SHERI POLSTER CHAPPELL, Magistrate Judge.
This matter comes before the Court on Plaintiff's Memorandum of Law in Support of Claim for Disability Benefits (Doc. #21) filed on October 28, 2011. The Government filed is Memorandum in Support of the Commissioner's Decision (Doc. #22) on December 27, 2011.
The Undersigned has reviewed the record, including a transcript of the proceedings before the Administrative Law Judge (ALJ), the exhibits filed and administrative record, and the pleadings and memoranda submitted by the parties in this case and issues the following Order.
Plaintiff filed applications for a period of disability, disability insurance benefits, and Supplemental Security Income (SSI) on May 6, 2008. (Tr. 142-48, 151-53). Those applications were denied. (Tr. 76-77, 80-81, 89-90, 92-93). Subsequently, Plaintiff had a hearing before Administrative Law Judge (ALJ) Ruben Rivera, Jr. on January 6, 2010. (Tr. 34-47). At the hearing, Plaintiff appeared and testified. By decision dated January 26, 2010, the ALJ determined Plaintiff was not disabled. (Tr. 13-28). The Appeals Council denied Plaintiff's request for review (Tr. 1-5) and the Commissioner's final decision is now subject to judicial review pursuant to sections 205(g) and 1631(c)(3) of the Social Security Act, 42 U.S.C. §§ 405(g), 1383(c)(3). Plaintiff filed the instant Complaint on May 2, 2011 (Doc. #1).
The Plaintiff is a thirty-six (36) year-old female — thirty-three (33) years old at the time of the application — who has a twelfth (12th) grade education and has worked over the years as a certified nursing assistant as a private home health aide and with the mentally disabled, and a sales associate for department stores. (Tr. 40, 177). The Plaintiff alleges disability due to Acquired Immunodeficiency Syndrome (AIDS)/Human Immunodeficiency Virus (HIV), Depression, Obesity, Hypertension and Joint Pain. (Tr. 166, 325). The Plaintiff's problems became disabling to the extent she stopped working on May 4, 2008, due to symptoms from the alleged impairments. She was missing work and allegedly could no longer fulfill the demands of the job as a sales associate/customer service representative of walking and interacting with others, due to residuals of diarrhea, nightmares, difficulty concentrating, joint pain and numbness in the hands and legs. (Tr 40-45, 166). The Plaintiff was treated primarily by Dr. Marshall D'Souza at the McGregor Clinic, Dr. Kenneth A. Berdick, and a mental health counselor, Dr. Terri M. Erwin, Ph.D. (Tr. 244-67, 322-64, 425-70).
On January 26, 2010, after reviewing all of the evidence and testimony, ALJ Ruben Rivera, Jr. issued a "Notice of Decision — Unfavorable." (Tr. 16-28). The ALJ found that Plaintiff had the severe impairments of asymptomatic human immunodeficiency virus (HIV), depression, and obesity. (Tr. 18, Finding No. 3). The ALJ then found that Plaintiff did not have an impairment or combination of impairments that met or medically equaled one of the listed impairments at 20 C.F.R. pt. 404, subpt. P, app. 1 (2011). (Tr. 19, Finding No. 4). Considering the record overall, the ALJ determined that Plaintiff retained the residual functional capacity (RFC) to perform a range of medium work with some additional non-exertional mental limitations. (Tr. 20, Finding No. 5). With these limitations, the ALJ found Plaintiff could perform her past relevant work as patient transporter or sales attendant. (Tr. 27, Finding No. 6). As a result, the ALJ determined that Plaintiff was not under a disability, as defined in the Act, since the alleged onset date of May 4, 2008, through the date of the decision. (Tr. 28, Finding No. 7).
The scope of this Court's review is limited to determining whether the ALJ applied the correct legal standards, and whether the findings are supported by substantial evidence.
The Commissioner's findings of fact are conclusive if supported by substantial evidence (42 U.S.C. § 405(g)). "Substantial evidence is more than a scintilla — i.e., the evidence must do more than merely create a suspicion of the existence of a fact, and must include such relevant evidence as a reasonable person would accept as adequate to support the conclusion."
Where the Commissioner's decision is supported by substantial evidence, the District Court will affirm, even if the reviewer would have reached a contrary result as finder of fact, and even if the reviewer finds that the evidence preponderates against the Commissioner's decision.
The Court "may not decide the facts anew, reweigh the evidence, or substitute [its] judgment for that of the [Commissioner]."
The law defines disability as the inability to do 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 twelve (12) months (42 U.S.C. §§ 416 (I), 423 (d)(1); 20 C.F.R. § 404.1505). The impairment must be severe, making the plaintiff unable to do his or her previous work, or any other substantial gainful activity which exists in the national economy (42 U.S.C. § 423(d)(2); 20 C.F.R. §§ 404.1505-404.1511). To determine whether the plaintiff is disabled, the ALJ is required to evaluate the claim according to the established five-step evaluation process.
The Plaintiff states that the ALJ committed three errors for which this case should be revered and remanded for further development or for payment. Specifically, Plaintiff alleges: (1) the ALJ failed to follow the opinion of treating sources; (2) the ALJ erred in finding that Plaintiff could perform past relevant work in the range of medium and light work; and (3) the ALJ failed to develop a full and fair record. The Plaintiff alleges that the ALJ's decision was not based on substantial evidence. The Court will consider each of these issues below.
In this case, the Plaintiff argues that the ALJ disregarded the reports of examining physicians, which were indicative of inability to perform substantial gainful activity. Plaintiff asserts that the treating physician, Dr. Marshall D'Souza, opined that Plaintiff's condition impaired her ability to work. (Tr. 422-24). And that this opinion was shared by Dr. J.L. Bernard, J.D., Ph.D., who opined that Plaintiff was probably unemployable and gave her a poor prognosis, as well as Dr. Henley. (Tr. 374-76, 467-70).
Substantial weight must be given to the opinion, diagnosis and medical evidence of a treating physician unless there is good cause to do otherwise. 20 C.F.R. § 404.1527 (d);
The ALJ is required to review all of the medical findings and other evidence that supports a medical source's statement that a claimant is disabled. However, the ALJ is responsible for making the ultimate determination about whether a claimant meets the statutory definition of disability. 20 C.F.R. § 404.1527 (e). The ALJ is not required to give any special significance to the status of a physician as treating or non-treating in weighing an opinion on whether the claimant meets a listed impairment, a claimant's residual functional capacity (20 C.F.R. §§ 404.1545 and 404.1546), or the application of vocational factors because that ultimate determination is the providence of the Commissioner. 20 C.F.R. § 404.1527 (e).
In his opinion, the ALJ gave weight to Dr. Ronald Kline and Dr. James Levasseur, Ph.D., and one of Dr. Erwin's opinions. (Tr. 25). The ALJ discounted part of Dr. Levasseur's opinion, the second of Dr. Erwin's opinions and Dr. D'Souza's medical statement. (Tr. 26). The Court notes though that the ALJ provided good explanation for the weight given to each source given the objective medical evidence available in the record.
The medical evidence shows that Plaintiff was diagnosed with HIV in 1990. (Tr. 246). Plaintiff did not seek treatment until August 2000. (Tr. 349). Plaintiff regularly receives treatment from the personnel at McGregor Clinic and Dr. Marshall D'Souza oversees her care. (Tr. 146-267, 300-17, 325-64, 404-21, 478-84). The treatment notes from McGregor Clinic show that Plaintiff was generally asymptomatic and doing well on her aniretroviral treatments, even though she was sometimes noncompliant with her medications. (Tr. 255, 257, 259, 306, 406, 408). In April 2008, Plaintiff had not been to the clinic for treatment in two years and had a low CD4 count and percentage. (Tr. 254, 256, 258, 345). At that time, the examiner noted he discussed compliance and side effects with Plaintiff, but included no other note and continued Plaintiff on her medication. (Tr. 254). Plaintiff began taking the antiretroviral medication at that time and was subsequently noted to be doing well by June 2008 and feeling better, even though she was sometimes noncompliant with her medication. (Tr. 480, 306, 309). Plaintiff's lab results showed continued improvement in her condition. (Tr. 407,409, 411, 416, 420; 481). Plaintiff received a note from the McGregor Clinic in July 2008 that indicated she should not work for 3-4 weeks. (Tr. 304). The ALJ noted that this note suggests that the physician did not believe Plaintiff was completely unable to work. (Tr. 24).
Dr. Kline, a state agency medical consultant, reviewed Plaintiff's medical history in October 2008. (Tr. 365-72). He opined that Plaintiff could perform medium work with no additional postural, manipulative, visual, communicative or environmental limitations. (Tr. 366-69).
With regard to Dr. D'Souza, he noted in his medical statement that per Plaintiff, she had dizziness, significant fatigue, numbness in her hands, occasional diarrhea, and nightmares/hallucinations. (Tr. 423). As the ALJ noted, the severity of these side effects are not supported by the medical evidence. (Tr. 21). For example, at Plaintiff's hospital visit in September 2009, Plaintiff denied conditions such as diarrhea, weakness, or vomiting. (Tr. 473). The treatment notes from McGregor Clinic also do not indicate the severity of these symptoms. (Tr. 325-48, 404-12). In September 2009, Dr. D'Souza opined that based on Plaintiff's statements, she could work for two hours a day, stand and walk for three hours total in an eight-hour day, sit for 15-20 minutes at a time and lift ten pounds occasionally and frequently. (Tr. 423). In the section on psychological problems, Dr. D'Souza noted Dr. Erwin treated Plaintiff and that per Plaintiff's statements, she had moderate impairments in her ability to work with others, and a marked impairment in her ability to maintain attention and concentration, and an extreme impairment in her ability to understand, remember and carry out detailed instructions. (Tr. 423). Dr. D'Souza made a point of indicating on the form that the limitations included were "per pt" or per the patient's statements. (Tr. 423). The ALJ noted in his decision:
(Tr. 24, internal citations omitted). Accordingly, the ALJ noted and considered Dr. D'Souza's medical opinion but noted that the opinion was not based on other objective medical evidence in the record.
With regard to Dr. Bernard, he was a consultive examiner who assessed Plaintiff in October 2008. (Tr. 374-75). He observed that Plaintiff's thought processes were rational, clear and logical, with unremarkable content. (Tr. 375). He also observed that Plaintiff's sensorium was clear, her judgment and insight were average, her estimated intellectual ability was average, and the testing score was not indicative of cognitive dysfunction, which the ALJ considered. (Tr. 22, 375). He diagnosed Plaintiff with major depressive disorder and opined that she was likely unemployable, but she could handle her own finances. (Tr. 275). The ALJ found, however, that Dr. Bernard's conclusions were contrary to the results of the mental status examination. (Tr. 23). And therefore afforded his conclusion little weight when compared to his objective assessment based on SSR 96-6p. Therefore, the ALJ considered the medical evidence offered by Dr. Bernard and the Plaintiff has presented the Court with nothing to indicate that the ALJ's opinion was not based on substantial evidence in the record.
The ALJ considered other medical evidence, including that in November 2008, Dr. Levasseur, Ph.D., a state agency psychological consultant, reviewed Plaintiff's medical evidence. (Tr. 377-93). He opined that Plaintiff could understand and follow instructions, demonstrate a cooperative attitude, make basic work decisions, and adapt adequately to work environments. (Tr. 393). He opined that Plaintiff had a reduced ability to concentrate in her ability to complete complex tasks and a reduction in her social interaction ability that limited her to work with low social demands. (Tr. 393). The ALJ considered that Plaintiff's medication was helpful, but she also alleged some side effects. (Tr. 24, 41, 44).
The evidence regarding Plaintiff's mental condition shows that Plaintiff was treated by Terry Erwin, Ph.D., a licensed mental health counselor, who diagnosed Plaintiff with an adjustment disorder with mixed anxiety and depressed mood.
In November 2008, Dr. Erwin opined that Plaintiff did not suffer from a mental impairment that significantly interferes with her daily functioning. (Tr. 395). Then in September 2009, Dr. Erwin assessed that Plaintiff had no limitation in her ability to maintain personal appearance and hygiene and only mild limitations in her ability to accept instruction from and respond appropriately to criticism from supervisors, work in proximity to others without distracting them or exhibiting behavioral extremes, relate to the general public and maintain socially appropriate behavior, carry through instructions and complete tasks independently, respond appropriately to changes in the work setting, remember locations and workday procedures, be aware of normal hazards and take precautions, and behave in a predictably, reliably, and in an emotionally stable manner. (Tr. 467-70). Dr. Erwin opined that Plaintiff had moderate limitations in her ability to respond appropriately to co-workers or peers, perform work tasks in work day and work week at a consistent pace, process subjective information accurately, and use appropriate judgment, maintain attention and concentration for more than brief periods of time, and perform at production levels expected by most employers. (Tr. 469). The medical evidence was considered by the ALJ (Tr. 23, 25-26) when determining Plaintiff's RFC. The ALJ discussed the weight given to Dr. Erwin's opinions based on the other objective medical evidence:
The Court agrees with Defendant that considering all of the medical evidence, the ALJ found by properly using the factors in the regulations, that Drs. Kline, Levasseur and Bernard's opinions were consistent with each other and with the other medical evidence and gave each great weight. (Tr. 26). As for Dr. Levasseur's opinion that Plaintiff must be in an environment that requires low social demands, the ALJ gave that particular limitation less weight because the medical evidence showed that Plaintiff was able to act cooperatively and appropriate with others (Tr. 26). The ALJ explained that the limitation on social demands was not supported by the medical evidence available and therefore did not give it great weight. (Tr. 26).
Plaintiff argues that the ALJ improperly determined that the Plaintiff could perform work at the medium exertional level and return to her past relevant work as a sales attendant. (Tr. 27). Specifically, the Plaintiff argues that the ALJ's findings regarding the Plaintiff's RFC are not supported by the findings of any of the examining or treating sources and that the Plaintiff's subjective complaints are credible and expected.
The fourth step in the evaluation process requires the ALJ to determine the plaintiff's residual functional capacity (RFC) and based on that determination, decide whether the plaintiff is able to return to his/her previous work.
The ALJ made the following findings with respect to Plaintiff's RFC:
Plaintiff argues that the ALJ's RFC determination is improper because he improperly discredited the Plaintiff's complaints because she participated in activities such as the birth of her friend's baby on her birthday, cooked some food on one particular holiday, read literature recommended by her mental healthcare counselor in order to cope with stress, and she tries to take care of her children. (Tr. 23).
Where an ALJ decides not to credit a claimant's testimony about pain or other, the ALJ must articulate specific and adequate reasons for doing so, or the record must be obvious as to the credibility finding.
A lack of a sufficiently explicit credibility finding becomes a ground for remand when credibility is critical to the outcome of the case.
The Court agrees with Defendant that contrary to Plaintiff's argument, the ALJ properly considered Plaintiff's credibility in evaluating the RFC. If the objective medical evidence does not confirm the severity of the alleged symptoms but the claimant establishes that she has an impairment that could reasonably be expected to produce her alleged symptoms, then the intensity and persistence of her alleged symptoms and their effect on her ability to work must be evaluated.
The ALJ also considered Plaintiff's activities of daily living in evaluating her credibility. (Tr. 23-25). While the performance of everyday tasks cannot be used to make a determination that the Plaintiff was not disabled, daily activities can be used as a measure of the Plaintiff's credibility in regard to his ability to perform certain tasks. See
During the third step of the sequential evaluation, the ALJ considered Plaintiff's limitations in three categories. (Tr. 19). The ALJ found that Plaintiff was mildly limited in activities of daily living and moderately limited in social functioning and her ability to concentrate, persist or keep pace. (Tr. 19). The ALJ then reflected the degree of limitation in each category in the functional limitations included in the RFC. (Tr. 20). Contrary to Plaintiff's argument, those limitations are consistent with the functional limitations included in the RFC that Plaintiff could perform simple work, respond appropriately to supervision and deal with changes in routine. (Tr. 20). The ALJ explained that despite these moderate limitations, Plaintiff is able to work as evidenced by her daily activities and the medical evidence. (Tr. 23).
Considering all of Plaintiff's activities and the medical evidence compared with her subjective complaints, the ALJ properly found that Plaintiff's complaints were not entirely credible as to the severity and limiting effects. Substantial evidence supports the ALJ's RFC finding that Plaintiff could perform unskilled medium work.
Plaintiff argues that the ALJ failed to develop a full and fair record because he did not elicit the testimony of a Vocational Expert (VE). Defendant argues that this was not required. After correctly finding that Plaintiff's impairments did not meet or equal a listed impairment, the ALJ assessed Plaintiff's RFC to determine if she could perform her past relevant work. See 20 C.F.R. §§ 404.1520(a)(4)(iv), (e), (f), 416.920(a)(4)(iv), (e), (f). Given Plaintiff's RFC for a range of unskilled medium work and the demands of her past relevant work, the ALJ found that Plaintiff could perform her past relevant work as a patient transporter or sales attendant either as previously performed or as performed in the national economy. (Tr. 27-28). In finding that Plaintiff could perform her past relevant work as a patient transporter and a sales attendant, the ALJ properly relied on the Dictionary of Occupational Titles (DOT) (Tr. 27-28).
The ALJ has a duty to fully and fairly develop the record.
However, while it is well established that the ALJ has a duty to develop a full and fair record, that duty only extends to the record for the twelve (12) months preceding the filing of an application for benefits.
Plaintiff argues the ALJ should have used the services of a VE because the ALJ included nonexertional limitations. (Pl.'s Br. at 9-10). However, when an ALJ finds that a claimant can perform her past relevant work, testimony from a VE is not necessary.
Accordingly, it is now
The decision of the Commissioner is