SONJA F. BIVINS, Magistrate Judge.
Plaintiff Johnny A. Reed (hereinafter "Plaintiff"), seeks judicial review of a final decision of the Commissioner of Social Security denying his claim for a period of disability, disability insurance benefits, and supplemental security income under Titles II and XVI of the Social Security Act, 42 U.S.C. §§ 401, et seq., and 1381, et seq. On May 25, 2017, the parties consented to have the undersigned conduct any and all proceedings in this case. (Doc. 19). Thus, the action was referred to the undersigned to conduct all proceedings and order the entry of judgment in accordance with 28 U.S.C. § 636(c) and Federal Rule of Civil Procedure 73. Upon careful consideration of the administrative record and the memoranda of the parties, it is hereby
Plaintiff protectively filed his application for benefits on October 1, 2012, alleging disability beginning April 30, 2011 based on diabetes, problems with legs, back problems, problems with right ankle, no sight in right eye, problems with left eye, and high blood pressure. (Tr. 133, 171, 183). Plaintiff's application was denied and upon timely request, he was granted an administrative hearing before Administrative Law Judge James Barter on February 10, 2014. (Tr. 34). Plaintiff attended the hearing with his counsel and provided testimony related to his claims. (
Having exhausted his administrative remedies, Plaintiff timely filed the present civil action. (Doc. 1). Oral argument was conducted on June 1, 2017 (Doc. 21), and the parties agree that this case is now ripe for judicial review and is properly before this Court pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3).
Plaintiff was born on August 22, 1968, and was forty-five years of age at the time of his administrative hearing on February 10, 2014. (Tr. 34, 39, 171). Plaintiff graduated from high school. (Tr. 39).
Plaintiff worked from 2003 to 2011 as a self-employed handyman and as a sales person in a hardware store from 1986 to 2001. (Tr. 39, 184). At the administrative hearing, Plaintiff testified that he cannot work now because he has problems with blindness in his right eye (detached retina), low vision in his left eye, diabetes for which he takes insulin, high blood pressure, leg pain (neuropathy), and low back pain.
In reviewing claims brought under the Act, this Court's role is a limited one. The Court's review is limited to determining 1) whether the decision of the Secretary is supported by substantial evidence and 2) whether the correct legal standards were applied.
An individual who applies for Social Security disability benefits must prove his or her disability. 20 C.F.R. §§ 404.1512, 416.912. Disability is defined as the "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." 42 U.S.C. §§ 423(d)(1)(A);
The claimant must first prove that he or she has not engaged in substantial gainful activity. The second step requires the claimant to prove that he or she has a severe impairment or combination of impairments. If, at the third step, the claimant proves that the impairment or combination of impairments meets or equals a listed impairment, then the claimant is automatically found disabled regardless of age, education, or work experience. If the claimant cannot prevail at the third step, he or she must proceed to the fourth step where the claimant must prove an inability to perform their past relevant work.
Plaintiff argues that the ALJ's RFC for a range of sedentary work is not supported by substantial evidence because it is not based on an RFC assessment by a medical expert. (Doc. 12 at 2). Specifically, Plaintiff argues that the record is devoid of an RFC assessment by any medical expert, except for the opinion of a single decision maker. Plaintiff further states that he requested an additional consultative examination, but the request was denied. (Doc. 12 at 4). In addition, Plaintiff argues that the ALJ did not assign appropriate weight to his treating physician.
Residual functional capacity is a measure of what Plaintiff can do despite his or her credible limitations.
In his decision, the ALJ found that Plaintiff has the severe impairments of diabetes mellitus with diabetic retinopathy in the right eye, gout, hypertension, obesity, lower back pain, and peripheral neuropathy. (Tr. 22). Even so, the ALJ found that Plaintiff still has the RFC to perform a range of sedentary work with the following restrictions: Plaintiff "cannot climb ladders, ropes and scaffolds and cannot crawl. [He] has the ability to occasionally climb stairs, stoop, crouch and kneel, but he cannot work at unprotected heights, should avoid hazards, and should avoid jobs that require good depth perception or fine vision." (Tr. 25). Based upon the testimony of the vocational expert, the ALJ concluded that although Plaintiff is unable to perform his past work as a sales clerk, he could perform the jobs of "brake linings coater" and "surveillance system monitor," and "waxer," all of which are sedentary and unskilled. (Tr. 28-29). Thus, the ALJ found that Plaintiff is not disabled. For the reasons discussed herein, the Court finds that the ALJ's decision is supported by substantial evidence.
At the outset, it should be noted that Plaintiff's contention that the ALJ's RFC assessment is not based on substantial evidence simply because the record is devoid of a formal RFC assessment by an examining medical source is incorrect. "The ALJ's RFC assessment may be supported by substantial evidence, even in the absence of an opinion from an examining medical source about Plaintiff's functional capacity."
Second, in fulfilling his or her duty to conduct a full and fair inquiry, the ALJ has the discretion to order a consultative examination where the record establishes that such is necessary to enable the ALJ to render a decision.
Having reviewed the record in this case, the Court finds no error in the ALJ's decision to deny Plaintiff's request for an additional consultative examination. Indeed, the record before the ALJ contained examination findings and consultative reports from a board certified family practitioner, Dr. Thomasina Sharpe, M.D., and from a consulting optometrist, Dr. John W. Clardy, O.D. (Tr. 292, 300).
Turning first to Dr. Sharpe's consultative report dated December 1, 2012, Dr. Sharpe noted that Plaintiff had a history of diabetes for approximately twenty years for which he was being treated with medication and insulin. Significantly, Dr. Sharpe noted that Plaintiff had no kidney disease, no cerebral vascular accident, no heart disease, no hospitalizations, and no emergency room visits in the previous two years.
Next, the record before the ALJ contained the consultative report of Dr. John W. Clardy, O.D., an optometrist who performed an eye examination on Plaintiff on November 27, 2012, and found that Plaintiff had a detached retina in the right eye (with a poor prognosis),
Also, with respect to Plaintiff's vision problems, the record contained the treatment notes of Plaintiff's internist, Dr. Huguette Douyon, M.D., who documented repeatedly throughout 2012 to 2014 that Plaintiff reported "no blurred vision." (Tr. 334, 351, 354, 357, 363, 366, 380, 387). Significantly, Plaintiff testified at his hearing in 2014 that, even with his vision problems, he is able to read large print with glasses and can read a newspaper with magnification. (Tr. 43). In addition, he is able to drive, mow, shop, pay bills, count change, and cook. (Tr. 41, 48, 176-80).
Also, with respect to Plaintiff's low back pain, the record confirms the ALJ's finding that there is no objective evidence, such as MRIs or x-rays, showing any significant impairment of the spine. (Tr. 27). To the contrary, Dr. Douyon treated Plaintiff's back pain with medication only and repeatedly instructed him to exercise and engage in regular physical activity. (Tr. 335, 351-52, 381). Also, as stated, Plaintiff reported driving, shopping, and mowing the lawn, and there is no evidence of any problems with ambulation or the need for a cane or other assistive device. (Tr. 176-80, 302).
With respect to Plaintiff's gout in his right arm and hand, Dr. Douyon found in January 2012 that Plaintiff had stiffness and decreased range of motion in his right elbow; however, he had normal muscle strength and no joint swelling. Dr. Douyon recommended only ice and elevation. (Tr. 286-87). In December 2012, Dr. Sharpe found normal range of motion in Plaintiff's upper extremities bilaterally. (Tr. 302).
With respect to Plaintiff's hypertension, the record shows that Dr. Douyon prescribed medication, diet, and exercise, while noting Plaintiff's poor compliance with his medication. (Tr. 247, 250, 358, 363). Nothing in the record suggests that Plaintiff's hypertension, or any of his impairments for that matter, resulted in limitations in excess of the RFC.
Based on the foregoing, the Court finds that the record was sufficient to enable the ALJ to determine Plaintiff's RFC without obtaining an RFC assessment from a medical source. The Court further finds that substantial evidence supports the ALJ's determination that Plaintiff can perform a range of sedentary work with the stated restrictions. Indeed, Plaintiff has failed to show that any limitations caused by his impairments exceed the RFC and are not accommodated by the RFC and its stated restrictions. Accordingly, Plaintiff's claim must fail.
Last, Plaintiff argues that the ALJ erred in failing to consider the impact of obesity on his ability to work, despite finding it to be a severe impairment. Plaintiff claims that the ALJ did not mention obesity, except when he found it to be severe. (Doc. 12 at 5). Plaintiff's claim is without merit.
Social Security Ruling 02-1p guides courts in evaluating disability claims brought by a claimant with obesity, providing that an ALJ will consider a claimant's obesity at every step of the sequential evaluation process.
Contrary to Plaintiff's argument, the record shows that the ALJ expressly considered Plaintiff's obesity throughout the sequential evaluation process, including in assessing whether Plaintiff met a Listing. The ALJ stated:
(Tr. 24). The ALJ concluded, based on the medical evidence of record, that Plaintiff's physical impairments, in conjunction with his obesity, did not meet a Listing. (
(Tr. 27-28). The ALJ discussed Plaintiff's significant activities of daily living (driving, mowing, shopping, walking short distances, visiting family and church), as well as Dr. Sharpe's observation that Plaintiff was able to bend to remove his shoes and socks and was able to get on and off the examining table, although with some difficulty noted with respect to the latter. (Tr. 25-27, 177-79). The ALJ concluded that, "although the claimant has been diagnosed as being morbidly obese, which may be attributing to some pain in his extremities, he is still able to walk, attend church and visit with his father and brother weekly, indicating no serious limitation on his ability to ambulate effectively." (
Having reviewed the evidence at length, the Court concludes that the ALJ's findings, including his specific reference to SSR 02-1p, sufficiently demonstrate that he properly considered Plaintiff's obesity and its effect on his other impairments at all steps of the evaluation process. It is the Plaintiff who bears the burden of proving his disability in this case.
For the reasons set forth herein, and upon careful consideration of the administrative record and memoranda of the parties, it is hereby