Plaintiffs complaints about other adverse side effects from this drug, nowhere does Plaintiff complain about the frequency of urination.”). However, as the ALJ acknowledged in her decision, “[w]henever statements about the intensity, persistence, or functionally limiting effects of pain or other symptoms are not substantiated by objective medical evidence, the undersigned must make a finding on the credibility of the statements
Nevertheless, in his Recommended Ruling, Judge Garfinkel points out that the ALJ’s decision does not even discuss Mr. Cobb’s claim of excessive urination as a result of his treatment for hypertension, and certainly the ALJ’s general assessment of Mr. Cobb’s credibility in no way refers to his claim of frequent urination.
See
Rec. Ruling [doc. # 21] at 31 (“The ALJ made no reference to his need to urinate frequently in her decision.”). Judge Garfinkel also accurately notes that the ALJ assessed Mr. Cobb’s overall credibility when she found that his “statements concerning the intensity, persistence and limiting effects of [his] symptoms [were] not credible to the extent they are inconsistent with the residual functional capacity assessment..."
See id.
at 33; Record [doc. # 13] at 26. However, even assuming the ALJ found Mr. Cobb’s claim of increased urination was unsupported by the medical record, her blanket and general statements regarding Mr. Cobb’s credibility lack the requisite specificity for Mr. Cobb or any subsequent reviewer to determine the weight the ALJ attributed to Mr. Cobb’s claims regarding the frequency of urination, not to mention the basis for the ALJ’s assessment of the weight of that claim. As the Social Security Administration’s own procedures recognize, “[i]t is not sufficient to make a conclusory statement that ‘the individual’s allegations have been considered’ or that ‘the allegations are (or are not) credible.’ ”
See
SSR 96-7p,
Nor did the ALJ assess the limiting effects of any claimed increased urination in light of Mr. Cobb’s other daily activities.
Compare Poupore v. Astrue,
The absence of any discussion of Mr. Cobb’s credibility on this specific issue is particularly troubling since the Commissioner’s vocational expert responded to the ALJ that “if the hypothetical individual had to urinate every hour and would be off task and away from the work site this would be beyond the typical work breaks of 10-15 minutes after 2 hours or work, 30-45 minutes after 4 hours of work, and 10-15 minutes after 6 hours of work.” Record [doc. # 13] at 353. The vocational expert answered that hourly urination in addition to intermittent breaks throughout the day for dizziness would mean that “the individual could not perform any work on a sustained basis.” Id. Yet, despite this seemingly critical finding as to how Mr. Cobb’s urinatioh needs might affect his ability for substantial gainful activity, there is no discussion of this issue in the ALJ’s denial of his claim. This is so despite the fact that the vocational expert’s response indicated that such a limitation might affect Mr. Cobb’s ability to perform any work that exists in significant numbers in the national economy. See Record [doc. # 13] at 352-53. In these circumstances, the ALJ was required to expressly assess Mr. Cobb’s credibility and determine whether Mr. Cobb’s claimed side effect could act as a limitation on his ability to work. Yet, it is apparent that the ALJ did not do so.
Therefore, instead of reviewing the record for substantial evidence in support of any such factual finding, the Court, like Judge Garfinkel, is forced to guess that the ALJ must have discredited Mr. Cobb’s statements regarding the extent and disruptive effect of his increased urination on the basis of the federal reviewing official’s findings or Mr. Cobb’s other, unrelated statements that he could go grocery shopping and attend church, both of which he stated took approximately two hours.
See
Rec. Ruling [doc. # 21] at 31.
However, the Court’s task on de novo review does not include guessing about what may or may not have been going through the ALJ’s mind on this important issue or substituting the Court’s judgment for that of the Commissioner.
See Veino v. Barnhart,
Finally, Judge Garfinkel correctly notes in his Recommended Ruling that Mr. Cobb did not raise his frequent urination as a limitation during his administrative hearing despite the ALJ’s invitation for him to discuss his objections to the underlying record as well as any way in which his strokes had affected him.
See
Rec. Ruling [doc. #21] at 33;
see also
Record [doc. # 13] at 48, 51, and 59. This is so despite Mr. Cobb’s discussion of other physical problems such as dizziness, foot drop, decreased mobility, strength and endurance, and speech problems. While ordinarily these gaps would be significant, the Court is unwilling to hold these gaps against Mr. Cobb since he was proceeding
pro se
and this was a central issue for both Mr. Cobb and the vocational expert. “[Wjhere the claimant was handicapped by lack of counsel at the administrative hearing, the reviewing court has a duty to make a searching investigation of the record to ensure that the claimant’s rights have been adequately protected.”
Hankerson,
It is quite apparent that the ALJ serves an important function in developing and evaluating the record. “It is the ALJ’s duty to investigate and develop the facts and ... arguments both for and against the granting of benefits.... The ALJ therefore owes a duty to the Commissioner as well as to the claimant.”
Butts v. Barnhart,
As the Court previously stated, whether substantial evidence exists to support the Commissioner’s decision in this case is a close question. However, given the particular facts of this case — namely, the ALJ’s heightened obligation to a pro se claimant, the ALJ’s failure to question Mr. Cobb about his urinary needs, and the absence of any specific credibility finding on this issue despite its central importance in the vocational expert’s response — the Court grants Mr. Cobb’s objection that the ALJ’s decision was not based on substantial evidence because the ALJ failed to expressly and directly consider his urinary needs and the vocational expert’s testimony. Although the Commissioner may ultimately decide this issue precisely as Judge Garfinkel predicts in his Recommended Ruling, process matters, and the ALJ should be required to address Mr. Cobb’s urinary needs at the hearing and before denying his disability claim. Mr. Cobb’s ability to engage in substantial gainful activity as a result of his frequent urination remains to be explored on remand. Therefore, the Court reverses the decision of the Commissioner of Social Security and remands the case for a rehearing in accordance with Sentence Four of 42 U.S.C. § 405(g).
II.
Accordingly, the Court ACCEPTS in part and REJECTS in part the Recommended Ruling on Pending Motions [doc. # 16]. The Court accepts the Recommended Ruling in its entirety with the exception of its legal conclusion that the ALJ did not err in failing to address Mr. Cobb’s increased urination at the hearing or in failing to take this into account in her assessment of his ability to perform other
IT IS SO ORDERED.
Notes
. In light of the Court's decision on Mr. Cobb’s second objection, the Court need not reach Mr. Cobb's third and fourth objections — namely, the scope of the hypothetical questions presented to the vocational expert and Mr. Cobb’s possible entitlement to minimal retroactive benefits. The court notes that these objections were not raised before Judge Garfinkel. The Court leaves it to the Commissioner to decide whether Mr. Cobb, who is now proceeding with the benefit of counsel, may pursue these issues on remand.
See, e.g.,
20 C.F.R. § 416.945(a)(2) ("We will consider all of your medically determinable impairments of which we are aware ... when we assess your residual functional capacity.”);
Burns v. Barnhart,
