MICHAEL A. TELESCA, District Judge.
Represented by counsel, Kimberly Marie Poles ("Plaintiff") brings this action pursuant to Title XVI of the Social Security Act ("the Act"), seeking review of the final decision of the Commissioner of Social Security ("the Commissioner") denying her application for Supplemental Security Income ("SSI"). The Court has jurisdiction over this matter pursuant to 42 U.S.C. § 405(g). For the reasons discussed below, the Commissioner's decision is reversed, and the matter is remanded for further administrative proceedings.
Plaintiff protectively filed for SSI benefits on June 22, 2011, alleging disability since June 1, 2011. T.166-72.
The parties have filed cross-motions for judgment on the pleadings pursuant to Rule 12(c) of the Federal Rule of Civil Procedure. The Court adopts and incorporates by reference herein the undisputed and comprehensive factual summaries contained in the parties' briefs. The Court will discuss the record evidence in further detail below as necessary to the resolution of the parties' motions.
When considering a claimant's challenge to the decision of the Commissioner denying benefits under the Act, the district court is limited to determining whether the Commissioner's findings were supported by substantial record evidence and whether the Commissioner employed the proper legal standards.
"The deferential standard of review for substantial evidence does not apply to the Commissioner's conclusions of law."
"[A]n ALJ does not face a claimant such as [Plaintiff] in an adversarial posture."
Comments indicating the appearance of bias against Plaintiff based on her history of incarceration and drug use are evident throughout his decision. For instance, the ALJ begins his analysis as follows:
T.28. Plaintiff also argues that the ALJ included unnecessary comments regarding her subjective complaints that evinced a negative bias toward her. The record substantiates this assertion.
Claimants seeking benefits indisputably are entitled to have a fair and impartial decision-maker, for "a basic element of due process is the right to an impartial and unbiased adjudication of a claim."
Plaintiff argues that the ALJ's residual functional capacity ("RFC") assessment is legally erroneous and unsupported by substantial evidence due to the ALJ's selective reading of the record and mischaracterization of the medical evidence. The Court agrees.
For example, the ALJ stated that "the claimant testified that arthritis, carpal tunnel syndrome, depression and mental impairments prevent her from working" but "most of these conditions are simply not found in the medical evidence." T.28. The ALJ's use of the term "most" without specifying which conditions and impairments he believed were "not found" in the record is so vague as to be nearly meaningless. The only condition as to which the Court has not found treatment records is carpal tunnel syndrome. However, the record is replete with treatment notes referencing Plaintiff's history of mental issues dating back to her childhood, and she has been diagnosed with multiple mental disorders that appear resistant to treatment. In addition, the record contains objective medical evidence documenting findings consistent with osteoarthritis.
With regard to Plaintiff's mental impairments, she has been variously diagnosed with psychotic disorder, anti-social disorder, anxiety disorder, depressive disorder, major depressive disorder with psychotic features, and schizophrenia. For instance, on August 17, 2011, consultative psychologist Dr. Christine Jean-Jacques noted that Plaintiff reported being hospitalized for psychiatric reasons on at least one occasion, though she did not remember when; Plaintiff told Dr. Jean-Jacques that she had gone through "a lot of problems" as a child. T.285. At the time of the consultative examination ("CE"), Plaintiff was being seen by LMSW Erin Carlson bi-weekly at St. Mary's Mental Health Outpatient Center. Dr. Jean-Jacques diagnosed Plaintiff with major depressive disorder, severe, with psychotic features; anxiety disorder, not otherwise specified ("NOS"); and alcohol and cocaine dependence/abuse, in sustained remission. T.288. Dr. Jean-Jacques stated that the results of the CE "appear to be consistent with psychiatric problems that may significantly interfere with the claimant's ability to function on a daily basis."
On September 28, 2011, psychiatrist Isis Bottros, M.D. performed a psychiatric medication review, noting that Plaintiff's jail records indicated that while incarcerated at Albion Correctional Facility for a year, she was treated for symptoms of depression, anxiety and psychosis, and prescribed Remeron (an antidepressant), Vistaril (a sedative sued to treat anxiety, tension, and agitation), and Risperdal (an atypical antipsychotic). Recently, Plaintiff had been started on Seroquel (an atypical antipsychotic) and trazodone (a tetracyclic antidepressant) which helped with her anxiety and auditory hallucinations, but not her depressed mood. On examination, Dr. Bottros noted that Plaintiff's mood was depressed, her thought process displayed paranoid ideation; and she heard voices commanding her and conversing with her. Dr. Bottros added Zoloft (a selective serotonin reuptake inhibitor) for her depressive symptoms.
On February 12, 2012, Plaintiff was seen by psychiatrist Chaya Bhuvaneswaran, M.D. for a psychiatric medication review. T.399-405. Dr. Bhuvaneswaran noted Plaintiff's diagnoses of psychotic disorder, NOS, and antisocial personality disorder. Plaintiff had "very limited" insight regarding the benefits of sustained evaluation and input by her treatment team; it was unclear to Dr. Bhuvaneswaran whether this was reflective of Plaintiff's personality or mood state. T.408.
On February 15, 2013, Plaintiff saw psychiatrist Gregory Seeger, M.D. at Genesee Mental Health Center for a psychiatric medication review. T.929-30. Dr. Seeger diagnosed Plaintiff with schizophrenia, paranoid type on Axis I, and deferred diagnosis on Axis II. He observed that Plaintiff was irritable and "highly anxious" with a labile affect, some psychomotor restlessness, and loud and rapid speech. She reported prominent auditory hallucinations and prominent paranoia and her judgment was impaired, although not to the point of being a danger to herself or others. As these excerpts from the medical records demonstrate, Plaintiff's depression and mental impairments are consistently substantiated by her treatment records. Yet, the ALJ concluded that "the only evidence that the claimant saw a psychiatrist is Dr. Reddy's note from June of 2012," T.30, which is inconsistent with the foregoing treatment records from multiple psychiatrists. The omitted records from,
With regard to Plaintiff's testimony that she suffered from arthritis, this also is supported by the record. Plaintiff has consistently sought treatment for chronic lumbar back pain. For instance, on February 9, 2010, Plaintiff reported radiating lower back pain and tingling to her hip. T.248. A lumbar x-ray showed mild disc space narrowing and marginal osteophyte
"Courts in this Circuit have found reversible error where an ALJ arrives at an RFC assessment in reliance on a mischaracterization or misstatement of the record."
In addition to committing multiple errors in characterizing the medical evidence, the ALJ arrived at internally inconsistent conclusions. For instance, in his psychiatric review technique, the ALJ found that Plaintiff had no restrictions with regard to activities of daily living, mild difficulties in social functioning, and moderate difficulties with regard to maintaining concentration, persistence, or pace. T.26. However, according to disability analyst Dr. Thomas Harding, whose opinion the ALJ accorded "significant" weight, T.31, Plaintiff has "moderate" limitations across all three domains. The ALJ's rationale in purporting to give significant weight to Dr. Harding's opinion, while rejecting the majority of that same opinion, cannot be gleaned from the decision, especially due to the multiple factual omissions and errors committed by the ALJ. This and other internal inconsistencies in the ALJ's decision provide an additional basis for remand.
Plaintiff argues that ALJ's credibility analysis was legally erroneous and not based on substantial evidence. The Court agrees, as discussed further below.
In assessing a claimant's subjective complaints of disabling pain and other limitations, the ALJ first must determine whether the claimant suffers from a "medically determinable impairment that could reasonably be expected to produce" the symptoms alleged. 20 C.F.R. § 416.929(b). Second, the ALJ must evaluate the intensity and persistence of those symptoms considering all of the available evidence; and, to the extent that the claimant's subjective contentions are not substantiated by the objective medical evidence, the ALJ must engage in a credibility inquiry.
As an example in the present case, the ALJ relied heavily on his disbelief of Plaintiff's statement that she lived alone (despite having four children and a fiancé), in order to find her subjective complaints not credible. The record indicates, however, that Plaintiff's children all were adults; there is nothing unusual or suspicious about adult children not living with their mother. Likewise, there is nothing unusual or suspicious about engaged individuals living separately before marriage. If the ALJ found this testimony to be highly relevant and indicative of dissembling, he could have, and should have asked Plaintiff for clarification.
The ALJ also did not believe Plaintiff's reported history of psychotic disorder and anti-social personality disorder, stating that "there is no support for this history in the record." T.29. Again, this is a mischaracterization of the record. For instance, LMSW Erin Carlson indicated that "collateral contacts" confirmed that Plaintiff had a "long history of depression and acting out behaviors. She was in and out of foster care and residential placements since the age of four. When she was older she was kicked out of several residential placements due to physical aggression and running away behaviors." T.276. If the ALJ felt this was inadequate, he could have, and should have, developed the record by requesting mental health records from Plaintiff's childhood and adolescence.
In sum, although the ALJ provided "specific" reasons for discounting Plaintiff's credibility, the Court cannot find that they were "legitimate" reasons because they are based on a misconstruction of the record.
The ALJ also improperly relied on the so-called "sit and squirm" test to find that Plaintiff's subjective complaints of pain when sitting, T.28, were less than credible.
Although the ALJ has the discretion to weigh Plaintiff's testimony and other evidence in the record, his failure to consider certain testimony, and his misconstruction of other testimony, warrants a remand in this case.
For the foregoing reasons, the Court finds that the Commissioner's determination was erroneous as a matter of law and was not supported by substantial evidence. Accordingly, Defendant's Motion for Judgment on the Pleadings is denied, and Plaintiff's Motion for Judgment on the Pleadings is granted to the extent that the matter is remanded for further administrative proceedings consistent with this opinion. Specifically, the ALJ is directed to consider the entire record and to refrain from selectively citing or mischaracterizing the record and to re-evaluate Plaintiff's credibility in light of the appropriate regulatory factors. Since the Court is ordering remand, and there is currently no report from any of Plaintiff's treating psychiatrists, the ALJ is directed to take this opportunity to obtain a mental residual functional capacity assessment from Plaintiff's treating psychiatrist.