JOHN D. EARLY, Magistrate Judge.
Plaintiff Ruby L. T. ("Plaintiff") filed a Complaint on February 6, 2018, seeking review of the Commissioner's denial of her applications for disability insurance benefits ("DIB") and supplemental security income ("SSI"). The parties filed a Joint Submission ("Jt. Stip.") regarding the issues in dispute on November 26, 2018. The matter now is ready for decision.
Plaintiff filed her application for DIB on October 31, 2013, and her application for SSI on November 15, 2013, alleging disability commencing on June 29, 2013.
On November 10, 2016, the ALJ issued a written decision finding Plaintiff was not disabled. AR 18-29. The ALJ found Plaintiff had not engaged in substantial gainful activity since the alleged onset date and found Plaintiff had severe impairments of hypertension, diverticulitis, and gastroesophageal reflux disease. AR 20. The ALJ also found Plaintiff did not have an impairment or combination of impairments that met or medically equaled a listed impairment and had the residual functional capacity ("RFC") to perform a full range of light work, specifically Plaintiff: (1) could lift 20 pounds occasionally and 10 pounds frequently; (2) could stand, walk, and sit for six hours out of an eight-hour workday; (3) was unlimited in her ability to push and pull, other than as indicated for lifting at the light-exertional level; and (4) could frequently climb ramps, stairs, ladders, ropes, and scaffolds. AR 22-23.
The ALJ determined Plaintiff could perform her past relevant work as a cashier, accounting clerk, and bank teller, as actually and generally performed. AR 27. The ALJ also determined that, in addition to her past relevant work, Plaintiff could perform other jobs existing in the national economy. AR 27. Considering Plaintiff's age as a "younger individual" on the alleged onset date, her education, work experience, RFC, and the VE's testimony, the ALJ concluded Plaintiff could also perform the jobs of office worker, ticket taker, and mail sorter. AR 27-28. Accordingly, the ALJ concluded that Plaintiff was not under a "disability," as defined in the Social Security Act, from the alleged onset date through the date of the decision. AR 29.
Plaintiff's request for review of the ALJ's decision by the Appeals Council was denied, making the ALJ's decision the Commissioner's final decision. AR 1-5. This action followed.
Under 42 U.S.C. § 405(g), this court may review the Commissioner's decision to deny benefits. The ALJ's findings and decision should be upheld if they are free from legal error and supported by substantial evidence based on the record as a whole.
Lastly, even if an ALJ errs, the decision will be affirmed where such error is harmless (
When the claimant's case has proceeded to consideration by an ALJ, the ALJ conducts a five-step sequential evaluation to determine at each step if the claimant is or is not disabled.
First, the ALJ considers whether the claimant currently works at a job that meets the criteria for "substantial gainful activity."
After determining the claimant's RFC, the ALJ proceeds to the fourth step and determines whether the claimant has the RFC to perform her past relevant work, either as she "actually" performed it when she worked in the past, or as that same job is "generally" performed in the national economy.
If the claimant cannot perform her past relevant work, the ALJ proceeds to a fifth and final step to determine whether there is any other work, in light of the claimant's RFC, age, education, and work experience, that the claimant can perform and that exists in "significant numbers" in either the national or regional economies.
The claimant generally bears the burden at each of steps one through four to show he or she is disabled, or he or she meets the requirements to proceed to the next step; and the claimant bears the ultimate burden to show he or she is disabled.
The parties present two disputed issues (Jt. Stip. at 4):
In determining a claimant's RFC, an ALJ must consider all relevant evidence in the record, including medical records, lay evidence, and "the effects of symptoms, including pain, that are reasonably attributable to the medical condition."
"There are three types of medical opinions in social security cases: those from treating physicians, examining physicians, and non-examining physicians."
In Issue 1, Plaintiff contends that in evaluating the medical evidence and assessing the RFC, the ALJ should not have disregarded the opinion of Dr. Roth. Jt. Stip. at 4-6. On June 27, 2011, Dr. Roth examined Plaintiff and completed an "agreed medical evaluation" in conjunction with Plaintiff's workers compensation claim. AR 369-73. Plaintiff presented subjective complaints of neck pain radiating to her left shoulder, and left-hand pain, with carpal tunnel syndrome symptomatology. AR 389, 398. Upon examination of the cervical spine, Dr. Roth noted that manual compression of Plaintiff's head and neck did not produce any symptoms. AR 398. Dr. Roth also found Plaintiff had no sensory loss in her upper extremities. AR 399. Plaintiff had no weakness in her shoulder or wrist flexors. AR 399. The bilateral shoulder examination revealed largely normal findings, including normal range of motion and a lack of cross-arm adduction pain. AR 401. The wrist examination showed no swelling or deformities and normal range of motion. AR 401. Plaintiff's range of motion for all fingers was normal. AR 401. Dr. Roth found that the Phalen's
In assessing the RFC, the ALJ took into consideration the opinions of the State agency review physicians, consultative examiners, and treating physicians. AR 26. The ALJ addressed the opinions and assigned respective weight. AR 25-26. Regarding Dr. Roth's opinion about Plaintiff's functional limitations, the ALJ found it not relevant because it was made two years prior to the alleged onset date. AR 26. The ALJ also noted that there was no medical source statement from any source that was more restrictive than the RFC. AR 26.
The ALJ provided valid reasons for disregarding Dr. Roth's assessed limitations. While an ALJ must consider all medical opinion evidence,
Further, Plaintiff has not shown, and the evidence does not demonstrate, that her condition worsened.
The ALJ also correctly noted that no medical source statement evaluating symptoms during the relevant period was more restrictive than the RFC. AR 26. The consultative examiner and two State agency physicians examined Plaintiff or her records and determined that she did not have any manipulative limitations. AR 86-87, 97-98, 111-12, 123-24, 380-85. The consultative examiner specifically found that Plaintiff could "perform gross and fine motor skills of reaching, carrying, lifting, feeling, handling and fingering with
Accordingly, the ALJ provided legally sufficient reasons supported by substantial evidence for finding Dr. Roth's assessed limitations not relevant, and the ALJ's analysis constituted a rational interpretation of the evidence.
Where a disability claimant produces objective medical evidence of an underlying impairment that could reasonably be expected to produce the pain or other symptoms alleged, absent evidence of malingering, the ALJ must provide "`specific, clear and convincing reasons for' rejecting the claimant's testimony regarding the severity of the claimant's symptoms."
In Issue 2, Plaintiff argues the ALJ improperly discounted her subjective complaints. Jt. Stip. at 10-13.
During the administrative hearing, Plaintiff testified she last worked as a bus driver. AR 40-41, 55. She was able to work part-time from July to October 2013 but had to stop when her legs and muscles gave out. AR 41-42, 55. Her main problem is whole-body pain, including in her left arm, knees, legs, and spine. AR 43-46. She also has carpal tunnel, arthritis in her fingers, and lupus, which causes her fingers to swell. AR 44, 58. She cannot bend her left thumb, and she has pain in her fingers. AR 44-45. She has difficulty sitting. AR 46. In addition to pain, she is fatigued. AR46-47. She also has diverticulitis, which causes stomach pain and constipation. AR 48. Gout affects her ankles and toes. AR 52-53. She has good days and bad days. AR 49. She tries to relax and alleviate pain with meditation. AR 50. She lives with her daughter and helps her around the house, but her daughter does most of the work. AR 50-51, 55. She can no longer do her prior accounting job because of her problems sitting and her hand and neck pain. AR 52-53. She has been taking online classes for a bachelor's degree in criminal justice, achieving A and B grades. AR 60-62. She prepares reports for the classes. AR 62. She also takes math, English, and Constitutional law classes online. AR 62. Her plan in taking the classes is to obtain work from home, possibly counseling children. AR 62.
Plaintiff completed a function report on January 10, 2013, describing similar subjective complaints. AR 23, 246-53. In addition to the symptoms she alleged at the hearing, she mentioned chest pain and an enlarged heart in the report. AR 23, 247.
Plaintiff also completed a pain questionnaire on December 22, 2012, again relaying symptoms discussed at the hearing. AR 243-45. She said she cannot walk more than 70 feet, stand for more than 30 minutes, or sit for more than two hours. AR 245. Her pain is aggravated by lifting, bending, and kneeling.
The ALJ found Plaintiff's medically determinable impairments could reasonably be expected to cause some of the alleged symptoms, but her statements "concerning the intensity, persistence[,] and limiting effects of [the] symptoms" were inconsistent with: (1) her ability to take online college classes; (2) her plans to pursue employment; (3) the objective medical evidence; (4) her routine and conservative treatment; and (5) the lack of a medical source statement supporting her allegations.
First, the ALJ properly discounted Plaintiff's testimony that her arthritic pain and swelling in her fingers precluded her from performing the manipulative activities required for her previous job as an accounting clerk. AR 24. The ALJ found that her ability to take classes online for a year and prepare reports for those classes, was inconsistent with her allegations of the severity of her limitations. AR 24.
Second, and relatedly, the ALJ properly found that Plaintiff's taking college classes with the intention of pursuing a career and working from home counseling children, was inconsistent with her allegation that she could not work. AR 24, 60-62.
Third, the ALJ found the severity of Plaintiff's subjective allegations was diminished in light of the objective evidence. AR 24-25. "Although lack of medical evidence cannot form the sole basis for discounting pain testimony, it is a factor that the ALJ can consider in his credibility analysis."
Fourth, the ALJ discounted Plaintiff's complaints because she received routine, conservative treatment since the alleged onset date, particularly for her chest pain, hypertension, and diverticulitis. AR 24. For example, her treatment plan for these and other symptoms consisted of exercise on the treadmill, dietary changes, medication, and follow-up appointments. AR 291, 293-95, 356, 428, 454, 490-91, 506. The ALJ properly relied on this factor.
Fifth, the ALJ discounted Plaintiff's subjective complains because no medical source statement from an examining or treating physician endorsed the extent of her alleged functional limitations. AR 24. As discussed above, no opinion during the relevant period was more restrictive than the RFC, let alone concluded Plaintiff was disabled. AR 24, 86-87, 97-98, 111-12, 123-24, 380-85. Accordingly, this final reason is supported by substantial evidence.
The Court finds the ALJ provided sufficiently specific, clear, and convincing reasons for discounting Plaintiff's symptom testimony, specifically, Plaintiff's ability to take college classes with the intent to work, the conflict with objective medical evidence, routine and conservative treatment, and the lack of a medical source statement supporting disability. Those grounds, together, are sufficient to affirm the ALJ's decision on the issue.
IT THEREFORE IS ORDERED that Judgment be entered affirming the decision of the Commissioner and dismissing this action with prejudice.