The opinion of the court was delivered by: Wexler, District Judge.
Charles Bennett ("plaintiff") brings this action pursuant to §
205(g) of the Social Security Act (the "Act"), as amended,
42 U.S.C. § 405(g), for review of a final decision of the Secretary
of the United States Department of Health and Human Services
("Secretary"), denying plaintiff's application for disability
insurance benefits and supplemental security income benefits.
Presently before the Court are the parties' cross-motions for
judgment on the pleadings pursuant to Rule 12(c) of the Federal
Rules of Civil Procedure.
The following facts are not in dispute. On December 9, 1987,
plaintiff filed an application for disability insurance benefits
and supplemental security income benefits, alleging disability as
of December 17, 1986. The application was denied initially and
again on reconsideration. Plaintiff then requested a hearing,
which was held on October 5, 1988, before an Administrative Law
Judge ("ALJ"). In a decision dated February 18, 1989, the ALJ
found that plaintiff was not disabled within the meaning of the
Act. The ALJ's ruling became the final decision of the Secretary
when, on August 3, 1989, the Appeals Council denied plaintiff's
request for review.
Plaintiff now appeals to this Court seeking reversal of the
Secretary's decision. After careful consideration, this Court
finds that additional evidence is required with respect to
plaintiff's current residual functional capacity, and therefore,
remands the case to the Secretary for further proceedings
consistent with this opinion.
On the date that plaintiff filed for benefits, he was forty-one
years old and had a history of heart complications. He has a high
school education and has earned some college credits. Plaintiff
has been employed in the past as a modified machinist in the
aircraft industry, an auto mechanic, and a field technician. He
was last employed as a sheet metal mechanic for an air
conditioning company, where he apprenticed for six months before
injuring his back in December of 1986.
Plaintiff sustained an injury to his lower back while at work
on December 17, 1986. He initially was seen at the emergency room
of Brookhaven Memorial Hospital for pain in his left ribs. X-rays
of plaintiff's ribs and chest taken at that time were negative,
and plaintiff was instructed to rest and avoid heavy lifting for
four days. He was advised to see an orthopedist if his condition
did not improve within the four day period.
Dr. Edward Yambo, plaintiff's family physician, treated
plaintiff from January 12, 1987 to June 4, 1987. X-rays taken of
plaintiff's lumbosacral spine proved negative. Dr. Yambo's
examination disclosed a bulging disc at L4-L5 without evidence of
herniation or spinal stenosis.
Dr. Yambo referred plaintiff to Dr. Dwight C. Blum, an
orthopedic surgeon, in early April of 1987. Dr. Blum reported
that plaintiff exhibited tenderness over the sacroiliac joints
and paraspinals, as well as decreased range of motion. No
neurologic deficits were discovered, however, and Dr. Blum's
x-rays of plaintiff's lumbosacral spine disclosed no bony
abnormalities, fractures, or dislocations. Dr. Blum diagnosed
plaintiff's condition as an "acute lumbosacral sprain contusion."
Dr. Blum prescribed Clinoril, and advised plaintiff to begin a
physical therapy regimen.
Plaintiff subsequently underwent computerized tomographic
evaluation ("CT-scan") of his lumbar spine. The CT-scan revealed
a bulging disc at L4-L5, but yielded no evidence of herniation or
of spinal canal stenosis. No further medication or treatment was
prescribed at that time. Plaintiff pursued a course of physical
therapy through the summer of 1987, then ceased to participate in
the program, claiming that the activity exacerbated his
An early residual functional capacity assessment, completed in
February of 1988, specified that plaintiff was capable of lifting
or carrying a maximum of twenty pounds; unlimited pushing or
pulling; frequently lifting or carrying ten pounds; standing or
walking a total of about six hours in an eight hour day; and
sitting approximately six hours in an eight hour day. The
assessment indicated, further, that plaintiff could frequently
climb, balance, stoop, kneel, crouch, and crawl, and that his
capacity to reach and handle was unlimited.
Plaintiff began treatment with Dr. Victor Gold in February of
1988, in response to plaintiff's complaints of pain in his lower
spine. Upon examination, Dr. Gold determined that plaintiff had
markedly decreased range of motion in flexion, extension, and
bending of the lumbosacral spine. Plaintiff's reflexes and motor
and sensory responses, however, were deemed normal, and leg
raising was negative. Dr. Gold concluded that plaintiff
demonstrated disc bulging at L4-L5 and, in view of plaintiff's
continued symptomology and persistent complaints of pain,
recommended that plaintiff undergo a magnetic resonance imaging
("MRI") of his lumbosacral spine, and that he be fitted for a
corset. An MRI of plaintiff's spine, performed in June of 1988,
revealed a left-sided asymmetric bulge at L4-L5.
On July 6, 1988, Dr. Gold submitted a medical progress report
to the New York State Workers' Compensation Board based on his
examination of plaintiff that same day. The report indicated that
plaintiff's pain continued and that straight leg raising was
positive. Dr. Gold requested authorization for a lumbosacral
brace, and suggested that plaintiff begin a back exercise
program. Dr. Gold indicated on the Workers' Compensation ...