VITALIANO, D.J.
Plaintiff Daniel L. Smith seeks review, pursuant to 42 U.S.C § 405(g), of the final decision of the Commissioner of Social Security ("Commissioner"), dated February 26, 2013, finding that he was not "disabled" and, as a result, ineligible to receive Disability Insurance Benefits ("DIB") or Supplemental Security Income ("SSI"), as provided, respectively, under Titles II and XVI of the Social Security Act (the "Act"). The parties have filed cross-motions for judgment on the pleadings, pursuant to Rule 12(c) of the Federal Rules of Civil Procedure. Plaintiff argues that the administrative law judge ("ALJ") erred in failing to apply the appropriate legal standards and that the decision was not supported by substantial evidence. The Commissioner stands by her determination. For the reasons that follow, the Commissioner's motion is denied and Smith's cross-motion is granted to the extent that this case is remanded for further administrative proceedings.
On February 8, 2011, Smith, a military veteran, filed applications for DIB and SSI based on a compounding of illnesses and disorders: post-traumatic stress disorder ("PTSD"), osteoarthritis, anxiety, depression, fibromyalgia, anemia and high blood pressure. Record, Dkt. No. 8 ("R"), at 24, 248. The Social Security Administration ("SSA") denied the applications on April 28, 2011. R. at 24. Following this rejection by SSA, Smith properly requested review through an administrative hearing, which took place, on September 28, 2012, before ALJ Robert Gonzalez. R. at 23-24. Smith,
Smith completed high school before enlisting in the U.S. Army in 1988. R. at 47, 299 He subsequently completed two years of college. R at 47, 249. At the hearing, on direct examination, Smith stated that, during his three years of service, he was deployed to Iraq in Operation Desert Storm. R. at 53, 299. Unfortunately, Smith's time "in country" took both a psychological and physical toll on him. R. at 52-56. The horror of battle, including the loss of a close friend, caused him to experience PTSD, including traumatic flashbacks, which could occur as often as four times per week. R. at 53-55. In fact, he began to suffer a flashback during his testimony, forcing the ALJ to pause the proceedings for five minutes. R. at 54-55. As to physical impairments, Smith testified that he suffers from a pain that radiates down the left side of his body from his neck to his hip. R. at 56. That this pain, he continued, persists despite the physical and neurological therapy he has received. R. at 56. Additionally, although he takes Gabapentin for nerve pain and Baclofen for muscle relaxation, these medications cause their own set of debilitating side effects, including syncope, dizziness and nausea. R. at 57.
With those unfortunate maladies as his legacy, Smith left the armed services to rejoin civilian life and search for work. In 1994, Smith, following in the footsteps of many veterans of his era, began working as a security guard. R. at 299. It was a position he would hold for 16 years. R. at 70-71. However, he testified that this work did not permit him to use a cane, which caused him to experience back spasms and difficulty standing for prolonged periods. R. at 73. As time went on, these troubles caused him to be frequently absent and tardy, R. at 58, which resulted in his termination in September 2010, R. at 47. Smith went on to testify that, in 2011, hoping to find a more suitable occupation, he attended a certified home health aide course. R. at 48. Smith completed the course and immediately began looking for part-time work in the home health field. R. at 49, 71. The recurrence of his PTSD, however, forced him to stop his job search. R. at 50, 71-72. As of the date of the hearing, Smith remained unemployed. R. 47-48.
During Smith's direct testimony, the ALJ posed a series of questions focusing on his functional capabilities. R. at 63-65. Smith testified, in sum, that he lives alone, cooks mostly prepared foods, is able to do his own laundry, and that a neighbor who knows of his disabilities drives him to the grocery store and helps him with cleaning. R. at 63-65. The ALJ also interrogated him about his dismissal as a security guard, questioning whether it was, in fact, due to disability-caused absenteeism and lateness. R. at 58-59. Throughout, the ALJ repeatedly questioned Smith about his alcohol use, noting what the ALJ perceived to be slips and slurs during his testimony. R. at 60-63, 88. Then, most improperly, the ALJ asked Smith's lawyer to smell her client's breath, effectively making counsel an unsworn witness. R. at 75. She advised, contrarily, that Smith's breath did
Not long after, on February 26, 2013, the ALJ issued his decision affirming SSA's denial of Smith's benefits. R. at 35. The decision tracked the appropriate administrative regulations for determining
Important for this review, in any event, the ALJ made clear that his determination largely rested on his view that the diagnoses provided by certain of Smith's treating physicians were beyond belief. For instance, he gave little weight to the diagnosis of Dr. Julia Golier, a psychiatrist. R. at 28-29. Dr. Golier had treated Smith since 2009. R. at 751. Highlighted in a Mental Capacity Assessment ("MCA"), dated April 4, 2011, Dr. Golier noted that Smith had marked limitations in several areas essential to holding steady work, including his abilities to maintain attention and concentration for extended periods, to perform activities within a fixed schedule, and to complete a normal workday or workweek without interruptions from psychologically based symptoms. R. at 748-49. Further, Dr. Golier noted that, without improvements in each of these deficits, Smith would be absent from a job an average of four or more times a month. R. at 749.
Significantly, nine months later, Dr. Golier noted no improvement in any of these areas. R. at 680-82. Quite the opposite. Smith's condition, as described in the second MCA, had worsened, with Smith exhibiting additional marked limitations in his abilities to travel in unfamiliar places or use public transit and to set realistic goals or make plans independently. R. at 682. Yet, the ALJ disregarded this analysis, concluding that Dr. Golier's "assessment regarding the claimant's marked mental limitations is ... poorly supported by substantial evidence, namely her own treatment notes." R. at 28.
The ALJ also gave limited weight to the opinion of Dr. David Mahony, a psychologist, because Dr. Mahony had, the ALJ wrote, based his assessments of Smith's
The decision of the ALJ became the final order of the Commissioner on June 13, 2014 when the Appeals Council denied Smith's request for review. R. at 1-5. Smith filed this action on August 13, 2014 to challenge the Commissioner's adverse determination.
Section 405(g) of the Act empowers district courts to review a disability decision of the Commissioner and affirm, reverse, or modify it, "with or without remanding... for a rehearing."
Courts are advised to "keep[ ] in mind that it is up to the agency, and not [the] court, to weigh the conflicting evidence in the record."
A "disability" justifying SSI benefits exists if the claimant demonstrates an "inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment ... 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 primary guidance governing the assessment of disability is the "treating physician rule." In making a disability determination, an ALJ must generally give "controlling weight" to the opinion of the claimant's treating physician or psychiatrist as to the nature and severity of his patient's physical and/or mental impairments if that opinion is "well-supported by medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with the other substantial evidence in [the] case record." 20 C.F.R. § 404.1527(c)(2). Although the ultimate determination of disability is left to the ALJ hearing the proof, 20 C.F.R. § 404.1527(e)(2), it is equally clear that "a statement by a treating source that a claimant is disabled should not be disregarded,"
Most important, if refusing to accord controlling weight to a treating physician's medical opinion, in order to satisfy the plain-articulation standard, the ALJ "must explicitly [show his consideration of]," among other things, "(1) the frequen[c]y, length, nature, and extent of treatment; (2) the amount of medical evidence supporting the opinion; (3) the consistency of the opinion with the remaining medical evidence; and, (4) whether the physician is a specialist."
In reviewing this record, it is obvious that the ALJ did not adhere to these standards in applying the treating physician rule. Although, as is the nature of the VA system, Smith saw many healthcare professionals in his efforts to treat his illnesses and disorders, the record still certainly reflects that his longest-treating, most frequently seen and most substantive provider of services was Dr. Golier.
Notwithstanding Dr. Golier's lengthy experience with Smith and the thorough analysis of his history and treatment that were the bases for her diagnosis, the ALJ afforded her opinion little weight. R. at 28. His reason, in sum, was that her treatment notes did not support her assessments since they indicated that Smith was looking for work as a home healthcare aide in September 2011. Stunningly, without reference to an opinion by another healthcare professional calling Dr. Golier's opinion into question, the ALJ opined on his own that the treatment notes signified that Smith was, in fact, capable of working. R. at 28, 34. It hardly needs saying, however, that Smith, whose SSI and DIB applications had recently been denied, may have believed he had no alternative but to look
Simply stated, there is no meaningful discussion of the frequency, length, nature and extent of the treatment provided by Dr. Golier nor the special expertise incorporated in her opinion. Nor is there a substantive analysis of how Dr. Golier's opinion contrasted with other healthcare or vocational evidence developed in the record. Moreover, as noted earlier, after cursorily devaluing Dr. Golier's opinion, the ALJ relied on his own understanding of Dr. Golier's treatment notes to discount the opinion of
Furthermore, even where the ALJ did rely on Dr. Golier's findings, he cherry-picked those that supported his personal view. For example, he cites for reference Dr. Golier's finding that Smith responded positively to anti-depressant medication and was able to concentrate on a mental status examination. R. at 28. But this minor point is clearly overshadowed by Dr. Golier's consistent finding that Smith suffered from major depression and insomnia. R. at 619-22, 627-33, 711-12. These findings went overlooked in favor of the ALJ's own yardstick, which "arbitrarily substitute[d] his own judgment for competent medical opinion."
Finally, it should not go unnoticed that Smith's psychological disabilities were on full display at the hearing. The ALJ had to pause the proceeding for five minutes to allow him to collect himself after testifying about his war-time service in the Army. R. at 54-55. Seeing Smith's condition at the hearing should have left little doubt of his compromised state, but it did not even register in the notice of determination. R. at 24-35. At any rate, it should have alerted the ALJ to develop the record further before rejecting the opinions of Drs. Golier and Mahony.
On another front, as previously noted, Smith testified that he lives alone, cooks mostly prepared foods, is able to do his own laundry, and that a neighbor who knows of his disabilities drives him to the grocery store and helps him with cleaning. R. at 63-65. On this testimony of a struggle to meet daily needs, the ALJ, in large part, apparently rests his conclusion of non-disability, finding that Smith is "able to tend to his personal needs, cook, clean, shop and do the laundry." R. at 33. Yet, the conclusion turns a blind eye to Smith's testimony that his neighbor helps him clean the apartment and drive him to the grocery store because the neighbor knows
In line with the foregoing, the Commissioner's motion for judgment on the pleadings is denied and Smith's cross-motion is granted to the extent that the final order of the Commissioner is reversed, the decision of the ALJ is vacated, and the matter is remanded to the Commissioner for further administrative proceedings consistent with this order.
The Clerk of Court is directed to enter judgment accordingly and to close this case for administrative purposes.
So Ordered.