MARGARET A. NAGLE, Magistrate Judge.
Plaintiff filed a Complaint on December 13, 2012, seeking review of the denial of plaintiff's application for a period of disability, disability insurance benefits ("DIB"), and supplemental security income ("SSI"). On January 17, 2013, the parties consented, pursuant to 28 U.S.C. § 636(c), to proceed before the undersigned United States Magistrate Judge. The parties filed a Joint Stipulation on September 9, 2013, in which: plaintiff seeks an order reversing the Commissioner's decision and remanding this case for the payment of benefits or, alternatively, for further administrative proceedings; and the Commissioner requests that her decision be affirmed or, alternatively, remanded for further administrative proceedings. The Court has taken the parties' Joint Stipulation under submission without oral argument.
Plaintiff filed an application for a period of disability, DIB, and SSI on June 29, 2009. (Administrative Record ("A.R.") 12.) Plaintiff, who was born on March 14, 1971 (A.R. 19),
After the Commissioner denied plaintiff's claim initially and upon consideration, plaintiff requested a hearing. (A.R. 12.) On June 27, 2011, plaintiff, who was represented by counsel, appeared and testified at a hearing before Administrative Law Judge William K. Mueller (the "ALJ"). (Id.) Vocational expert ("VE") Troy L. Scott also testified. (Id.) On September 6, 2011, the ALJ denied plaintiff's claim (A.R. 12-21), and the Appeals Council subsequently denied plaintiff's request for review of the ALJ's decision (A.R. 1-3). That decision is now at issue in this action.
In his September 6, 2011 decision, the ALJ found that plaintiff met the insured status requirements of the Social Security Act through December 31, 2013, and plaintiff has not engaged in substantial gainful activity since June 16, 2009, the alleged onset date of her disability. (A.R. 14.) The ALJ determined that plaintiff has the severe impairment of an affective disorder. (Id.) The ALJ also determined that plaintiff has the medically determinable impairments of "degenerative disk disease of her lumbar spine and obesity," but "[t]hese impairments are non-severe because alone and combined they do not cause [plaintiff] more than minimal limitations." (Id.) The ALJ concluded, however, that plaintiff does not have an impairment or combination of impairments that meets or medically equals the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1 (20 C.F.R. §§ 404.1520(d), 404.1525, 404.1526, 416.920(d), 416.925, 416.926). (A.R. 15.)
After reviewing the record, the ALJ determined that plaintiff has the residual functional capacity ("RFC") to perform a full range of work at all exertional levels but with the following nonexertional limitations: simple repetitive routine tasks with only occasional interaction with the public and coworkers. (A.R. 15.) In making this finding, the ALJ considered the subjective symptom testimony of plaintiff, which the ALJ found was not entirely credible, as well as the medical evidence and opinions of record. (A.R. 16-19.)
Based on plaintiff's age, education,
Thus, the ALJ concluded that plaintiff has not been under a disability, as defined in the Social Security Act, since June 16, 2009, the alleged onset date, through September 6, 2011, the date of the ALJ's decision. (A.R. 21.)
Under 42 U.S.C. § 405(g), this Court reviews the Commissioner's decision to determine whether it is free from legal error and supported by substantial evidence in the record as a whole.
Although this Court cannot substitute its discretion for that of the Commissioner, the Court nonetheless must review the record as a whole, "weighing both the evidence that supports and the evidence that detracts from the [Commissioner's] conclusion."
The Court will uphold the Commissioner's decision when the evidence is susceptible to more than one rational interpretation.
Plaintiff claims that the ALJ erred in failing to properly consider: (1) the medical evidence regarding her physical and mental impairments; and (2) her subjective complaints. (Joint Stipulation ("Joint Stip.") at 3.)
It is the responsibility of the ALJ to analyze evidence and resolve conflicts in medical testimony.
An ALJ must provide "clear and convincing reasons" for rejecting the uncontradicted opinion of an examining physician.
In determining a claimant's RFC, an ALJ will consider all the relevant evidence in the record. 20 C.F.R. §§ 404.1545(a)(1), 416.945(a)(1). In so doing, the ALJ will consider all of the claimant's medically determinable impairments, including those that are not "`severe.'" 20 C.F.R. §§ 404.1545(a)(2), 416.945(a)(2). The ALJ also will consider "any statement about what [the claimant] can still do that have been provided by medical sources." 20 C.F.R. §§ 404.1545(a)(3), 416. 945(a)(3).
An April 1, 2009 MRI of plaintiff's lumbar spine indicated "minimal degenerative disk disease with 3-4 MM circumference disk protrusion/disk bulging at L4-5 and 6 MM paracentral L5-S1 disk protrusion" and "mild degenerative facet joint hypertrophy in the lower lumbar spine causing only mild to moderate neural foraminal compromise at L4-5 and L5-S1." (A.R. 264.) The MRI did not reveal "subluxation or compression fracture or spinal stenosis." (Id.)
On October 8, 2009, after reviewing plaintiff's medical history, including the April 2009 MRI, state agency physician Keith J. Wahl, M.D., opined that the "evidence is supportive of a light [RFC] with mild disk protrusion, normal gait and normal neuro," and he concluded that a "light [RFC] with seizure precautions" would be appropriate for plaintiff. (A.R. 502-03.) Specifically, he opined that plaintiff could: lift and carry twenty pounds occasionally and ten pounds frequently; stand and/or walk about six hours in an eight-hour workday; sit about six hours in an eight-hour workday; climb ramps and stairs, balance, stoop, kneel, crouch, crawl occasionally, but never climb ladders/ropes or scaffolds; and not push and/or pull with her lower extremities. (A.R. 497-98.) Further, plaintiff would need to avoid concentrated exposure to vibration (such as work with vibrating tools) and all exposure to hazards such as heights. (A.R. 499.) As a seizure precaution, plaintiff should also avoid unprotected heights, open bodies of water, open electrical circuits, driving, or use of heavy equipment.
A March 27, 2011 MRI of plaintiff's lumbar spine, indicated "mild degenerative disk disease and facet joint disease at the L5-S1 level." (A.R. 850.)
At step two of the sequential evaluation process, the ALJ is tasked with identifying a claimant's "severe" impairments. 20 C.F.R. §§ 404.1520(a)(4)(ii), 404.1520(c), 416. 920(a)(4)(ii), 416.920(c). A severe impairment is one that "significantly limits [a claimant's] physical or mental ability to do basic work activities."
In finding that plaintiff's lumbar degenerative disk disease was not severe, the ALJ relied on a March 2011 MRI, indicating mild degenerative disk disease and facet joint disease at the L5-S1 level. (A.R. 17.) However, by relying solely on the March 2011 MRI in concluding that plaintiff's mild degenerative disk disease is non-severe, the ALJ implicitly ignores Dr. Wahl's opinion, who limited plaintiff to a light RFC based, in part, on plaintiff's mild disk protrusion, as indicated by the April 2009 MRI.
Moreover, the ALJ's error cannot be deemed harmless. In general, an ALJ's failure to discuss a claimant's impairment at step two may be deemed harmless only when the ALJ's error did not prejudice a claimant at later steps in the sequential evaluation process. In
In this case, unlike in
The ALJ stated that he gave "limited weight" to Dr. Wahl's opinion that plaintiff could only perform a range of light work, because Dr. Wahl "did not examine [plaintiff], review all of her records or have sufficient information to determine her credibility." (A.R. 19.) Having given Dr. Wahl's opinion such limited weight, the ALJ determined that plaintiff's "physical impairments are non-severe causing her no exertional limitations." (Id.)
The ALJ's first reason for rejecting Dr. Wahl's opinion — to wit, that Dr. Wahl did not examine plaintiff — is not a convincing reason. If an examination of was essential to credit a physician's opinion, then the only opinions an ALJ would be required to consider would be those of treating and examining physicians. But the regulations require the ALJ to consider the opinions of all physicians. See 20 C.F.R. §§ 404.1527(d), 416.927(d). Thus, the ALJ cannot simply reject the opinions of state agency physicians based on a lack of examination. Social Security Ruling ("SSR") 96-6p (opinions of state agency physicians and psychologists must be considered).
The ALJ's second reason for rejecting the Dr. Wahl's opinion — to wit, that Dr. Wahl did not review all of plaintiff's records and have sufficient information to determine her credibility — is not convincing for several reasons.
First, given that there are no other medical opinions in the record assessing plaintiff's physical functional limitations, the ALJ's duty to develop the record was triggered by his conclusion that Dr. Wahl's opinion was not based on a sufficiently complete picture of plaintiff's condition. Absent a reliable medical opinion regarding plaintiff's physical impairments and related functional limitations, the ALJ lacked a necessary foundation on which to make a proper determination of whether plaintiff has an impairment that precludes her from gainful employment.
Second, the ALJ may not discredit a state agency physician's opinion, because that physician had insufficient information to determine plaintiff's credibility. Because Dr. Wahl's opinion appears to be based on plaintiff's medical records, and there is nothing in the record to suggest that Dr. Wahl relied more heavily on plaintiff's subjective complaints than the objective medical evidence of record, the ALJ's second reason does not constitute a clear and convincing reason for rejecting his opinion. See generally
Third, it is not entirely clear upon whose medical opinion the ALJ relied in determining that plaintiff could perform a full range of work at all exertional levels. In fact, the record is entirely devoid of any physician's opinion that supports the ALJ's determination. Accordingly, it appears that the ALJ's RFC assessment is based on nothing more than his own lay medical opinion, and it is well-settled that an ALJ may not render a medical judgment and interject his own medical opinion, nor may he substitute his own diagnosis for that of the claimant's physician. See
Accordingly, the ALJ erred in finding plaintiff's degenerative disk disease of the lumbar spine to be non-severe due to his failure to give clear and convincing reasons for rejecting Dr. Wahl's opinion and his apparent reliance on his own medical opinion, an opinion he is not qualified to make.
Plaintiff contends that the ALJ failed to properly consider the medical evidence pertaining to her mental impairments, particularly the opinion of treating physician Gurmeet Multani.
On December 16, 2009. Dr. Multani completed an "Evaluation Form For Mental Disorder," which indicated that he first examined plaintiff in August 2005, and examined her once a month thereafter. (A.R. 520.) He diagnosed plaintiff with schizophrenia and depression. (Id.) Dr. Multani opined that plaintiff has difficulty dealing with reality, has been hearing voices, and is agitated and delusional. (Id.) She has poor ability to carry out tasks and feels depressed, anxious, and overwhelmed. (Id.) Further, plaintiff is poorly motivated, has been isolated and withdrawn, and has poor coping skills. (Id.) She is unable to deal with stress and has mood swings. (Id.) On mental status examination, Dr. Multani noted that plaintiff is tense and anxious but cooperative, has good eye contact, and is fairly verbal and expressive. (A.R. 521.) Plaintiff is oriented to time, place and person, but she has poor judgment, concentration, and memory. (Id.) Further, her insight is lacking. (Id.) Plaintiff shows signs of depression and anxiety, but exhibits no homicidal or suicidal ideations. (Id.) Finally, plaintiff is confused and has auditory hallucinations and paranoid ideations. (Id.)
On July 19, 2010, Dr. Multani completed another "Evaluation Form For Mental Disorders" for plaintiff. (A.R. 581-84.) Dr. Multani's opinions in this form were similar to, if not the same as, those set forth in his December 2009 responses. (Id.) However, on this form, Dr. Multani also discussed plaintiff's current level of functioning. (A.R. 582-83.) Dr. Multani noted, somewhat inconsistently, that plaintiff: does not need assistance to properly care for her personal affairs uses public transportation, pays bills, can "maintain residence," and cares for her own grooming and hygiene; has difficulty interacting appropriately and communicating effectively with family members, neighbors, and friends; cannot sustain attention and cannot complete everyday household routines; is unable to carry out tasks and "should not be able to go out for training for work or apprenticeship for eight hours a day." (Id.)
The ALJ gave "limited weight" to Dr. Multani's opinion because his opinion: (1) is internally inconsistent; (2) does not acknowledge plaintiff's history of exaggerating her symptoms and inconsistencies in her claims; (3) relies exclusively on plaintiff's unsupported subjective complaints; and (4) is not supported by the treatment records of other physicians of record. (A.R. 18.)
The ALJ's first reason for rejecting Dr. Multani's opinion — to wit, that his opinion was internally inconsistent — is specific and legitimate. As noted by the ALJ, Dr. Multani opined that plaintiff does not need assistance to properly care for her personal affairs and can "maintain residence." (A.R. 18, 583.) However, this appears to be inconsistent with his conclusion, in the same report, that plaintiff cannot complete everyday household routines. (Id.) Further, Dr. Multani opined that plaintiff cannot sustain attention, is unable to carry out tasks and work on goals, and could not work 8-hours a day, which the ALJ also properly noted is inconsistent with his opinion that plaintiff is able to take care of herself and live independently. (Id.); see
The ALJ's second and third reasons for rejecting Dr. Multani's opinion — to wit, that Dr. Multani fails to acknowledge plaintiff's history of exaggerating her symptoms and inconsistencies in her claims and appears to rely exclusively on plaintiff's unsupported subjective complaints — is unavailing. It is true that the opinion of a physician premised primarily or to a large extent on a claimant's subjective complaints may be given less weight where the evidence in the record supports the ALJ in discounting the claimant's credibility. See
The ALJ's fourth reason for rejecting the opinion of Dr. Multani — that his opinion is inconsistent with the treatment records of other physicians — is impermissibly conclusory, because it provides no specific reference to any such alleged inconsistency. (See A.R. 18); see also
Moreover, it is again not entirely clear upon whose medical opinion(s) the ALJ relied in assessing that plaintiff would only be limited to "simple repetitive routine tasks with occasional interaction with the public and coworkers." (A.R. 15.) The ALJ only notes that he has considered plaintiff's "records, subjective complaints, activities of daily living and the testimony herein and finds the above impairments and residual functional capacity" in determining plaintiff's RFC. (A.R. 19.) It appears from the record, however, that the ALJ may have relied upon the opinion of state agency reviewing physician Dr. Skopec in assessing plaintiff's non-exertional RFC, because a part of Dr. Skopec's limitations are reflected in the ALJ's RFC assessment for plaintiff.
In sum, as the ALJ only provided one specific and legitimate reason for rejecting Dr. Multani's opinion and because his RFC determination with respect to plaintiff's non-exertional RFC is not supported by substantial evidence, the ALJ must reconsider, on remand, Dr. Multani's opinion when reassessing plaintiff's RFC.
Once a disability claimant produces objective medical evidence of an underlying impairment that is reasonably likely to be the source of claimant's subjective symptom(s), all subjective testimony as to the severity of the claimant's symptoms must be considered.
After considering plaintiff's testimony, the ALJ cited no evidence of malingering by plaintiff and concluded that "[plaintiff]'s medically determinable impairments could reasonably be expected to cause the alleged symptoms." (A.R. 17.) However, the ALJ determined that plaintiff's "statements concerning the intensity, persistence and limiting effects of [her] symptoms are not credible to the extent they are inconsistent with the [RFC] assessment." (Id.) Given the absence of malingering, the ALJ's reasons for finding that plaintiff is not credible with respect to her subjective symptom testimony must be "clear and convincing." The ALJ has proffered several reasons in rejecting plaintiff's subjective symptoms, and the Court discusses the principal reasons below.
The ALJ first rejected plaintiff's subjective symptom testimony based on his conclusion that "her [medical] records do not support the degree of limitations [plaintiff] asserted." (A.R. 17.) Assuming arguendo that the objective medical evidence did not corroborate the degree of plaintiff's allegedly disabling symptoms, this factor cannot form the "sole basis" for discounting plaintiff's subjective symptom testimony.
The ALJ's second reason for discounting plaintiff's credibility — to wit, plaintiff's drug-seeking behavior, her tendency to exaggerate her complaints in order to receive prescription pain medication, and the inconsistent statements about her drug use — is clear and convincing.
As the ALJ noted, plaintiff "requested pain medication, reporting that she lost prior prescriptions and has left [a hospital] against medical advice" which suggested that plaintiff was drug-seeking. (A.R. 17.) Plaintiff presented to the emergency room six times between February 8, 2009, and February 26, 2009, alternating between Community Hospital of San Bernardino ("CHSB") and Arrowhead Regional Medical Center ("ARMC"). (A.R. 224-31, 321-24, 332-33.) On February 8, 2009, plaintiff went to ARMC, stating that she had back pain and had run out of her pain medication; plaintiff was prescribed Vicodin. (A.R. 230-31.) On February 13, 2009, plaintiff went to CHSB, stating that she had back pain and had run out of pain medication; plaintiff was prescribed Norco. (A.R. 332, 344.) On February 14, 2009, plaintiff again went to ARMC, stating that she had back pain and herniated disks; plaintiff was given a prescription to refill Norco. (A.R. 229.) On February 17, 2009, plaintiff presented to ARMC, stating that she had lower back pain and had run out of her pain medication, however it was noted that plaintiff had filled her prescription on February 9, and January 25, 2009. (A.R. 226.) On February 21, 2009, plaintiff again went to CHSB, stating that she had lower back pain and was requesting pain medication; plaintiff was given a prescription for Vicodin and Motrin. (A.R. 321-23.) On February 26, 2009, when plaintiff again presented herself to ARMC, it was noted that this visit was plaintiff's fifth emergency department visit, and plaintiff had stated that she had lost her other prescriptions. (A.R. 225.) Plaintiff was denied her pain medication refill. (Id.) On June 8, 2010, Dr. Doan Nguyen of ARMC noted that plaintiff was "very medication seeking" and that plaintiff was "exaggerating her symptoms ... [in order to stay] in the hospital longer than she needed to." (A.R. 740.) Thus, the ALJ reasonably inferred from the foregoing that plaintiff was very "medication seeking" and that she exaggerated her complaints of pain to get pain medication; and as a result, the ALJ properly rejected her credibility. See
The ALJ also discussed plaintiff's inconsistent statements about her alcohol and drug-use. As noted by the ALJ, plaintiff testified that she has "not had a problem with drugs and alcohol since 2002." (A.R. 16.) However, in October 2009, plaintiff was diagnosed with "alcohol abuse with no mention of remission and cocaine and opiate dependence in remission." (A.R. 16, 549.) Further, on May 31, 2010, plaintiff "showed positive for opiods." (A.R. 739.) Plaintiff also denied her drug and alcohol history to her treatment providers. (A.R. 216, 226, 230, 232, 236, 238, 240, 242, 244, 250, 254, 269, 275, 288, 295, 301, 303, 305, 308.) Thus, this was a proper reason to discount plaintiff's credibility and her exaggerated testimony regarding her subjective symptoms. See
The ALJ's next ground for finding plaintiff not to be credible is also clear and convincing. The ALJ is entitled to use ordinary techniques of credibility evaluation, including the claimant's reputation for lying, prior inconsistent statements concerning her symptoms, and other testimony by the claimant that appears less than candid.
The ALJ also rejected plaintiff's credibility, because plaintiff had "previously applied for benefits asserting an inability to work, but testified she performed work while self employed during the time covered by her earlier application." (A.R. 16.) As noted by the ALJ, plaintiff alleged, in a prior application for disability, an inability to work prior to 2009. (Id.) However, plaintiff's earnings record indicates that she engaged in substantial gainful work activity, earning $975 a month, as a house cleaner between 2003 and 2008. (A.R. 36-39, 139, 158, 167.) Thus, this was a clear and convincing reason to reject plaintiff's credibility. See
The ALJ next concluded noted that, when plaintiff was treatment complaint, she significantly improved. (A.R. 16.) The ALJ's reason is supported by substantial evidence. When asked if her psychiatric medications work for her, plaintiff testified, "[p]retty much, they've been working, but it's not that I feel completely okay with myself. It controls my — what I feel, what I see." (A.R. 44.) Further, after reviewing plaintiff's medical records, Dr. Skopec noted that it "[a]ppears when compliant w[ith] meds[, symptoms] improved." (A.R. 519.) Thus, the ALJ was entitled to discount plaintiff's credibility based on her positive response to conservative treatment. See
Because the ALJ's credibility finding was supported by substantial evidence, the Court "may not engage in second-guessing."
The decision whether to remand for further proceedings or order an immediate award of benefits is within the district court's discretion.
Remand is the appropriate remedy to allow the ALJ the opportunity to remedy the above-mentioned deficiencies and errors. On remand, the ALJ must correct the above-mentioned deficiencies and errors. After so doing, the ALJ may need to secure a consultative examination for plaintiff and reassess plaintiff's RFC, in which case, testimony from a VE likely will be needed to determine what work, if any, plaintiff can perform.
Accordingly, for the reasons stated above, IT IS ORDERED that the decision of the Commissioner is REVERSED, and this case is REMANDED for further proceedings consistent with this Memorandum Opinion and Order.
IT IS FURTHER ORDERED that the Clerk of the Court shall serve copies of this Memorandum Opinion and Order and the Judgment on counsel for plaintiff and for defendant.