JOHN G. KOELTL, District Judge.
This is an appeal from a denial by the Commissioner of Social Security of claims for Title II Social Security Disability Insurance Benefits ("DIB") and Title XVI Supplemental Security Income ("SSI") under the Social Security Act. The plaintiff, Ramon Luis Davila, Jr., filed claims for DIB and SSI alleging that he has bipolar disorder, schizoaffective disorder, post-traumatic stress disorder, substance use disorder, asthma, and scoliosis. His claims were denied after an Administrative Law Judge ("ALJ") found that the plaintiff is not disabled within the meaning of the Social Security Act.
The plaintiff now brings this appeal arguing that the ALJ failed to give sufficient weight to the opinions of two treating medical sources in violation of the "treating source rule." The plaintiff further argues that the ALJ erred in finding that the plaintiff's impairment did not meet the listing at 20 C.F.R. Part 404, Subpart P, Appendix 1, § 12.04; erred in failing to consider the side effects of the plaintiff's medications on his residual functional capacity; and that the ALJ's finding that there are jobs in the economy that the plaintiff could perform is not supported by substantial evidence.
The parties have cross-moved for judgment on the pleadings pursuant to Rule 12(c) of the Federal Rules of Civil Procedure. As discussed below, the Commissioner's motion is
The administrative record contains the following facts.
The plaintiff was born in 1978 and was thirty-six years old at the time of the ALJ's decision. (R. 59, 274.) He completed high school, (R. 59), and worked as a bank teller, an insurance claims representative, and a customer service representative, (R. 49).
On December 15, 2014, the plaintiff filed an application for DIB and SSI, alleging disability beginning on January 5, 2012. (R. 274-86.) The plaintiff alleged disability due to bipolar disorder, post-traumatic stress disorder ("PTSD"), anxiety, lower back pain, and muscle spasms. (R. 303.) The plaintiff's claims were initially denied, (R. 118-22), and the plaintiff then requested a hearing before an ALJ, (R. 126-28).
The plaintiff, represented by counsel, attended an initial hearing before the ALJ on August 12, 2015. (R. 28-29.) The plaintiff, the plaintiff's mother, and a vocational expert named Andrew Vaughn testified. (R. 28-29.) A second hearing was held by video on December 8, 2015. (R. 56.) Dr. Sharon Kahn, a medical expert in psychiatry; Dr. Dorothy Kunstadt, a medical expert in internal medicine; and Victor Alberigi, a vocational expert, testified at the second hearing. (R. 56.) The plaintiff also submitted medical records in support of his application.
The plaintiff's medical records show that the plaintiff was hospitalized for psychiatric treatment and diagnosed with bipolar disorder in 2011. (R. 489.) At that time, he was experiencing auditory hallucinations that were telling him to kill himself. (R. 489.)
In 2012, the plaintiff lost his job due to excessive absences. (R. 489.)
On October 17, 2014, the plaintiff was psychologically evaluated by the Federation Employment and Guidance Services in connection with an application he filed for public assistance (R. 452-57.) At that examination, the plaintiff reported that he had been diagnosed with bipolar disorder, (R. 454), that he was hospitalized in October 2011, (R. 454), and that his last mental health appointment was on January 12, 2012, (R. 454). The examiner found that the plaintiff was "depressed[,] irritable[,] and will have a problem relating at work." (R. 465.)
In October 2014, the plaintiff began seeing a psychiatrist, Dr. Laurence Dopkin, and a psychologist, Dr. Karthik Gunnia (together, the "treating doctors"). (R. 472-76.) From October 2014 to at least May 26, 2015, the plaintiff met with Dr. Dopkin two to four times per month and with Dr. Gunnia once per month. (R. 472.)
On February 5, 2015, Dr. Dopkin submitted a Treating Physician's Wellness Plan Report, in which he indicated that the plaintiff had bipolar disorder and suffered from depression, poor appetite, low energy, low self-esteem, poor concentration, difficulty making decisions, sleeping problems, and continued depressive episodes despite treatment. (R. 466.) Dr. Dopkin opined that the plaintiff would be unable to work for at least twelve months. (R. 467.)
On February 12, 2015, Dr. Gunnia reported that the plaintiff was being treated for schizoaffective disorder with the medications Seroquel and Remeron. (R. 469.)
On May 26, 2015, the treating doctors provided a joint Medical Source Statement. (R. 472-76.) In this joint statement, the doctors stated that the plaintiff's GAF
The treating doctors reported in the joint Medical Source Statement that the plaintiff had frequent auditory hallucinations, racing thoughts, intermittent suicidal ideations, and difficulties with concentration and memory. (R. 473.) The plaintiff was taking Seroquel and Remeron, which caused lethargy. (R. 473.) The two treating doctors further opined that the plaintiff would have to be absent from work more than three times a month, that he had extreme loss of his ability to maintain attention and concentration, and extreme loss of ability to complete a normal workday without interruptions from psychologically based symptoms. (R. 473-74.) The plaintiff also showed a marked loss of his ability to understand, remember, and carry out detailed instructions, maintain regular attendance and be punctual, sustain an ordinary routine without special supervision, deal with the stress of semi-skilled work, work in coordination with or proximity to others without being unduly distracted, accept instructions and respond appropriately to criticism from supervisors, or perform at a consistent pace without an unreasonable number and length of rest periods. (R. 474.)
The treating doctors also reported moderate limitations in his ability to understand, remember, and carry out very short simple instructions, make simple work related decisions, interact appropriately with the public, get along with coworkers, respond appropriately to changes in a routine work setting, travel in unfamiliar places, and use public transportation. (R. 474.) The treating doctors further opined that the plaintiff had moderate difficulties in maintaining social functioning, frequent deficiencies of concentration, persistence or pace, and repeated episodes of decompensation. (R. 475-76.)
In connection with his application for benefits, the plaintiff attended three consultative examinations, in January,
Overall, the three consultative examiners reported (1) that the plaintiff's evaluation appeared "to be consistent with psychiatric problems and these have interfered with the claimant's ability to function socially in the workplace on a daily basis," (Dr. Howard Tedoff, R. 445); (2) that the plaintiff's prognosis was guarded without consistent psychological treatment, (Dr. Arlene Broska, R. 493); and (3) that the plaintiff's psychiatric problems "may significantly interfere with [his] ability to function on a daily basis," (Dr. W. Amory Carr, R. 526-27).
At the hearings before the ALJ, the plaintiff testified that, at that time he filed his claim, he lived with his mother who cooked and cleaned for him and had to remind him to maintain his personal hygiene. (R. 36.) He testified that he had "bad thoughts" at times, trouble sleeping, nervousness and anxiety around others, that it was hard for him to get out of the house, (R. 38), that there were days he could not get out of bed, (R. 78), that he experienced both auditory and visual hallucinations, (R. 51), and that he would sometimes rock back and forth holding his head to shut out the voices in his head, (R. 62).
The plaintiff's mother also testified and generally confirmed the plaintiff's description of his symptoms. She testified that the plaintiff was often tired and depressed, (R. 47-48), that on a bad day, he had "a lot of anxiety, irritation, and confusion," (R. 44), and that three to four times a week he would rock back and forth and pace around the house threatening to end his life, (R. 44-45). She also testified that he would sometimes talk to himself. (R. 44-46.)
Dr. Kahn, a psychologist, testified as a medical expert. (R. 69.) Dr. Kahn did not examine the plaintiff and indeed Dr. Kahn never met the plaintiff. Dr. Kahn opined that the plaintiff's mental impairment did not meet a listing under 20 C.F.R. Part 404, Subpart P, Appendix 1. (R. 70.) Dr. Kahn testified that she disagreed with the treating doctors' conclusions in their joint Medical Source Statement because, in Dr. Kahn's view, there was no reasoning to support their determination of marked impairments. (R. 81.) Dr. Kahn asserted that she agreed with the treating doctors' data, but "disagree[d] with their interpretation of the data." (R. 86.) She claimed that the plaintiff's impairments would cause the claimant moderate limitations in activities of daily living and in social functioning, but no problems with memory, concentration, and pace. (R. 18.) She further opined that the claimant could do simple routine repetitive work. (R. 18.)
On January 20, 2016, the ALJ issued a decision finding that the plaintiff was not disabled. (R. 9-27.) The ALJ's decision became the final decision of the Commissioner on June 9, 2017, when the Appeals Council denied the plaintiff's request for review. (R. 1-4.) This appeal followed.
A court may set aside a determination by the Commissioner only if it is based on legal error or is not supported by substantial evidence in the record.
A claimant qualifies as disabled if the claimant suffers from 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 months" that prevents the claimant from engaging in any "substantial gainful activity." 42 U.S.C. § 1382c(a)(3)(A).
The Commissioner's regulations provide a five-step inquiry to determine if a claimant is disabled. At Step One, the Commissioner considers whether the claimant is engaged currently in substantial gainful activity. If not, the Commissioner proceeds to Step Two and considers whether the claimant has a severe impairment that limits the claimant's mental or physical ability to do basic work activities. If the claimant has a severe impairment, the Commissioner proceeds to Step Three, which requires determining, based solely on medical evidence, whether the claimant has an impairment listed in Appendix 1 of the regulations. If so, the Commissioner shall consider the claimant disabled without considering the vocational factors of age, education, and work experience. If the impairment is not listed in the regulations but is determined to be a severe impairment, Step Four requires the Commissioner to determine the claimant's residual functional capacity ("RFC") and, based on that determination, ask whether, despite the claimant's severe impairment, the claimant can perform the claimant's past work. Finally, if the claimant is unable to perform such past work, at Step Five the Commissioner determines whether there is other work that the claimant could perform. 20 C.F.R. §§ 404.1520(a), 416.920(a);
Where the claimed impartment is a mental impairment, Social Security Regulations require the ALJ to use a "special technique" to evaluate the claim.
When employing this five-step process, the Commissioner must consider four factors in determining a claimant's entitlement to benefits: "(1) the objective medical facts; (2) diagnoses of medical opinions based on such facts; (3) subjective evidence of pain or disability testified to by the claimant or others; and (4) the claimant's educational background, age, and work experience."
The "treating source rule" requires an ALJ who is deciding whether the claimant is disabled to consider the opinion of the claimant's treating doctors.
Where, as in this case, "mental health treatment is at issue, the treating physician rule takes on added importance."
If an ALJ gives opinions of a treating doctor less than controlling weight, the ALJ must specify "good reasons,"
In this case, the ALJ determined that the plaintiff satisfied Steps One and Two and determined, at Step Four, that the plaintiff could not perform his past work. However, the ALJ found that the plaintiff did not meet a listing at Step Three and, at Step Five, the ALJ held that there were jobs in the economy that the plaintiff could perform.
The ALJ found that the plaintiff's mental impairments did not meet or medically equal any of the impairments listed in 20 C.F.R. Part 404, Subpart P, Appendix 1. (R. 14-15.) The plaintiff argues that the ALJ should have found that he qualified under listing § 12.04: "Affective Disorders."
Under § 12.04, a claimant qualifies for the listed impairment if the claimant satisfy either paragraphs A and B or paragraphs A and C. Paragraph A can be satisfied by showing that the claimant has depressive syndrome, manic syndrome, or bipolar syndrome. The plaintiff argues that the ALJ erred in finding the plaintiff did not meet the requirements of paragraph A-1 — "depressive syndrome" — and paragraph B of the § 12.04 listing. The ALJ did not address paragraph A but found that the plaintiff did not meet the § 12.04 listing because the plaintiff did not satisfy paragraph B.
To satisfy paragraph A-1 of the § 12.04 listing, a claimant must show a "[m]edically documented persistence, either continuous or intermittent, of . . . [d]epressive syndrome characterized by at least four of the following":
20 C.F.R. Part 404, Subpart P, Appendix 1, ¶ A-1.
The plaintiff's medical records satisfy the requirements of paragraph A. In the treating doctors' joint Medical Source Statement,
To satisfy the paragraph B criteria of the § 12.04 listing, the mental impairments must result in at least two of the following: (1) marked restriction of activities of daily living; (2) marked difficulties in maintaining social functioning; (3) marked difficulties in maintaining concentration, persistence, or pace; or (4) repeated episodes of decompensation, each of extended duration.
In the treating doctors' joint Medical Source Statement, the doctors found that the plaintiff satisfied two of these categories. The doctors stated that the plaintiff has "frequent" deficiencies of concentration, persistence, or pace
Under the treating source rule, the ALJ was required to give great weight to the treating doctors unless there were good reasons not to do so.
First, the ALJ stated that he gave "little weight" to the treating doctors' opinions that the plaintiff had marked limitations in concentration, persistence, and pace because the treating doctors did not provide any objective test results or data. This was not a proper reason to discount the treating doctors' opinion. If the ALJ believed the doctors' records were insufficient, the ALJ should have developed the record to determine why objective test results had not been provided.
Second, the ALJ gave little weight to the treating doctors' opinions on concentration, persistence, and pace because — according to the ALJ — their opinions were contradicted by the consultative examination reports. That is simply not true. The consultative examiners did not specifically give an opinion on whether the plaintiff had a marked impairment regarding concentration, persistence, and pace. And, overall, the consultative examiners concluded that the plaintiff's impairment would hinder his ability to work. (
Third, the ALJ stated that the treating doctors' opinion on decompensation was not supported by the record because the plaintiff had been hospitalized only once for psychological reasons. (R. 19.) However, the plaintiff might not have been hospitalized for each decompensation episode. Under the regulations, hospitalization is only one means of showing an episode of decompensation.
Therefore, the ALJ erred by rejecting the treating doctors' opinion and should have found either that the plaintiff qualified for the § 12.04 listing or that more information was needed to resolve the alleged insufficiency of evidence.
The plaintiff also argues that the ALJ erred by finding that his RFC qualified him for jobs in the economy. At Step Four of the sequential evaluation process, the ALJ found that the plaintiff had the RFC to
(R. 16.) Based on this RFC, the ALJ found, at Step Five, that the plaintiff could work as a packing line worker, mail clerk, or as an assembler of small products. The plaintiff argues that the ALJ incorrectly found that the plaintiff would be able to maintain regular attendance and be punctual or sustain an ordinary routine.
In the joint Medical Source Statement, the plaintiff's treating doctors opined that the plaintiff had extreme loss of his ability to maintain attention and concentration and extreme loss in his ability to complete a normal workday without interruptions from psychologically based symptoms. (R. 474.) The treating doctors further opined that the plaintiff had marked loss in his ability to maintain regular attendance and be punctual, to sustain an ordinary routine, or to perform at a consistent pace without an unreasonable number and length of rest periods. (R. 474.) They opined that the plaintiff would be absent from work more than three times a month. (R. 473.) At the plaintiff's hearing, the ALJ stated he took "judicial notice that if a person is late with unskilled work that they are going to be terminated." (R. 52-53.)
However, the ALJ gave "little weight" to the treating doctors' opinions. The ALJ stated that the treating doctors' findings were contradicted by "the findings of all three consultative examiner[s'] mental status exams in January, July, and September 2015." (R. 19.) The ALJ also stated that the treating doctors' opinions that "[the plaintiff] would have multiple episodes of decompensation" was "not supported by the record." (R. 19.)
Contrary to the ALJ's assertion, the consultative examiners found that the plaintiff would struggle to maintain a regular work schedule and stay on task while at work. Dr. Tedoff opined that the plaintiff had moderate to marked limits in his ability to maintain a regular schedule. (R. 445.) Dr. Broska opined that there was evidence of moderate limitation in the plaintiff's ability to maintain a regular schedule. (R. 492.) And Dr. Carr opined that the plaintiff had moderate limitation in his ability to maintain a regular schedule and that the plaintiff's "psychiatric problems . . . may significantly interfere with [his] ability to function on a daily basis." (R. 527.)
The ALJ noted the consultative examiners' findings and assigned "partial weight" to two of the opinions and "little weight" to the third opinion. The ALJ gave partial weight to Drs. Tedoff's and Broska's opinions, reasoning that "the finding of moderate to marked limitations in maintaining a regular schedule is not supported and the [plaintiff's] treating psychiatrist reported that the [plaintiff] attends scheduled psychiatric appointments and weekly therapy sessions, and takes prescribed medication, which suggests an ability to maintain a regular schedule." (R. 19.) The ALJ gave Dr. Carr's opinion "little weight," because, the ALJ said, the opinion "[wa]s not supported by [Dr. Carr's] essentially normal findings in the mental status exam, and the opinion appears internally inconsistent, as the doctor opines that the [plaintiff] would be moderately to markedly limited in both his ability to perform simple tasks and his ability to perform complex tasks." (R. 19-20.)
The ALJ gave "great weight" to the opinion of Dr. Kahn, the psychological medical examiner. Dr. Kahn never examined the plaintiff but testified that the plaintiff had no problems with memory, concentration, or pace, and that the plaintiff could do simple routine repetitive work. The ALJ stated that Dr. Kahn's opinion was supported by all three consultative examiners' opinions and entitled to "great weight."
The ALJ's decision in this case to assign the greatest weight to the opinion of the medical expert, who never met or examined the plaintiff, and to discount or reject the opinions of the two treating doctors and the three consultative examiners, constitutes reversible error.
Moreover, the ALJ's statement that the consultative examiners' opinions supported Dr. Kahn's opinion and did not support the treating doctors' opinions was simply incorrect. The treating doctors and the consultative examiners each noted that the plaintiff would struggle to maintain attendance and stay on task. And, in any event, the treating doctors had a longitudinal relationship with the plaintiff that eclipsed that of the consultative examiners and Dr. Kahn; the treating doctors were in the best position to evaluate and opine on the plaintiff's condition.
The ALJ rationalized that the plaintiff would not struggle to maintain attendance and focus in a job because he was able to attend therapy and take his medication. This was a poor reason to discount the treating doctors' and consultative examiners' opinions. There is plainly a difference between showing up at work each day and attending periodic therapy sessions. At bottom, the ALJ substituted his opinion for that of the treating doctors and the consultative examiners. He found that because the plaintiff was able to attend weekly therapy sessions and take medication, the plaintiff had the "ability to maintain a regular schedule." (R. 19.) It was improper for the ALJ to substitute his opinion on a medical issue for that of a medical professional.
For the foregoing reasons, the Commissioner's cross-motion for judgment on the pleadings, (Dkt. No. 13), is
The Court has considered all of the arguments raised by the parties. To the extent not specifically addressed, the arguments are either moot or without merit. The Clerk of Court is directed to enter judgment remanding this case to the Commissioner of Social Security for further proceedings consistent with this Opinion. The Clerk is also directed to close all pending motions and to close this case.
20 C.F.R. Part 404, Subpart P, Appendix 1.