PAUL L. ABRAMS, Magistrate Judge.
Plaintiff filed this action on October 3, 2012, seeking review of the Commissioner's denial of his applications for Disability Insurance Benefits and Supplemental Security Income payments. The parties filed Consents to proceed before the undersigned Magistrate Judge on October 29, 2012, and November 7, 2012. Pursuant to the Court's Order, the parties filed a Joint Stipulation on May 28, 2013, that addresses their positions concerning the disputed issues in the case. The Court has taken the Joint Stipulation under submission without oral argument.
Plaintiff was born on July 12, 1972. [Administrative Record ("AR") at 38.] He has a high school education [AR at 136] and past relevant work experience as a truck driver. [AR at 137, 153-64.]
Plaintiff filed his application for Disability Insurance Benefits on June 1, 2010, and protectively filed his application for Supplemental Security Income payments on June 7, 2010, alleging that he has been disabled since November 12, 2007, due to depression and problems with his right knee, right leg, and left foot, among other things. [AR at 38-39, 104-18, 135-43, 173-77, 181-85.] After his applications were denied initially and upon reconsideration, plaintiff requested a hearing before an Administrative Law Judge ("ALJ"). [AR at 42-54, 57.] A hearing was held on August 22, 2011, at which time plaintiff appeared with counsel and testified on his own behalf. A vocational expert also testified. [AR at 26-37.] On September 16, 2011, the ALJ determined that plaintiff was not disabled. [AR at 14-21.] On July 27, 2012, the Appeals Council denied plaintiff's request for review. [AR at 1-3, 10.] This action followed.
Pursuant to 42 U.S.C. § 405(g), this Court has authority to review the Commissioner's decision to deny benefits. The decision will be disturbed only if it is not supported by substantial evidence or if it is based upon the application of improper legal standards.
In this context, the term "substantial evidence" means "more than a mere scintilla but less than a preponderance — it is such relevant evidence that a reasonable mind might accept as adequate to support the conclusion."
Persons are "disabled" for purposes of receiving Social Security benefits if they are unable to engage in any substantial gainful activity owing to a physical or mental impairment that is expected to result in death or which has lasted or is expected to last for a continuous period of at least twelve months. 42 U.S.C. § 423(d)(1)(A);
The Commissioner (or ALJ) follows a five-step sequential evaluation process in assessing whether a claimant is disabled. 20 C.F.R. §§ 404.1520, 416.920;
In this case, at step one, the ALJ concluded that plaintiff has not engaged in any substantial gainful activity since his alleged disability onset date, November 12, 2007. [AR at 16.] At step two, the ALJ concluded that plaintiff has the severe impairment of patella-femoral arthrosis. [
Plaintiff contends that the ALJ improperly: (1) failed to consider the existence of any closed periods of disability; (2) failed to consider the opinion of an examining physician; (3) rejected the opinion of plaintiff's treating physician; and (4) discounted plaintiff's subjective symptom testimony. [Joint Stipulation ("JS") at 4-5.] As set forth below, the Court agrees with plaintiff, in part, and remands the matter for further proceedings.
On November 12, 2007, plaintiff was in a car accident and sustained a fracture to his right patella. [AR at 263.] On November 16, 2007, plaintiff underwent "right knee open repair fracture of the patella." [AR at 345.] Thereafter, on October 23, 2008, plaintiff underwent a second surgery on his right knee — "[a]rthroscopy . . . with closed manipulation of the right knee." [AR at 214, 253.] Almost one year later, on September 23, 2009, plaintiff's right knee gave out while he was walking, "causing him to twist his left foot and right knee" as he fell. [AR at 344.] On November 5, 2010, plaintiff underwent surgery on his right knee for the third time, which included the following procedures: "[a]rthroscopic partial right lateral meniscectomy"; "[a]rthroscopic lateral retinacular release"; "[o]pen excision of scar tissue formation, patellar tendon"; "[m]edial retinacular release"; and "[c]omplete synovectomy, medial compartment, lateral compartment, and anterior intercondylar notch regions." [AR at 405-07.]
"To determine whether a claimant's testimony regarding subjective pain or symptoms is credible, an ALJ must engage in a two-step analysis."
On September 9, 2010, plaintiff completed a form entitled "Exertion Questionnaire Since Your Disability Began." [AR at 165-67.] In the questionnaire, plaintiff stated that he lives in a house that has two steps in front of the house and three steps at the side of the house. [AR at 165-66.] He stated that the steps affect him "by putting pressure to get up the stairs." [AR at 166.] Plaintiff reported that he uses a brace and a cane for support, but that after walking for 15 minutes, he is "in pain" and it seems to him like he has been walking "for hours." [AR at 165, 167.] Plaintiff also reported that he can lift five pounds two to three times a week, and can carry only "light grocer[ies] like egg[s], beans [and] bread." Plaintiff stated that he can sweep, mop, and wash dishes, but that these chores take him about an hour to complete because he must take breaks. [AR at 166.] He also reported more generally that housework takes him one to two hours to finish because he "can[']t stand on [his] feet so long," otherwise he "get[s] pain [in his] knee and legs." [AR at 167.] Plaintiff stated that he washes his car once every two weeks, and that he can rake leaves if he takes breaks every 15 minutes. He also stated that he can shop for groceries, "but . . . take[s] [his] son with [him]," and that he drives, but sometimes has to stop because he "get[s] really bad pains." [AR at 166.]
At his August 22, 2011, administrative hearing, plaintiff testified that he stopped working because of the car accident in 2007. Plaintiff further testified that when his right knee gave out in September of 2009 and he twisted his left foot as a result, he "thought [he] just sprained it, but actually it was fractured." [AR at 31.] He testified that prior to his third knee surgery in November of 2010, he had stiffness in his right knee, he could only stand for 5 minutes before needing to sit down, and his knee would be "asleep" if he sat for 30 minutes. [AR at 28-29.] Plaintiff acknowledged that, following his third surgery, he had "improvement" with his knee in that he does not "feel as much . . . stiffness," "can walk [a] little bit better," and "can sort of . . . bend it a little bit more . . . than . . . before." [
At step one of the two-step credibility analysis, the ALJ found that plaintiff's "medically determinable impairment could reasonably be expected to cause the alleged symptoms." [AR at 19.] The ALJ nevertheless concluded that plaintiff's "statements concerning the intensity, persistence and limiting effects of these symptoms are not credible to the extent they are inconsistent with the [ALJ's RFC findings for plaintiff]." [AR at 19-20.] Thus, at step two, as the record contains no evidence of malingering by plaintiff,
The ALJ gave the following reasons for discrediting plaintiff's subjective symptom testimony: (1) plaintiff "testified that he has had improvement with less pain, stiffness, numbness and tingling since his November 2010 right knee surgery"; (2) his daily activities; and (3) the objective medical evidence. [AR at 18, 20.]
The ALJ's first reason for discounting plaintiff's statements about the severity of his subjective symptoms was that plaintiff "testified that he has had improvement with less pain, stiffness, numbness and tingling since his November 2010 right knee surgery." [AR at 18.] The ALJ also stated later in his decision that plaintiff "testified that surgery has allowed for significant improvement." [AR at 20.] The latter statement by the ALJ is a mischaracterization of plaintiff's testimony, however. When the ALJ asked plaintiff at the hearing whether plaintiff experienced any improvement with his right knee after his third surgery, plaintiff stated, "Yes, I did," and explained that he does not "feel as much . . . stiffness," "can walk [a] little bit better," and "can sort of . . . bend it a little bit more . . . than . . . before." [AR at 29.] Plaintiff did not testify that his third surgery resulted in "significant improvement" with his right knee, and the Court finds that such a characterization does not accurately summarize plaintiff's statements that his surgery resulted in less stiffness, the ability to "walk [a] little better," and the ability to "bend it a little bit more" than before. While plaintiff did testify to some improvement, the fact that a person "makes some improvement does not mean that [his] impairments no longer seriously affect his ability to function in a workplace."
Second, after noting that plaintiff testified his pain, stiffness, numbness, and tingling lessened after his third surgery, the ALJ stated: "Despite these allegations, [plaintiff] is able to shop for groceries, sweep, mop, wash dishes, wash his car, and rake leaves with appropriate breaks." [AR at 18.] As best as the Court can discern, it appears that the ALJ found plaintiff's representation — that he had significant pain, stiffness, numbness, and tingling prior to his November 2010 surgery — incredible because plaintiff stated in his September 9, 2010, exertion questionnaire that he can perform the above activities of daily living. The ALJ's summary of plaintiff's statements in that questionnaire also mischaracterizes the evidence, however. While plaintiff stated that he can shop for groceries, he also stated that he takes his son with him, that he is in pain after he walks for 15 minutes, and that he can only carry "light grocer[ies]" such as eggs, beans, and bread. Similarly, plaintiff reported that he must take breaks every 15 minutes when he rakes leaves, and that chores such as sweeping, mopping, and washing dishes take him approximately one hour to complete because he needs to take breaks. Finally, plaintiff stated that he washes his car once every two weeks, but also stated that housework generally takes him one to two hours to complete because he "can[']t stand on [his] feet so long," otherwise he "get[s] pain [in his] knee and legs." In light of plaintiff's statements as a whole, the Court does not find that his asserted daily activities constitute a clear and convincing reason to discount his allegations about the severity of his symptoms. Further, engaging in some household chores or activities is not necessarily inconsistent with a finding of disability.
Lastly, the ALJ discounted plaintiff's credibility because he found that "the objective findings in this case fail to provide strong support for [plaintiff's] allegations of disabling symptoms and limitations." [AR at 18.] While an ALJ may consider whether a lack of objective medical evidence supports the degree of limitation, this "cannot form the sole basis for discounting pain testimony."
The ALJ failed to offer any legally adequate reason for discounting plaintiff's credibility. Remand is warranted on this issue.
In evaluating medical opinions, the case law and regulations distinguish among the opinions of three types of physicians: (1) those who treat the claimant (treating physicians); (2) those who examine but do not treat the claimant (examining physicians); and (3) those who neither examine nor treat the claimant (non-examining physicians).
Where a treating physician's opinion does not contradict other medical evidence, the ALJ must provide clear and convincing reasons to discount it.
On October 7, 2009, Dr. Philip A. Sobol performed an initial orthopedic evaluation of plaintiff, which included a physical examination, a neurological examination, and taking x-rays of plaintiff's right knee and left foot. [AR at 342-54.] Based on his findings, Dr. Sobol diagnosed plaintiff with "[s]tatus post open reduction/internal fixation, right patella fracture, with resultant calcification, patellar tendon, with residual internal derangement and possible nerve stretch and hamstring strain, secondary to recent fall," as well as "[l]eft displaced fifth metatarsal fracture, secondary to [the first diagnosis]." [AR at 352.] Dr. Sobol fitted plaintiff with a short moon boot, advised plaintiff to continue using his knee brace and crutches, prescribed pain medications, requested authorization for an MRI of his right knee, referred him to a surgeon for a surgical consultation concerning his right foot, and opined that plaintiff would be temporarily totally disabled for eight weeks. [AR at 352-54.] An MRI of plaintiff's right knee was taken on November 10, 2009 [AR at 341], and on November 20, 2009, Dr. Sobol saw plaintiff again and viewed his MRI. Dr. Sobol rendered the same diagnoses, refilled plaintiff's prescriptions, referred him for physical therapy, and opined that he would be temporarily totally disabled for another six weeks. [AR at 330-31.] Between January 2010 and October 2010, Dr. Sobol saw plaintiff once every six weeks, continued to opine that he was temporarily totally disabled, and referred him for his third knee surgery. [AR at 332-40, 383-85.] Following plaintiff's third knee surgery on November 5, 2010, and up until May 11, 2011, Dr. Sobol continued to see plaintiff once every six to seven weeks, recommend treatment for his right knee and left foot, prescribe medications to him, and opine that he was temporarily totally disabled. [AR 442-47, 451-52.] On June 6, 2011, Dr. Sobol completed a "Medical Opinion Re: Ability to Do Work-Related Activities (Physical)" form concerning plaintiff. In the form, Dr. Sobol opined that plaintiff can lift and carry less than 10 pounds occasionally and frequently; stand and walk less than 2 hours in an 8-hour workday, but would need to change positions every 5 to 10 minutes; sit approximately two hours in an 8-hour workday, but would need to change positions every 15 to 20 minutes; occasionally twist; and never stoop/bend, crouch, or climb stairs and ladders. He also opined that plaintiff would "need the opportunity to shift at will from sitting or standing/walking"; that he frequently would need to lie down at unpredictable intervals during the day; and that he remained temporarily totally disabled pending further evaluation and treatment. Dr. Sobol stated that his opinions were based on plaintiff's examinations, x-rays, history, and surgeries. [AR at 485-87 (emphasis omitted).]
In his decision, the ALJ noted that Dr. Sobol's opinions "contain issues reserved to the Commissioner[,] . . . such as whether an individual is disabled under the [Social Security] Act." However, the ALJ then assigned "partial weight . . . to Dr. Sobol's opinion of [plaintiff's] inability to crouch and climb," without explicitly rejecting or assigning any weight to the remainder of Dr. Sobol's opinion. [AR at 19.]
Dr. Sobol's opinion on the ultimate issue of whether plaintiff was disabled during part of the alleged disability period conflicted with that of examining physician Warren David Yu, who opined on August 28, 2010, that plaintiff could perform modified sedentary work. [See AR at 369-72.] Thus, while the ALJ correctly stated that the determination of a claimant's ultimate disability is reserved to the Commissioner (
Further, Dr. Sobol's opinion that plaintiff can only sit for about 2 hours out of an 8-hour workday; can never stoop, bend, or climb; would need the opportunity to shift at will from sitting or standing/walking; and would frequently need to lie down at unpredictable intervals, conflicts with Dr. Yu's opinion that plaintiff can sit for up to 6 hours in an 8-hour workday (without additional restrictions on sitting), and can perform occasional stooping, bending, and climbing. Thus, to the extent the ALJ did not adopt Dr. Sobol's opinion, he was required to give specific and legitimate reasons to reject that portion of the doctor's opinion. Here, the ALJ adopted Dr. Sobol's opinion that plaintiff cannot crouch or climb, but did not mention the rest of his opinion concerning plaintiff's limitations. [AR at 19.] The ALJ's decision does not explain why he implicitly rejected the bulk of Dr. Sobol's opinion concerning plaintiff's limitations, but adopted the doctor's opinion that plaintiff cannot crouch or climb. [
The ALJ failed to give any specific and legitimate reasons to reject Dr. Sobol's opinion.
As a general rule, remand is warranted where additional administrative proceedings could remedy defects in the Commissioner's decision.
Accordingly,