ANNA J. BROWN, District Judge.
Plaintiff Jeffrey L. Anderson seeks judicial review of a final decision of the Commissioner of the Social Security Administration (SSA) in which she denied Plaintiff's applications for Disability Insurance Benefits (DIB) and Supplemental Security Income (SSI) under Titles II and XVI of the Social Security Act. This Court has jurisdiction to review the Commissioner's final decision pursuant to 42 U.S.C. § 405(g).
Following a review of the record, the Court reverses the decision of the Commissioner and remands this matter pursuant to Sentence Four, 42 U.S.C. § 405(g), for the immediate calculation and payment of benefits to Plaintiff.
Plaintiff protectively filed his applications on August 8, 2011, and alleged a disability onset date of June 29, 2009. Tr. 198-201, 229, 240.
The ALJ issued a decision on September 11, 2013, in which he found Plaintiff is not disabled. Tr. 14-38. That decision became the final decision of the Commissioner on May 14, 2015, when the Appeals Council denied Plaintiff's request for review. Tr. 1-4. See Sims v. Apfel, 530 U.S. 103, 106-07 (2000).
On July 16, 2015, Plaintiff filed a Complaint in this Court seeking review of the Commissioner's decision.
Plaintiff was born in August 1961 and was 49 years old on his alleged onset date. He completed four or more years of college and has a degree as a registered nurse. Tr. 241, 968. Plaintiff has a radiology limited license and certifications as a nursing assistant, medical assistant, and paramedic. Tr. 241, 968. Plaintiff has past relevant work experience as a registered nurse at an adult corrections facility from 1996 to 2009. Tr. 232.
Plaintiff alleges disability due to "bipolar, adjustment disorder, PTSD, chronic knee pain, left meralgia prasthica, left ulnar neuropathy, left pre-op trigger finger, chronic left shoulder impingement, L4-5 disc compression, high bp." Tr. 240.
The initial burden of proof rests on the claimant to establish disability. Molina v. Astrue, 674 F.3d 1104, 1110 (9
The district court must affirm the Commissioner's decision if it is based on proper legal standards and the findings are supported by substantial evidence in the record as a whole. 42 U.S.C. § 405(g). See also Brewes v. Comm'r of Soc. Sec. Admin., 682 F.3d 1157, 1161 (9
The ALJ is responsible for determining credibility, resolving conflicts in the medical evidence, and resolving ambiguities. Vasquez v. Astrue, 572 F.3d 586, 591 (9
At Step One the claimant is not disabled if the Commissioner determines the claimant is engaged in substantial gainful activity. 20 C.F.R. §§ 404.1520(a)(4)(I), 416.920(a)(4)(I). See also Keyser v. Comm'r of Soc. Sec., 648 F.3d 721, 724 (9
At Step Two the claimant is not disabled if the Commissioner determines the claimant does not have any medically severe impairment or combination of impairments. 20 C.F.R. §§ 404.1520(a)(4)(ii), 416.920(a)(4)(ii). See also Keyser, 648 F.3d at 724.
At Step Three the claimant is disabled if the Commissioner determines the claimant's impairments meet or equal one of the listed impairments that the Commissioner acknowledges are so severe as to preclude substantial gainful activity. 20 C.F.R. §§ 404.1520(a)(4)(iii), 416.920(a)(4)(iii). See also Keyser, 648 F.3d at 724. The criteria for the listed impairments, known as Listings, are enumerated in 20 C.F.R. part 404, subpart P, appendix 1 (Listed Impairments).
If the Commissioner proceeds beyond Step Three, she must assess the claimant's residual functional capacity (RFC). The claimant's RFC is an assessment of the sustained, work-related physical and mental activities the claimant can still do on a regular and continuing basis despite his limitations. 20 C.F.R. §§ 404.1520(e), 416.920(e). See also Social Security Ruling (SSR) 96-8p. "A `regular and continuing basis' means 8 hours a day, for 5 days a week, or an equivalent schedule." SSR 96-8p, at *1. In other words, the Social Security Act does not require complete incapacity to be disabled. Taylor v. Comm'r of Soc. Sec. Admin., 659 F.3d 1228, 1234-35 (9
At Step Four the claimant is not disabled if the Commissioner determines the claimant retains the RFC to perform work he has done in the past. 20 C.F.R. §§ 404.1520(a)(4)(iv), 416.920(a)(4)(iv). See also Keyser, 648 F.3d at 724.
If the Commissioner reaches Step Five, she must determine whether the claimant is able to do any other work that exists in the national economy. 20 C.F.R. §§ 404.1520(a)(4)(v), 416.920(a)(4)(v). See also Keyser, 648 F.3d at 724-25. Here the burden shifts to the Commissioner to show a significant number of jobs exist in the national economy that the claimant can perform. Lockwood v. Comm'r Soc. Sec. Admin., 616 F.3d 1068, 1071 (9
At Step One the ALJ found Plaintiff has not engaged in substantial gainful activity (SGA) since his June 29, 2009, alleged onset date. Tr. 19. The ALJ found Plaintiff met the insured status requirements through December 31, 2014.
At Step Two the ALJ found Plaintiff has severe impairments including left ulnar neuropathy, status post bilateral meniscus tear, status post shoulder arthroscopy, left pinky trigger finger, diabetes mellitus, degenerative disc disease, obstructive sleep apnea, bipolar disorder, post-traumatic stress disorder, and personality disorder. Tr. 19.
At Step Three the ALJ found Plaintiff's impairments do not meet or equal any listed impairment. Tr. 20. The ALJ found Plaintiff has the RFC for light work, except he can occasionally climb, kneel, crouch, and crawl. The claimant can perform only occasional bilateral overhead lifting and simple, routine tasks consistent with a specific vocational preparation level of one or two. The claimant does not require over-the-shoulder supervision. He can have occasional contact with co-workers but not any contact with the public. Tr. 22.
At Step Four the ALJ found Plaintiff is unable to perform any past relevant work. Tr. 31.
At Step Five the ALJ found Plaintiff is able to perform the occupations of pricer, car-lot attendant, and office cleaner. Tr. 32.
Plaintiff contends the ALJ erred by (1) failing to act fairly at the administrative hearing, (2) improperly weighing the medical evidence, and (3) failing to formulate an appropriate RFC assessment.
Plaintiff contends the ALJ erred by failing to develop the record fully and by failing to ensure Plaintiff's interests were fairly protected. He argues the ALJ should have provided him with the opportunity to qualify a friend as his representative at the hearing and should have advised him that the necessary form could be obtained in the adjacent office. Plaintiff also contends the ALJ erred by failing to advise him that his friend could testify on his behalf.
Plaintiff fired his lawyer, Todd Hammond, before the August 2013 hearing. Tr. 41. He was not represented by counsel at the hearing before the ALJ. Plaintiff brought a friend to the hearing and sought to have the friend represent him "because he is the only person I can trust." Tr. 41. Plaintiff thought he had completed the paperwork necessary to appoint his friend to be his representative, but he had not. Tr. 42. The ALJ told Plaintiff that "anybody can be a rep if they go through the process, but they can't just pop in here." Tr. 42. The discussion between Plaintiff and the ALJ continued as follows:
Tr. 42-43.
Thereafter the ALJ described the hearing process and questioned Plaintiff, a medical specialist, and the VE.
Plaintiff argues the ALJ erred by failing to advise Plaintiff that he could "qualify" his friend as his Representative by completing a form or an equivalent written statement. HALLEX I-1-1-11.A.
On this record the Court concludes the fact that the ALJ did not offer Plaintiff further information or an opportunity to complete the necessary paperwork to qualify his friend to be his representative did not violate the ALJ's duty to develop the record and to protect the claimant's interests.
Plaintiff cross-examined the VE and delivered a summary at the end of the hearing. Tr. 87-92. In the course of his summary Plaintiff stated he "felt I had a representative that could at least testify to my medical abilities that I had when I had them, and what I've been doing since then. . . ." Tr. 91. Plaintiff contends the ALJ erred by failing to develop the record when he did not tell Plaintiff that his friend could be called to testify.
The ALJ's duty to develop the record is "triggered only when there is ambiguous evidence or when the record is inadequate to allow for proper evaluation of the evidence." Mayes v. Massanari, 276 F.3d 453, 459-60 (9th Cir. 2001). In this case the ALJ had more than 1200 pages of medical records, Plaintiff's testimony, and the testimony of the medical expert. The record, therefore, was not "inadequate to allow for proper evaluation of the evidence." Moreover, Plaintiff does not point to any ambiguity in the evidence.
On this record the Court concludes the ALJ did not err when he did not advise Plaintiff that he could call his friend to testify.
Plaintiff contends the ALJ asked the medical expert, Sally Clayton, L.C.P., leading questions to obtain the "`non-disabling' functional limitations desired." Pl.'s Br. at 8.
To succeed in a claim "that the ALJ did not impartially assess the evidence . . . [a claimant] must show that the ALJ's behavior, in the context of the whole case, was so extreme as to display clear inability to render fair judgment." Bayliss v. Barnhart, 427 F.3d 1211, 1214-15 (9th Cir. 2005)(internal quotations omitted)(quoting Rollins v. Massanari, 261 F.3d 853, 858 (9th Cir. 2001)). This Court "must begin with a presumption that the ALJ was unbiased," which can only be rebutted "by showing a `conflict of interest or some other specific reason for disqualification.'" Id.
The Court notes Plaintiff has not identified a conflict of interest or any other specific reason to disqualify the ALJ, and the record does not reflect evidence of bias on the part of the ALJ. On this record the Court concludes the ALJ did not err by asking leading questions of the medical expert.
In summary, the Court concludes for these reasons the ALJ did not act unfairly at the administrative hearing.
Plaintiff contends the ALJ erred by improperly weighing the medical evidence.
Disability opinions are reserved for the Commissioner. 20 C.F.R. §§ 404.1527(e)(1); 416.927(e)(1). If there is not a conflict between medical source opinions, the ALJ generally must accord greater weight to the opinion of a treating physician than that of an examining physician. Lester, 81 F.3d at 830. More weight is given to the opinion of a treating physician because the person has a greater opportunity to know and to observe the patient as an individual. Orn v. Astrue, 495 F.3d 625, 632 (9
Even if one physician is contradicted by another physician, the ALJ may not reject the opinion without providing specific and legitimate reasons supported by substantial evidence in the record. Orn, 495 F.3d at 632; Widmark, 454 F.3d at 1066. The opinion of a nonexamining physician by itself is insufficient to constitute substantial evidence to reject the opinion of a treating or examining physician. Widmark, 454 F.3d at 1066 n.2. The ALJ may reject physician opinions that are "brief, conclusory, and inadequately supported by clinical findings." Bayliss v. Barnhart, 427 F.3d 1211, 1216 (9th Cir. 2005).
Dr. Chandagiri, a psychiatrist at the Veterans Affairs Medical Center, began treating Plaintiff in September 2012. On July 22, 2013, Dr. Chandagiri conducted a disability evaluation "to record the extent of impairment and disability due to [Plaintiff's] various mental health conditions that resulted in [Plaintiff's] inability to hold a job since June 1, 2009." Tr. 1434. Dr. Chandagiri noted Plaintiff was alert and oriented with impaired memory. Plaintiff also had a Saint Louis University Mental Status Examination (SLUMS) score of 26, which indicated mild cognitive disorder. Tr. 1435. Dr. Chandagiri found Plaintiff has pressured speech, is easily distracted, and exhibits a stable but anxious mood. Dr. Chandagiri opined Plaintiff "remains very severely disabled for complex medical and psychiatric reasons and will not be able to hold any gainful employment in any capacity permanently." Tr. 1435. Dr. Chandagiri also opined Plaintiff's disability is likely to last for more than 12 months and has existed for the last several years, and he noted Plaintiff had been treated in the clinic since 2002.
Dr. Chandagiri stated Plaintiff has been diagnosed with PTSD, Bipolar disorder type 1 recurrent recent episode manic or mixed, Personality disorder NOS, Cognitive disorder NOS, past head injuries, obstructive sleep apnea, chronic pain, and knee injury. He found Plaintiff's conditions "interfere with his ability to perform basic activities of daily living that are essential to any work place." Tr. 1436. Dr. Chandagiri administered the PCL C test for PTSD on which Plaintiff scored 69, "thus indicating high levels of ongoing symptoms of PTSD." Tr. 1436. Dr. Chandagiri also administered the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) on which Plaintiff scored 134 indicating "full disability." Tr. 1436.
Dr. Chandagiri reported Plaintiff's
Tr. 1436.
Dr. Chandagiri stated Plaintiff cannot sit still for over 30 minutes without becoming agitated unless he is at home. He avoids new places and crowds and cannot stand for long periods in a public place. He cannot walk more than one-half mile and does not even go out to meet his daughter.
Dr. Chandagiri noted Plaintiff's symptoms cause social isolation from friends, family, and former colleagues. Plaintiff avoids conversations with strangers. Dr. Chandagiri stated
Tr. 1437.
Dr. Chandagiri opined Plaintiff's limitations satisfy the criteria of a Social Security Listed Impairment with demonstrated loss of cognitive functioning, affective lability, mood changes, personality changes, thinking errors, and memory problems. He found Plaintiff has persistent difficulties in activities of daily living and repeated that Plaintiff was permanently disabled and unable to work in any full-time work or work-like setting. Tr. 1438.
The ALJ noted Dr. Chandagiri's opinion and stated it "is not given great weight." Tr. 30. The ALJ found Dr. Chandagiri's conclusion unpersuasive "because it does not address the claimant's specific functional abilities, but is a conclusion regarding the ultimate issue of disability, which is expressly reserved to the Commissioner." Tr. 29-30. The ALJ stated:
Tr. 30.
To support his opinion that Plaintiff is not disabled, the ALJ relies on multiple records documenting unremarkable mental-status examinations. Some of those records, however, are not mental-health examinations, but rather reflect examinations by providers and emergency-room personnel for Plaintiff's knee and back impairments. See Tr. 308, 412, 420, 425, 431, 433-34, 444, 514, 517, 520, 578, 593-94, 596, 599, 690, 743, 758, 761, 763, 801, 809. Several of the ALJ's citations also refer to duplicates of records previously cited. See Tr. 1062, 1150, 1163, 1166, 1169, 1269.
The ALJ points to Plaintiff's mental-health outpatient counseling notes from November and December 2009 and November 2010 in which Plaintiff reported continued difficulty in regulating his mood and presented with rapid speech and tangential thoughts. Tr. 483, 534. In the 2010 note Plaintiff describes experiencing anxiety and depression. Tr. 528. The ALJ also cites December 2009 and March 2011 notes from Gregory V. West, M.D., Plaintiff's primary-care physician, in which the doctor notes Plaintiff was appropriate, cooperative, and had normal insight and judgment. Tr. 458, 525-26, 822. Dr. West also found Plaintiff's PTSD screen was positive and referred him to undergo a mental-health evaluation. Tr. 525-26. The ALJ also cites a January 2011 mental-health evaluation in which Plaintiff's judgment appeared grossly intact, but the examining provider diagnosed an adjustment disorder. Tr. 783-84. In addition, the ALJ cites a December 2011 treatment note from Elizabeth Fernandez, M.D., in which she noted Plaintiff "seemed euthymic and not much pressured speech today." Tr. 1100.
The ALJ, however, also references a psycho-diagnostic examination from September 2011 in which B. Scot Cook, Psy.D., records "strong eye contact" with a rambling speaking manner and "obviously some issues with short-term and working memory as well as mathematical skills." Tr. 967. Dr. Cook diagnosed Plaintiff with Bipolar I Disorder, depressed; PTSD, and Adjustment Disorder with Anxiety. Tr. 970. He assessed Plaintiff with a GAF score of 36.
On this record the Court concludes the ALJ's discounting of the opinion of Dr. Chandagiri, Plaintiff's treating physician, on the basis of the opinions of Drs. West and Fernandez and other unidentified medical sources is not a legally sufficient reason supported by substantial evidence in the record for doing so.
The ALJ also finds Dr. Chandragiri's conclusion that Plaintiff has extreme limitations in social functioning is inconsistent with Plaintiff's level of activity and social interaction. Tr. 30.
The ALJ cited the January 2011 mental-health examination by Mark Dillon, Ph.D. Tr. 411-14. Dr. Dillon noted Plaintiff reported watching two or three television shows a day and would only watch comedies. Tr. 412. Plaintiff told Dr. Dillon that he spent his time working on his house and looking for jobs on the internet. He reported he and his fiancé go out to dinner about once a month, and he does laundry, cleaning, and work in the kitchen. He cleaned and organized the shop and the garage and added he was particularly active around the house because he was preparing it for sale. Plaintiff reported he enjoyed camping, having friends over, barbeques, and attending dinner parties. He stated "he primarily has friends from work, and has seen them less in the last year." Tr. 412. Dr. Dillon concluded Plaintiff's "social functioning has decreased at this point." Tr. 414.
The ALJ also noted Plaintiff's September 2011 report to Dr. Cook. Tr. 27. At that time Plaintiff reported a shower and breakfast routine, after which he searched for jobs online; checked his email; and performed light cooking, cleaning, laundry, dishes, and household chores. Tr. 969. Plaintiff said he refrained from tasks involving lifting, pushing, pulling, or other demanding physical chores. He no longer felt capable of hunting, fishing, or camping. "Socializing is largely limited to telephone conversations with friends. He makes some social contact via regular church attendance." Tr. 969.
household projects, and going to occasional appointments.
Tr. 969.
The ALJ noted Plaintiff exercised on a daily basis including "minor weight lifting" and walking two miles. Tr. 27. Plaintiff, however, reported in November 2012 that he walked two miles a day "depend[ing] on how bad knees are feeling)." Tr. 1515.
On this record the Court concludes the ALJ's determination that Plaintiff's activities are inconsistent with Dr. Chandragiri's opinion is not supported by substantial evidence and are not legally sufficient reasons for the ALJ to reject the opinion of Dr. Chandragiri, Plaintiff's treating physician.
In summary, the Court concludes the ALJ erred when he only gave some weight to the opinion of Plaintiff's treating physician, Dr. Chandragiri, because the ALJ did not provide legally sufficient reasons supported by substantial evidence in the record for doing so.
Dr. Kennemer reviewed Plaintiff's medical records and opined in December 2011 that Plaintiff had moderate limitations in his ability to understand, to remember, and to carry out detailed instructions; to maintain attention and concentration for extended periods; and to interact appropriately with the general public. Tr. 104-06. Dr. Henry reviewed Plaintiff's medical records in July 2012 and agreed with Dr. Kennemer. Tr. 120-21. Both psychological consultants stated Plaintiff was able to "understand, remember, and carry out short instruction (1-2 steps). [Claimant] is not able to understand, remember, and carry out more detailed instructions, so tasks should be broken down into simple task sequences." Tr. 104, 120. The consultants' opinion regarding "one to two step instructions" is uncontradicted. The ALJ gave some "weight" to the reviewing consultants. Tr. 29.
The ALJ found Plaintiff "can perform simple, routine tasks consistent with a specific vocational preparation (SVP) level of 1 or 2," but he did not adopt the limitation articulated by the reviewing consultants to "one to two step" instructions. Tr. 22. Moreover, the ALJ did not provide any specific reasons supported by substantial evidence in the record for rejecting the reviewing consultants' opinions as to Plaintiff's limitation to "one to two step" instructions.
In addition, an RFC limitation that specifically requires "one or two step instructions" is inconsistent with SVP level 2. This phrasing is "a nearly verbatim recital" of the definition of reasoning level 1. See Dictionary of Occupational Titles (DOT) App'x C (9th ed. 1991)(available at 1991 WL 688702) definition of reasoning level 1. See also Whitlock v. Astrue, Case No. 3:10-cv-357-AC, 2011 WL 3793347, at *5 (D. Or. Aug. 24, 2011).
On this record the Court concludes the ALJ erred by failing to incorporate into Plaintiff's RFC the reviewing consultants' assessment of Plaintiff as being limited to "one to two step" instructions, and, as a result, the ALJ posed an inaccurate hypothetical to the VE at Step Five.
The decision whether to remand for further proceedings or for immediate payment of benefits generally turns on the likely utility of further proceedings. Harman v. Apfel, 211 F.3d 1172, 1179 (9
The decision whether to remand this case for further proceedings or for the payment of benefits is a decision within the discretion of the court. Harman, 211 F.3d 1178.
The Ninth Circuit has established a three-part test "for determining when evidence should be credited and an immediate award of benefits directed." Harman, 211 F.3d at 1178. The court should grant an immediate award of benefits when
Id. The second and third prongs of the test often merge into a single question: Whether the ALJ would have to award benefits if the case were remanded for further proceedings. Id. at 1178 n.2.
This Court has determined the ALJ erred when he rejected the opinions of Drs. Kennemer, Henry, and Chandragiri. If credited, those opinions establish Plaintiff is disabled. Thus, the Court concludes Plaintiff is disabled based on this record and that no useful purpose would be served by a remand of this matter for further proceedings. See Harman, 211 F.3d at 117.
For these reasons, the Court
IT IS SO ORDERED.