MICHAEL A. TELESCA, District Judge.
Represented by counsel, Clay Primes, Jr., ("Plaintiff") brings this action pursuant to Titles II and XVI of the Social Security Act, challenging the final decision of the Commissioner of Social Security ("the Commissioner") denying his application for Disability Insurance Benefits ("DIB") and 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 consistent with this opinion.
On April 26, 2012, Plaintiff filed applications for DIB and SSI.
The parties have cross-moved for judgment on the pleadings pursuant to Rule 12(c) of the Federal Rules of Civil Procedure. In connection with their motions, the parties have comprehensively summarized the administrative transcript in their briefs, and the Court adopts and incorporates these factual summaries by reference. The record evidence will be discussed in further detail below, as necessary to the resolution of the parties' contentions. For the reasons that follow, the Court reverses the Commissioner's decision and remands the matter for further administrative proceedings consistent with this opinion.
When considering a claimant's challenge to the decision of the Commissioner denying benefits under the Act, a district court must accept the Commissioner's findings of fact, provided that such findings are supported by "substantial evidence" in the record.
The ALJ followed the five-step sequential evaluation promulgated by the Commissioner for adjudicating disability claims.
At step one, the ALJ found that Plaintiff had not engaged in substantial gainful activity since the alleged onset date. T.20. At step two, the ALJ found that Plaintiff had the following "severe" impairments: history of chronic heart failure, lumbar stenosis, sciatica, migraine headaches, and depression. T.20. At step three, the ALJ specifically considered Listings 1.04 (disorders of the spine), 4.02 and 4.00D2 (chronic heart failure while on a regimen of prescribed treatment), and 12.04 (affective disorders), and determined that Plaintiff's impairments, either singly or in combination, did not meet or equal any listed impairment.
The ALJ then assessed Plaintiff as having the residual functional capacity ("RFC") to perform the full range of light work, with the exception that he is limited to only simple tasks and only occasional interaction with coworkers and the general public.
At step four, the ALJ found that Plaintiff could not perform his past relevant work as an automotive detailer. T.26.
At step five, the ALJ found that Plaintiff was a "younger individual," with a limited education and the ability to communicate in English. Considering Plaintiff's age, experience, and RFC, and relying on the VE's testimony, the ALJ found that Plaintiff could perform other jobs that exist in significant numbers in the national economy, such as housekeeper/cleaner and agricultural produce sorter. T.27-28. Therefore, the ALJ entered a finding of "not disabled." T.28.
Plaintiff urges that remand is required because the ALJ mischaracterized the record and applied the incorrect legal standard when analyzing the credibility of his subjective complaints of pain and other limitations resulting from his impairments. The Court agrees, as discussed further below.
The Commissioner's regulations require an ALJ to consider "all of the available evidence" concerning a claimant's complaints of pain when such complaints are accompanied by "medical signs and laboratory findings . . . which could reasonably be expected to produce the pain or other symptoms alleged and which, when considered with all of the other evidence . . ., would lead to a conclusion that [he] [is] disabled." 20 C.F.R. §§ 404.1529(a), 416.929(a). ALJ must follow the two-step process set forth in the regulations for evaluating a claimant's symptoms such as pain, fatigue, shortness of breath, weakness, or nervousness.
If a claimant's statements about his or her symptoms are not substantiated by the objective medical evidence, the ALJ must make a finding as to the claimant's credibility, SSR 96-7p, 1996 WL 374186, at *4, paying particular attention to the following regulatory factors: (1) the claimant's daily activities; (2) the location, duration, frequency, and intensity of the claimant's pain or other symptoms; (3) precipitating and aggravating factors; (4) the type, dosage, effectiveness, and side effects of any medications; (5) treatment modalities, other than medication, for relief of the claimant's pain or other symptoms; (6) any measures used to relieve pain or other symptoms; and (7) other factors concerning the claimant's functional limitations and restrictions due to pain or other symptoms. 20 C.F.R. §§ 404.1529(c)(3), 416.929(c)(3). The ALJ's decision "must contain specific reasons for the finding on credibility, supported by the evidence in the case record, and must be sufficiently specific to make clear to the individual and to any subsequent reviewers the weight the [ALJ] gave to the individual's statements and the reasons for that weight." SSR 96-7p, 1996 WL 374186, at *2. While it is "not sufficient for the [ALJ] to make a single, conclusory statement" that the claimant is not credible or to recite the relevant factors, without analysis,
Here, the ALJ concluded that Plaintiff's medical impairments reasonably could be expected to cause the symptoms he alleged. T.23. However, the ALJ found that Plaintiff's statements regarding the intensity, persistence, and limiting effects of the symptoms were "not entirely credible for the reasons explained in [the] decision." T.23. The ALJ then proceeded to summarize the medical evidence and Plaintiff's testimony and other statements. Interspersed in this recitation are comments about Plaintiff's credibility.
As an initial matter, the ALJ "never set[ ] forth which of [P]laintiff's medical impairments he considered in determining whether those conditions could reasonably be expected to produce the debilitating pain of which [P]laintiff complains."
Plaintiff also raises a challenge to comments the ALJ made in his assessment of consultative physician Dr. Harbinder Toor's report dated August 6, 2012. On examination, Dr. Toor observed that Plaintiff appeared to be "in moderate pain" and walked with an "abnormal" gait, "slightly limping toward the left side with and without a cane." T.267. Dr. Toor observed a limited range of motion in Plaintiff's cervical and lumbar spine. He opined that Plaintiff has "moderate to severe" limitations in standing, walking, bending, and lifting; moderate limitations in sitting for long periods; and that "[p]ain interferes with his physical routine." T.269. The ALJ assigned Dr. Toor's opinion only "some" weight, noting that (1) Plaintiff "declined to lie down on the examining table" and (2) it was "unusual" for Dr. Toor to have found no muscle atrophy, "given the limitations the claimant alleges." T.24. With regard to Plaintiff declining to lie down on the examining table during the examination with Dr. Toor, the implication is that Plaintiff was exaggerating his pain, which led to Dr. Toor overstating the degree of functional limitations he has. However, Plaintiff's "alleged poor effort on testing with consultative examiners is consistent with [P]laintiff's treating physicians' repeated diagnoses of pain in the tested regions."
With respect to the ALJ's observation that it was "unusual" for Dr. Toor to have found no muscle atrophy, "given the limitations the claimant alleges[,]" T.24, this amounts to the ALJ impermissibly relying on his own lay opinion to fill perceived gaps in the evidentiary record.
The ALJ then stated, in his discussion of Plaintiff's back injury, that "[s]trength in both his lower extremities is within normal limits, his reflexes are intact and normal and sensations are intact in both lower extremities (internal citations omitted). Given that the claimant's strength in his lower extremities is within normal limits, it is reasonable to assume that the claimant walks a reasonable amount during the day." T.26 (emphasis supplied). However, "[t]his assessment is the result of a hunch and an ALJ may not rely on a hunch."
The ALJ repeated this error when he opined that Plaintiff "has not generally received the type of medical treatment one would expect from a totally disabled individual[.]" T.26. The ALJ identified no medical expert who opined that Plaintiff's medical treatment was atypical for a person who is disabled. Thus, the ALJ again improperly relied on his own lay opinion. Furthermore, the ALJ mischaracterized the record in his attempt to support this statement. In particular, he asserted that Plaintiff "did not complete physical therapy, and is not currently in physical therapy." T.26. Not only does this misrepresent the record regarding his attendance at physical therapy appointments, it omits any mention of the pain management and surgical consults Plaintiff underwent. With regard to physical therapy, orthopedist M. Gordon Whitbeck, M.D. indicated in February of 2014, that Plaintiff "was recommended to undergo a course of physical therapy which he has completed." T.347. This is consistent with the November 18, 2013, note from Dr. Ajai K. Nemani, a pain management specialist to whom Plaintiff was referred by Dr. Whitbeck, noting that Plaintiff had recently started a course of physical therapy. T.339. Along with the physical therapy, Plaintiff received a course of steroid epidural injections from Dr. Nemani, but reported they did not help.
Next, the ALJ also found that Plaintiff's subjective complaints are negated by certain of his activities. In particular, the ALJ relied on Plaintiff's testimony that he climbs up thirty to forty stairs a day. As noted above, the ALJ omitted mention of Plaintiff's later testimony that he avoided leaving the house in order to avoid having to climb stairs. The ALJ likewise did not explain how this stair-climbing is the equivalent of the ability to perform the exertional and nonexertional demands of light work on a "regular and continuing basis," i.e., "8 hours a day, for 5 days a week, or an equivalent work schedule[,]" SSR 96-8p, 1996 WL 374184, at *2.
The ALJ also found Plaintiff's complaints of pain less credible because his testimony revealed he attempted to shovel snow on one occasion during the previous winter. T.26. Although the ALJ did not ignore Plaintiff's qualifying comment that he was bedridden "for a week" after this activity, the ALJ nevertheless disregarded that testimony because the "treatment notes do not include mention of it," T.26, i.e., Plaintiff being confined to bed after this incident. It is improper for an ALJ to draw an adverse credibility inference based on a claimant's failure to seek, or noncompliance with, treatment "without first considering any explanations that the individual may provide, or other information in the case record that may explain infrequent or irregular medical visits or failure to seek medical treatment." SSR 96-7p, 1996 WL 374186, at *7. Despite having the opportunity to do so at the hearing, the ALJ failed to inquire into any possible reasons why Plaintiff did not seek medical treatment for the exacerbation of his back injury caused by his unsuccessful attempt to shovel snow. The Court notes that a January 2013, treatment note from neurologist Lawrence Samkoff, M.D., indicates that Plaintiff would be referred to his primary care physician for an appropriate prescription "as [Plaintiff] does not currently have insurance coverage." T.336. Not having health insurance "certainly provides an explanation for failing to seek treatment."
In sum, the ALJ committed legal error in analyzing Plaintiff's subjective complaints. Additionally, the ALJ relied on mischaracterizations of the record to justify his discounting of Plaintiff's testimony, which means that the ALJ's credibility assessment is not supported by substantial evidence.
For the foregoing reasons, the Commissioner's motion for judgment on the pleadings is denied. Plaintiff's motion for judgment on the pleadings is granted. The Commissioner's decision is reversed, and the matter is remanded for further administrative proceedings consistent with this Decision and Order. In particular, the ALJ is directed to consider the entire record and to re-evaluate Plaintiff's credibility in light of the appropriate regulatory factors, caselaw, and SSR 96-7p. The ALJ also is directed to obtain Plaintiff's treatment records from neurologist Dr. Pardee, to whom Dr. Whitbeck referred Plaintiff for testing, and who was mentioned in the records from Dr. Whitbeck which were submitted to the Appeals Council.