7th Circuit vacates, remands disability case where medical records belonging to different claimant may have been used in ALJ decision

IL file photo

An administrative law judge’s decision to deny a man’s disability application may have relied on medical records belonging to someone else, the 7^th Circuit Court of Appeals ruled Thursday in vacating a district court’s judgment and remanding the case.

Rene Martinez filed an application for supplemental security income in November 2017, alleging his disability began on Nov. 22 of that year.

According to court records, after Martinez’s application was denied initially and again on appeal, he requested a hearing on it before an ALJ.

The ALJ reviewed the evidence in the record and found that Martinez suffered from severe impairments but could nonetheless “perform the requirements of representative unskilled occupations such as a checker, routing clerk, and mail sorter,” and was not disabled under the Social Security Act.

After an appeals council denied Martinez’s request to review the ALJ’s decision, Martinez filed suit in the United States District Court for the Northern District of Indiana.

Before the district court issued its opinion, Martinez notified Kilolo Kijakazi, the commissioner of the Social Security Administration, that the administrative record included medical records regarding a different claimant.

When the commissioner filed the administrative record with the court, the commissioner noted that it was the full record.

The pages relating to the other claimant were removed, however, and replaced with a placeholder reading: “This page was removed as an exhibit by the appeals council because it does not refer to the claimant.”

Neither Martinez nor the district court saw a copy of the omitted pages.

The commissioner later refused to produce the pages after Martinez asked for them, claiming it would be inappropriate because they related to a different person.

Martinez moved the district court to compel the commissioner to include the full exhibit in the administrative record.

The district court denied that motion after concluding that the ALJ only cited the omitted pages twice, and, although its inclusion was an error, the error was harmless.

The district court affirmed the ALJ’s decision and held that it was supported by substantial evidence.

Martinez appealed and argued the appellate court must reverse the ALJ’s decision because the judge relied on evidence belonging to a different claimant.

The 7^th Circuit Court of Appeals agreed with Martinez that the ALJ’s decision was not supported by substantial evidence due to its reliance on medical records from someone other than Martinez and vacated the district court’s judgment, remanding the case to the ALJ.

Judge Amy St. Eve wrote the opinion for the appellate court.

St. Eve noted that the commissioner contends that the ALJ only cited the removed pages twice, but by the appellate court’s count, the ALJ cited those pages seven times.

In two instances, the ALJ’s analysis is sufficiently clear to allow the appellate court to definitively identify what page of exhibit B15F the ALJ was referencing and whether the ALJ’s reference was harmless error.

St. Eve wrote the court concluded in those two instances, there was harmless error.

“Aside from these two references, however, we cannot determine whether the ALJ erred and whether this error was harmless. Specifically, with regards to the other citations, the record is unclear as to whether the ALJ relied on the pages of exhibit B15F that referred to Martinez or pages that referred to the other claimant,” St. Eve wrote.

“The issues with this exhibit permeate the ALJ’s findings regarding the medical opinion evidence, and the ALJ’s findings regarding the symptom evidence that rely on its findings related to the medical opinions. For these reasons, we remand for the ALJ to re-evaluate both the symptom and medical opinion evidence and come to a decision based on evidence relevant only to Martinez,” St Eve wrote.

Judges Ilana Rovner and Joel Flaum concurred.

The case is Rene Martinez v. Kilolo Kijakazi, Acting Commissioner of Social Security, 22-1820.