Eileen S. Willett, United States Magistrate Judge
Pending before the Court is Terri Bowers-Crawford's ("Plaintiff") appeal of the Social Security Administration's ("Social Security") denial of her application for disability insurance benefits. The Court has jurisdiction to decide Plaintiff's appeal pursuant to 42 U.S.C. § 405(g). Under 42 U.S.C. § 405(g), the Court has the power to enter, based upon the pleadings and transcript of the record, a judgment affirming, modifying, or reversing the decision of the Commissioner of Social Security, with or without remanding the case for a rehearing. Both parties have consented to the exercise of U.S. Magistrate Judge jurisdiction. (Doc. 13).
After reviewing the Administrative Record ("A.R.") and the parties' briefing (Docs. 16, 17, 18), the Court finds that the Administrative Law Judge's ("ALJ") decision contains harmful legal error. For the reasons explained herein, the decision is reversed and the case is remanded to the Commissioner of Social Security for an immediate award of benefits.
The Social Security Act (the "Act") provides for disability insurance benefits to those who have contributed to the Social Security program and who suffer from a physical or mental disability. 42 U.S.C. § 423(a)(1). To be eligible for benefits based on an alleged disability, the claimant must show that he or she suffers from a medically determinable physical or mental impairment that prohibits him or her from engaging in any substantial gainful activity. 42 U.S.C. § 423(d)(1)(A). The claimant must also show that the impairment is expected to cause death or last for a continuous period of at least 12 months. Id.
To decide if a claimant is entitled to Social Security benefits, an ALJ conducts an analysis consisting of five questions, which are considered in sequential steps. 20 C.F.R. § 404.1520(a). The claimant has the burden of proof regarding the first four steps:
If the analysis proceeds to the final question, the burden of proof shifts to the Commissioner:
The Court must affirm an ALJ's decision if it is supported by substantial evidence and is based on correct legal standards. Molina v. Astrue, 674 F.3d 1104, 1110 (9th Cir. 2012); Marcia v. Sullivan, 900 F.2d 172, 174 (9th Cir. 1990). "Substantial evidence" is less than a preponderance, but more than a "mere scintilla." Richardson v. Perales, 402 U.S. 389, 401, 91 S.Ct. 1420, 28 L.Ed.2d 842 (1971) (quoting Consolidated Edison v. NLRB, 305 U.S. 197, 229, 59 S.Ct. 206, 83 S.Ct. 126 (1938)). It is "such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Id.
In determining whether substantial evidence supports the ALJ's decision, the Court considers the record as a whole, weighing both the evidence that supports and detracts from the ALJ's conclusions. Reddick v. Chater, 157 F.3d 715, 720 (9th Cir. 1998); Tylitzki v. Shalala, 999 F.2d 1411, 1413 (9th Cir. 1993). If there is sufficient evidence to support the ALJ's determination, the Court cannot substitute its own determination. See Morgan v. Comm'r of the Social Sec. Admin., 169 F.3d 595, 599 (9th Cir. 1999) ("Where the evidence is susceptible to more than one rational interpretation, it is the ALJ's conclusion that must be upheld."); Magallanes v. Bowen, 881 F.2d 747, 750 (9th Cir. 1989). The ALJ, not the Court, is responsible for resolving conflicts and ambiguities in the evidence and determining credibility. Magallanes, 881 F.2d at 750; see also Andrews v. Shalala, 53 F.3d 1035, 1039 (9th Cir. 1995).
Finally, the Court considers the harmless error doctrine when reviewing an ALJ's decision. An ALJ's decision need not be remanded or reversed if it is clear from the record that the error is "inconsequential to the ultimate nondisability determination." Tommasetti v. Astrue, 533 F.3d 1035, 1038 (9th Cir. 2008) (citations omitted); Molina, 674 F.3d at 1115 (an error is harmless so long as there remains substantial evidence supporting the ALJ's decision and the error "does not negate the validity of the ALJ's ultimate conclusion") (citations omitted).
Plaintiff, who was born in 1967, has been employed as a hospital admitting clerk and accounting clerk. (A.R. 98-99, 106). In 2012, Plaintiff filed an application for disability insurance benefits. (A.R. 174-75).
In his March 25, 2015 decision, the ALJ found that Plaintiff is not disabled within the meaning of the Social Security Act. (A.R. 61-74). The Appeals Council denied Plaintiff's request for review, making the ALJ's decision the final decision of the Social Security Commissioner. (A.R. 1-7, 55-56). On September 1, 2016, Plaintiff filed a Complaint (Doc. 1) requesting judicial review and reversal of the ALJ's decision.
The ALJ determined that Plaintiff has not engaged in substantial gainful activity since May 11, 2012, the alleged disability onset date. (A.R. 63). Neither party disputes this determination.
The ALJ found that Plaintiff has the following severe impairments: (i) status-post right lung surgery; (ii) migraine headaches; and (iii) history of non-specific versus pseudo seizures. (A.R. 63). This determination is undisputed.
The ALJ determined that Plaintiff does not have an impairment or combination of impairments that meets or medically equals an impairment listed in 20 C.F.R. Part 404, Subpart P, Appendix 1 of the Social Security regulations. (A.R. 64). Neither party challenges the ALJ's determination at this step.
The ALJ found that Plaintiff retained the residual functional capacity ("RFC") to perform sedentary work as defined in 20 C.F.R. § 404.1567(a), except that
(A.R. 64-65). Based on the assessed RFC and the testimony of the Vocational Expert ("VE"), the ALJ concluded that Plaintiff is capable of performing her past relevant work as a hospital admitting clerk and accounting clerk. (A.R. 73). Plaintiff disputes this determination, asserting that the ALJ improperly weighed the opinions of her treating physician and improperly discounted her testimony regarding her symptoms. (Doc. 16 at 13-22).
Given the conclusion at Step Four that Plaintiff could perform her past relevant work, the ALJ did not reach Step Five of the disability analysis.
In weighing medical source opinions in Social Security cases, there are three categories of physicians: (i) treating physicians, who actually treat the claimant; (2) examining physicians, who examine but do not treat the claimant; and (3) non-examining physicians, who neither treat nor examine the claimant. Lester v. Chater, 81 F.3d 821, 830 (9th Cir. 1995). An ALJ must provide clear and convincing reasons that are supported by substantial evidence for rejecting the uncontradicted opinion of a treating or examining doctor. Id. at 830-31; Bayliss v. Barnhart, 427 F.3d 1211, 1216 (9th Cir. 2005). An ALJ cannot reject a treating or examining physician's opinion in favor of another physician's opinion without first providing specific and legitimate reasons that are supported by substantial evidence. Bayliss, 427 F.3d at 1216; 20 C.F.R. § 404.1527(c)(4) (an ALJ must consider whether an opinion is consistent with the record as a whole); Thomas v. Barnhart, 278 F.3d 947, 957 (9th Cir. 2002); Tommasetti, 533 F.3d at 1041 (finding it not improper for an ALJ to reject a treating physician's opinion that is inconsistent with the record).
The ALJ reviewed records from Plaintiff's treating physician, Scot Fechtel, M.D. On December 10, 2012, Dr. Fechtel completed a disability form in which Dr. Fechtel opined that "while [Plaintiff's] treatment is ongoing the frequency and intensity of her migraine coupled with the threat of seizure makes it unlikely that she will be able to return to work even in a sedentary capacity." (A.R. 190). On June 4, 2014, Dr. Fechtel completed a Headache Questionnaire in which he stated that Plaintiff has "medically intractable chronic migraines" and indicated that Plaintiff's condition would last at least twelve months. (A.R. 555-56). Dr. Fechtel indicated that Plaintiff would generally be precluded from performing "even basic work" activities during the times she has a headache. (A.R. 556). Dr. Fechtel indicated on the form that Plaintiff has had "minimal response to multiple treatment trials" and opined that Plaintiff would miss work more than three times a month. (Id.).
The ALJ gave Dr. Fechtel's opinions little weight. (A.R. 71). Because Dr. Fechtel's opinions are contradicted by other acceptable medical sources,
In explaining why Dr. Fechtel's opinions were discounted, the ALJ stated "First, the headache form was completed eight months after the claimant's last appointment with Dr. Fechtel. Though the claimant testified that she saw him monthly, there is no documentary evidence in the record that she saw Dr. Fechtel after October 2013...." (A.R. 71). The record, however, reflects that Plaintiff saw Dr. Fechtel a number of times after October 2013.
The ALJ's second reason for discounting Dr. Fechtel's opinions is as follows:
(A.R. 72). The Court finds that the ALJ's statements above mischaracterize the record. Dr. Fechtel did not opine on the December 2012 disability form that Plaintiff had limitations relating to her gait or posture. Dr. Fechtel opined that Plaintiff's "migraines coupled with the threat of seizure makes it unlikely that she will be able to return to work even in a sedentary capacity." (A.R. 190). This opinion is also reflected in Dr. Fechtel's December 2012 treatment note in which Dr. Fechtel states: "Plaintiff has not been able to return [to work] due to a combination of intractable migraine which has not subsided since surgery and her seizures." (A.R. 476). The Court does not find that the notation in Dr. Fechtel's December 10, 2012 treatment record that Plaintiff had a normal gait and posture contradicts his opinion that Plaintiff is unable to perform even sedentary work as a result of migraines and possible seizures. The Court finds that Dr. Fechtel's opinions expressed in the December 2012 disability form are consistent with Dr. Fechtel's examination notes. The ALJ's second reason for discounting Dr. Fechtel's opinions is invalid.
The ALJ also stated that the limitations expressed in the December 2012 disability form were "far more extreme than the claimant's self-reports as to her activities (6E, 7E, and 8E)." (A.R. 71). The ALJ does not explain the reasons for reaching this conclusion. The Ninth Circuit has instructed that a court "cannot substitute [the court's] conclusions for the ALJ's, or speculate as to the grounds for the ALJ's conclusions. Although the ALJ's analysis need not be extensive, the ALJ must provide some reasoning in order for [the court] to meaningfully determine whether the ALJ's conclusions were supported by substantial evidence." Brown-Hunter v. Colvin, 806 F.3d 487, 495 (9th Cir. 2015) (internal quotations marks and citation omitted). Moreover, although Plaintiff stated that she could stand/walk for 1.5 hours and sit for three to four hours before pain occurs, Plaintiff reported that she is "in bed most all of the day, and unable to sleep most nights" as her "migraines cause vomiting and nausea, and prevent sleep." (A.R. 220, 227). Plaintiff also reported that while she "occasionally" does the laundry, her husband cares for her children and does "all of the cooking, cleaning, shopping and school-related duties" because her condition has worsened. (A.R. 224). The Court does not find that the ALJ's conclusion that Dr. Fechtel's opinions regarding Plaintiff's limitations are "far more extreme" than Plaintiff's reported limitations is based on substantial evidence in the record.
The ALJ also discounted Dr. Fechtel's opinions on the basis that the "opinions are quite conclusory, providing very little explanation of the evidence relied on [in] their formation." (A.R. 72). However, the opinions in the 2014 Headache Questionnaire and December 2012 disability form are supported by Dr. Fechtel's examination notes. As the Ninth Circuit has explained, "the treating physician's opinion as to the combined impact of the claimant's limitations — both physical and mental — is entitled to special weight." Lester, 81 F.3d at 833. "The treating physician's continuing relationship with the claimant makes him especially qualified to evaluate reports from examining doctors, to integrate the medical information they provide, and to form an overall conclusion as to functional capacities and limitations, as well as to prescribe or approve the overall course of treatment." Id. The Court finds that based on the record, the ALJ improperly rejected Dr. Fechtel's opinions on the ground that the opinions are "conclusory." See Garrison v. Colvin, 759 F.3d 995, 1013 (9th Cir. 2014) (finding that an
For the above reasons, the Court finds that the ALJ discounted Dr. Fechtel's opinions without providing specific and legitimate reasons that are supported by substantial evidence in the record.
Ninth Circuit jurisprudence "requires remand for further proceedings in all but the rarest cases." Treichler v. Comm'r of Soc. Sec. Admin., 775 F.3d 1090, 1101 n.5 (9th Cir. 2014). The Ninth Circuit, however, has adopted a test to determine when a case should be remanded for payment of benefits in cases where an ALJ has improperly rejected claimant testimony or medical opinion evidence. Id. at 1100-01; Garrison, 759 F.3d at 1020. This test is commonly referred to as the "credit-as-true" rule, which consists of the following three factors:
Where a court has found that a claimant has failed to satisfy one of the factors of the credit-as-true rule, the court does not need to address the remaining factors. Treichler, 775 F.3d at 1107 (declining to address final step of the rule after determining that the claimant has failed to satisfy the second step). Moreover, even if all three factors are met, a court retains the discretion to remand a case for additional evidence or to award benefits. Id. at 1101-02. A court may remand for further proceedings "when the record as a whole creates serious doubt as to whether the claimant is, in fact, disabled within the meaning of the Social Security Act." Garrison, 759 F.3d at 1021. In Treichler, the Ninth Circuit noted that "[w]here an ALJ makes a legal error, but the record is uncertain and ambiguous, the proper approach is to remand the case to the agency." 775 F.3d at 1105.
After examining the record, the Court finds no outstanding issues of fact to be resolved through further proceedings. Dr. Fechtel opined that Plaintiff would miss more than three days of work each
Based on the foregoing,
