MICHELLE H. BURNS, Magistrate Judge.
Pending before the Court is Plaintiff Bernard Laborin's appeal from the Social Security Administration's final decision to deny his claim for disability insurance benefits and supplemental security income. After reviewing the administrative record and the arguments of the parties, the Court now issues the following ruling.
Plaintiff filed applications for disability insurance benefits and supplemental security income alleging disability beginning August 8, 2008. (Transcript of Administrative Record ("Tr.") at 13, 163-66, 175-83.) His applications were denied initially and on reconsideration. (Tr. at 72-89, 90-106.) Thereafter, Plaintiff requested a hearing before an administrative law judge. (Tr. at 118.) A hearing was held on August 9, 2012, (Tr. at 38-71), and the ALJ issued a decision finding that Plaintiff was not disabled (Tr. at 10-28). The Appeals Council denied Plaintiff's request for review (Tr. at 1-6), making the ALJ's decision the final decision of the Commissioner. Plaintiff then sought judicial review of the ALJ's decision pursuant to 42 U.S.C. § 405(g).
The Court must affirm the ALJ's findings if the findings are supported by substantial evidence and are free from reversible legal error.
In determining whether substantial evidence supports a decision, the Court considers the administrative record as a whole, weighing both the evidence that supports and the evidence that detracts from the ALJ's conclusion.
In order to be eligible for disability or social security benefits, a claimant must demonstrate an "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). An ALJ determines a claimant's eligibility for benefits by following a five-step sequential evaluation:
At step one, the ALJ determined that Plaintiff had not engaged in substantial gainful activity since August 8, 2008 — the alleged onset date. (Tr. at 17.) At step two, she found that Plaintiff had the following severe impairments: lumbar herniated nucleus pulposus, status post diskectomy with residual foot drop, mild degenerative disc disease and facet disease, obstructive sleep apnea, asthma, morbid obesity, and hypertension. (Tr. at 17-18.) At step three, the ALJ stated that Plaintiff did not have an impairment or combination of impairments that met or medically equaled an impairment listed in 20 C.F.R. Part 404, Subpart P, Appendix 1 of the Commissioner's regulations. (Tr. at 18.) After consideration of the entire record, the ALJ found that Plaintiff retained "the residual functional capacity to [] lift and carry 20 pounds occasionally and 10 pounds frequently; stand and/or walk with normal breaks about four out of eight hours; sit with normal breaks about six out of eight hours; never push or pull with the right lower extremity; never climb ladders, ropes, or scaffolds; occasionally crawl; and frequently climb ramps or stairs. The claimant must avoid concentrated exposure to fumes, odors, dust, gases, poor ventilation, and unprotected heights. The claimant must avoid exposure to moving machinery. He needs to sit/stand at will."
In his brief, Plaintiff contends that the ALJ erred by: (1) failing to properly weigh medical source opinion evidence; (2) failing to properly consider his subjective complaints; (3) failing to properly consider lay witness or third-party statements; and (4) failing to properly consider "whether a listed impairment is met or equaled." Plaintiff requests that the Court remand for determination of benefits.
Plaintiff contends that the ALJ erred by failing to properly weigh medical source opinion evidence. Specifically, Plaintiff argues that the ALJ improperly rejected the opinion of treating physician Dat Tran, M.D., relying instead upon the opinions of the state agency physicians and reports of the consultative examiners.
"The ALJ is responsible for resolving conflicts in the medical record."
If a treating physician's opinion is not contradicted by the opinion of another physician, then the ALJ may discount the treating physician's opinion only for "clear and convincing" reasons.
Since the opinion of Dr. Tran was contradicted by consultative and reviewing doctors' opinions, as well as, other objective medical evidence, the specific and legitimate standard applies.
Historically, the courts have recognized the following as specific, legitimate reasons for disregarding a treating or examining physician's opinion: conflicting medical evidence; the absence of regular medical treatment during the alleged period of disability; the lack of medical support for doctors' reports based substantially on a claimant's subjective complaints of pain; and medical opinions that are brief, conclusory, and inadequately supported by medical evidence.
In March 2010, Keith Cunningham, M.D., performed an examination of Plaintiff in connection with his disability application. (Tr. at 446-52.) He noted that Plaintiff was massively obese but exhibited largely normal examination findings, including strength and range of motion, except for in his right foot, which had complete foot drop and decreased sensation and strength. Dr. Cunningham diagnosed chronic right foot drop secondary to lumbar radiculopathy, morbid obesity, suspected sleep apnea, and high blood pressure. Dr. Cunningham completed an opinion of Plaintiff's work-related activities in which he opined that Plaintiff could lift or carry 50 pounds occasionally and 10 pounds frequently; stand and walk six to eight hours per eight-hour workday; occasionally stoop, crouch, and climb ramps and stairs; never kneel, crawl, or climb ladders, ropes, or scaffolds; and should avoid working around heights. He also noted that Plaintiff used an assistive device. (Tr. at 446-52.)
In March 2011, Donald Fruchtman, D.O., also performed an evaluation of Plaintiff in connection with his disability application. (Tr. at 556-63.) Dr. Fruchtman found that Plaintiff had difficulty moving about, had discomfort squatting, had limited range of motion and abilities due to his right foot drop, walked with a limp, had pain and tenderness in his lumbar spine region and hip joints, and exhibited pain on straight leg raise tests, but had full (5/5) strength in his arms and left leg and largely normal sensation and reflexes. Dr. Fruchtman diagnosed lumbar disc syndrome with neuropathy, right foot drop secondary to nerve damage, morbid obesity, and high blood pressure. Dr. Fruchtman also completed an opinion of Plaintiff's work-related abilities in which he opined that Plaintiff could lift or carry 20 pounds occasionally and 10 pounds frequently; stand and walk two hours per eight-hour workday; sit for six to eight hours; never climb; occasionally stoop and crouch; frequently kneel and crawl; and should avoid working around heights and moving machinery. (Tr. at 556-63.)
In May 2011, state agency physician Terry Ostrowski, M.D., reviewed Plaintiff's medical records and opined that Plaintiff could lift and carry 20 pounds occasionally and 10 pounds frequently; stand and walk four and sit six hours per eight-hour workday; could not push or pull with his right foot; frequently climb ramps and stairs; occasionally crawl; never climb ladders, ropes, or scaffolds; could perform all other postural activities without restriction; and should avoid concentrated exposure to pulmonary irritants and hazards. (Tr. at 84-86.) Another state agency physician, John Fahlberg, M.D., later reviewed Plaintiff's medical records and largely agreed (Tr. at 99-102), as did a subsequent reviewing state agency doctor (Tr. at 583-84).
Finally, Dr. Tran completed a medical source statement regarding Plaintiff's abilities in which he opined that Plaintiff could sit less than two hours; stand and walk less than two hours; lift and carry less than 10 pounds; never perform most postural activities and never use his right foot; and should avoid any exposure to heights, moving machinery, marked changes in temperature and humidity, driving, and moderate exposure to dust, fumes, gases. He added that Plaintiff would be further limited by severe pain in his leg and was not able to work on a full time basis due to "dysfunction and use right leg [and] severe pain lower back." (Tr. at 615-16.)
In his evaluation of the objective medical evidence, the ALJ first addressed state agency physicians Dr. Ostrowski's (Tr. at 84-86) and Dr. Fahlberg's (Tr. at 99-102) opinions that Plaintiff could perform a range of light work and had the ability to stand and walk for four hours of an eight-hour workday. (Tr. at 20.) The ALJ found that these opinions were consistent with the record as a whole and gave them "great weight." (Tr. at 20.)
Next, the ALJ considered Dr. Cunningham's March 2010 opinion that Plaintiff could lift and carry 50 pounds occasionally and 10 pounds frequently and stand and walk six to eight hours in an eight-hour workday. (Tr. at 20, 446-52.) The ALJ gave Dr. Cunningham's opinion "significant weight" because it was supported by an actual examination of Plaintiff — which, as noted above, showed mostly normal findings aside from Plaintiff's right foot drop and resulting limitations. (Tr. at 446-52.)
Third, the ALJ discussed Dr. Fruchtman's March 2011 opinion that Plaintiff could perform a range of light work but could only stand and walk two hours per eight-hour workday. (Tr. at 20, 556-63.) The ALJ gave the opinion "some weight" after finding that certain restrictions set forth in the opinion were reasonable and supported by the record (e.g., that Plaintiff should avoid exposure to moving machinery due to his foot drop), but gave other portions of the opinion little weight (e.g., that Plaintiff could only stand and walk two hours total per eight-hour workday) because it was "at odds" with another examining doctor's opinion and the state agency doctors' opinions. (Tr. at 20.) Moreover, the ALJ found that the residual functional capacity assessment allowed Plaintiff to change positions between sitting and standing at will, which gave Plaintiff "flexibility" in completing a workday. (Tr. at 20.)
Finally, the ALJ addressed Dr. Tran's opinion that Plaintiff was unable to work full time; could sit, stand, and walk less than two hours each; could never lift more than 10 pounds; and could never perform postural movements. (Tr. at 20, 615-16.) The ALJ gave this opinion "very little weight" for a number of reasons. (Tr. at 20.) The ALJ stated that Dr. Tran's opinion was "extreme and inconsistent with every other opinion of record." (Tr. at 20.)
The Court finds that the ALJ properly weighed the medical source opinion evidence, and gave specific and legitimate reasons, based on substantial evidence in the record, for discounting Dr. Tran's opinion. The ALJ properly discredited the medical opinion due to inconsistencies with Plaintiff's treatment record and the medical evidence as a whole. The ALJ also found that said opinions were brief and lacked supporting clinical findings.
Plaintiff argues that the ALJ erred in rejecting his subjective complaints in the absence of clear and convincing reasons for doing so.
To determine whether a claimant's testimony regarding subjective pain or symptoms is credible, the ALJ must engage in a two-step analysis. "First, the ALJ must determine whether the claimant has presented objective medical evidence of an underlying impairment `which could reasonably be expected to produce the pain or other symptoms alleged.' The claimant, however, `need not show that her impairment could reasonably be expected to cause the severity of the symptom she has alleged; she need only show that it could reasonably have caused some degree of the symptom.'"
In weighing a claimant's credibility, the ALJ may consider many factors, including, "(1) ordinary techniques of credibility evaluation, such as the claimant's reputation for lying, prior inconsistent statements concerning the symptoms, and other testimony by the claimant that appears less than candid; (2) unexplained or inadequately explained failure to seek treatment or to follow a prescribed course of treatment; and (3) the claimant's daily activities."
Born in 1968, Plaintiff was 40 years old on his alleged onset date. He completed ninth grade and worked in the relevant past as a heavy equipment operator and construction laborer. He last worked in August 2008, after which he collected unemployment benefits and looked for work.
Plaintiff was represented by an attorney at the administrative hearing. (Tr. at 39.) Plaintiff testified that his main impediments to working were pain in his back, right foot drop (for which he wore a brace), asthma, and sleep apnea. (Tr. at 46.) He said that the 2008 lumbar discectomy surgery was not successful because it did not fix his foot drop and his pain was much worse after the surgery. (Tr. at 47-48.) Plaintiff said that the injections helped "for a couple of days" only (Tr. at 48, 59), and that the narcotic pain medications made him dizzy and sleepy. (Tr. at 58.) He said that doing any activity for too long — including sitting, standing, and walking — aggravated his pain. (Tr. at 49-50.)
Having reviewed the record along with the ALJ's credibility analysis, the Court finds that the ALJ made sufficient credibility findings and identified several clear and convincing reasons supported by the record for discounting Plaintiff's statements regarding his pain and limitations. Although the ALJ recognized that Plaintiff's medically determinable impairments could reasonably be expected to cause the alleged symptoms, she also found that Plaintiff's statements concerning the intensity, persistence, and limiting effects of the symptoms were not fully credible. (Tr. at 19-20.) "[Q]uestions of credibility and resolutions of conflicts in the testimony are functions solely of the ALJ."
Significantly, the ALJ relied on several inconsistencies in Plaintiff's statements in finding his claims to be incredible. (Tr. at 19.)
The ALJ gave other reasons for finding Plaintiff to be incredible. Specifically, the ALJ noted that Plaintiff received unemployment benefits — which requires an attestation that one is ready, willing, and able to work and actively looking for work — during some of the same time period that he is alleging disability. (Tr. at 19.)
In sum, the ALJ cited to the record, identifying a multiple inconsistencies that undermined the veracity of Plaintiff's allegations. (Tr. at 19-20.) While perhaps the individual factors, viewed in isolation, are not sufficient to uphold the ALJ's decision to discredit Plaintiff's allegations, each factor is relevant to the ALJ's overall analysis, and it was the cumulative effect of all the factors that led to the ALJ's decision. The Court concludes that the ALJ has supported his decision to discredit Plaintiff's allegations with specific, clear and convincing reasons and, therefore, the Court finds no error.
Plaintiff contends that the ALJ erred in failing to properly consider the statements of his wife, Lupe LaBorin, who completed a questionnaire describing Plaintiff's limited ability to sit, stand, walk, lift and perform postural activities, consistent with an inability to sustain work activity for a full work day or work week. (Tr. at 217-24.)
In determining whether a claimant is disabled, an ALJ must consider lay witness testimony regarding the claimant's inability to work.
Here, the ALJ considered the third-party statement and found that the statement failed to establish disability. (Tr. at 21.) In reaching this conclusion, the ALJ determined that, like Plaintiff's own statements, the lay witness statement was "simply not consistent with the preponderance of the opinions and observations by medical doctors in this case." (Tr. at 21.)
Even if there was a failure to properly discuss the third-party statement, the Court concludes that no reasonable ALJ, even if fully crediting the statement, could have reached a different disability determination. The limitations and symptoms contained in the third-party statement are entirely similar to and consistent with, those which Plaintiff described in his own testimony. As a result, because this Court concludes that the ALJ's decision to discredit Plaintiff's testimony was supported by substantial evidence, and because the third-party statement was consistent with Plaintiff's testimony, it was reasonable for an ALJ to disregard that statement as well.
Plaintiff contends that the ALJ failed to properly consider whether Plaintiff's impairments met or equaled Listing 1.04 in her step three evaluation. Specifically, Plaintiff argues that his impairment — in combination with his obesity — satisfied the requirements of Listing 1.04.
To meet the requirements of a listing, a claimant must have a medically determinable impairment that satisfies all of the criteria in the listing.
Here, the ALJ explicitly considered Plaintiff's obesity under SSR 02-1p, 2002 WL 34686281 (evaluation of obesity) and found that, while evidence showed Plaintiff's obesity exacerbated his back pain, there was "no evidence to show it precluded work activities altogether." (Tr. at 20.) The ALJ also explicitly considered the listings contained in section 1.00 (including section 1.04), but concluded that Plaintiff "does not meet or equal the requirements of [listings 1.00, 3.00, and 4.00] nor any other listing." (Tr. at 18.)
Indeed, both Dr. Cunningham's and Dr. Fruchtman's examinations indicate largely normal findings aside from weakness and atrophy in Plaintiff's right calf and foot, including full 5/5 strength in his arms and left leg and 4/5 strength in his right leg. (Tr. at 446-48, 560.) And, notably, The Pain Center treatment notes demonstrated "normal tone and strength" in both of Plaintiff's legs and negative straight leg raise tests (Tr. at 673-74, 699), as well as "normal" gait and station (Tr. at 546, 597). These findings establish that Plaintiff did not meet or medically equal the requirements of listing 1.04.
Thus, substantial evidence supports the ALJ's decision that Plaintiff did not have an impairment that met or medically equaled Listing 1.04.
Substantial evidence supports the ALJ's decision to deny Plaintiff's claim for disability insurance benefits and supplemental security income in this case. Consequently, the ALJ's decision is affirmed.
Based upon the foregoing discussion,