ALKA SAGAR, Magistrate Judge.
Pursuant to Sentence 4 of 42 U.S.C. § 405(g), IT IS HEREBY ORDERED that this matter is remanded for further administrative action consistent with this Opinion.
On May 28, 2014, Plaintiff filed a Complaint seeking review of the denial of her applications for Disability Insurance Benefits and Supplemental Security Income. (Docket Entry No. 1). The parties have consented to proceed before the undersigned United States Magistrate Judge. (Docket Entry Nos. 9-10). On October 14, 2014, Defendant filed an Answer along with the Administrative Record ("AR"). (Docket Entry Nos. 12-13). The parties filed a Joint Position Statement ("Joint Stip.") on December 30, 2014, setting forth their respective positions regarding Plaintiff's claims. (Docket Entry No. 15).
The Court has taken this matter under submission without oral argument.
On March 16, 2011, Plaintiff, formerly employed as a traffic supervisor for a customs house brokerage (
On October 14, 2010, the Administrative Law Judge, Robert S. Eisman, heard testimony from Plaintiff and vocational expert Korin Porter. (AR 31-64). On September 28, 2012, the ALJ issued a decision denying Plaintiff's application. (AR 17-25). After determining that Plaintiff had severe impairments — "history of Grave's disease, status post radioactive iodine treatment, transitioned to hypothyroidism with hormone replacement therapy; drug induced nephropathy; and obesity" (AR 19-20) —, the ALJ found that Plaintiff had the residual functional capacity
Plaintiff requested that the Appeal's Council review the ALJ's Decision. (AR 10). The request was denied on March 31, 2014. (AR 1-4). The ALJ's decision then became the final decision of the Commissioner, allowing this Court to review the decision.
Plaintiff alleges that the ALJ erred in failing to properly: (1) assess the opinions/findings of Plaintiff's treating and examining physicians; and (2) evaluate Plaitniff's credibility and/or subjective symptoms. (
After consideration of the record as a whole, the Court finds that Plaintiff's second claim of error warrants a remand for further consideration. Since the Court is remanding the matter based on Plaintiff's second claim of error, the Court will not address Plaintiff's first claim of error.
Plaintiff asserts that the ALJ failed to provide clear and convincing reasons for finding Plaintiff not fully credible. (
Plaintiff made the following statements in an Exertion Questionnaire dated June 7, 2011: (1) she lived in a house with family; (2) she is not able to sleep at night due to leg cramps; (3) she has to sit down after 5 minutes of moving around in the morning because of soreness; (4) she cannot stand for very long; her legs even cramp when she sits down; (5) her daily activities include cleaning the house — making the bed makes her tired and makes her arms and leg sore; vacuuming makes her tired, makes her arms hurt, and gives her headaches; and washing dishes (makes her legs sore); (6) she is able to walk up and down the block twice (makes her sore); (7) she does not climb stairs; (8) she lifts cooking pans at dinner every day; (9) she does not carry heavy objects because they make her sore and make her lose circulation in her hands; (10) she goes to the market every other day; (11) she makes the beds, cleans the bathroom and vacuums, but takes breaks between chores; (12) she drives an automatic car to local places, unless she is shaking too much; (13) she begins yard work but is unable to complete it because of soreness in her legs and arms (her husband completes it); (14) her disability causes her to do chores very slowly and sometimes she is not able to complete them because of shaking; (15) she sleeps 4 to 5 hours at nap; she is required to take naps every day; (16) she takes Methimazole 2 times a day (but used to take it 3 times a day) and Atenolol twice a day; and (17) writing down answers to questions makes her nervous and causes her whole body to shake and gives her bad haeadaches. (AR 158-60).
At the hearing, Plaintiff testified she has a husband and two grown children. She has a driver's license without any restrictions. She has not worked since August 2010. She last tried looking for work ("[a]nything that's available") in 2011. She was laid off from work in 2008 because her company was bought out. (
Her traffic manager job involved issuing paperwork to truckers going to the harbor to pick up containers. She did not lift anything more than a telephone. (
She is 5'5" tall and weighs 220. She had significant weight gain due to her hormones and medication. She is is taking a thyroid hormone replacement (she is seeing an endocrinologist, Dr. Gastilum). Last year she had radioactive iodine treatment. She has seen a nephrologist (Dr. Darwish) for her kidneys only once. She has not had a thyroidectomy. (
She was and still is diagnosed with Graves' disease. (
Her legs and muscles affect her ability to work the most. She is in a lot of pain. When she sits down, she feels fidgety and has to stand. (While she was talking during the hearing, she was fidgeting and her toes were tingling. She felt okay because she was able to stretch her legs there. At a desk job, after about 20 minutes, she would have to get up and walk around for a while). When she stands too long, she has to sit down. Her doctor told her the cause of her leg pain was Graves' disease, and the medicines for her hormone replacement therapy (Levothyroxine, Tenilow). For the past 6 months, her doctor has prescribed Vicodin (one every 6 hours), which has given her relief. Her leg pain causes her not to sleep a full night (she is taking Vicodin for that). She takes two naps a day every day (she elevates her knees, so that her legs are elevated above her heart). A foot stool under a desk would not help her. She gets tired with her medicines, especially Vicodin. (
Tremors in her right and left arms also affect her ability to work. That is under control, to some degree, with the medications. She starts to shake with tremors when she uses the computer (which is why she stopped using it). (
The issues with her legs and arms has mostly affected her physical activities, such as walking for exercise, moving around. (
She has other issues. She perspires a lot, which is caused by her hormones (she is not taking any medication for that). She has swelling around her eyes. She has swelling around her hands and ankles, which is common for Graves' diseases. The swelling subsides in the morning after she moves around a little bit. She has headaches for which she takes the Vicodin (which helps relieve them). She has carpal tunnel in her right hand. (
She does not smoke, and she drinks a glass of wine occasionally. (
For daily activities, she helps her daughter with chores, she tries to vacuum (but fatigue causes her to take breaks), she helps with the laundry (she sets up everything, but others carry things to the washing machine), she goes shopping with her husband, she cooks with the help of others (she has to sit down a lot when she cuts things). She does not do any more yard work, and her daughter takes care of their dog. With respect to hobbies, she used to play softball with her daughter (but her daughter no longer plays). She reads and watches television. She no longer spends time on the computer, or goes out to the movies or other activities. (
In the section concerning Plaintiff's RFC, the ALJ stated, "The claimant's testimony from the prior hearing, as well as the summary, weighing and analysis of the function reports and pain questionnaire's [sic] submitted in connection with the claimant's application, are included by reference herein[.]" (AR 16).
After summarizing Plaintiff's testimony at the administrative hearing concerning her symptoms and limitations, as well as the medical evidence in the record (
(AR 22).
The ALJ then concluded: "After careful consideration of the evidence, the undersigned finds that the claimant's medically determinable impairments could reasonably be expected to cause some of the alleged symptoms; however, the claimant's statements concerning the intensity, persistence and limiting effects of these symptoms are not credible to the extent that they are inconsistent with the above residual functional capacity assessment." (AR 23).
A claimant initially must produce objective medical evidence establishing a medical impairment reasonably likely to be the cause of the subjective symptoms.
Here, the ALJ failed to provide clear and convincing reasons for his finding that Plaintiff's testimony about the intensity, persistence and limiting effects of the symptoms was not fully credible.
First, the ALJ failed to "specifically identify `what testimony is not credible and what evidence undermines [Plaintiff's] complaints.'"
Second, the lack of objective medical evidence for Plaintiff's symptoms and limitations — cannot, by itself, support the credibility finding.
Third, the ALJ's discrediting of Plaintiff's testimony because he "did not observe any tremors or shaking of the upper extremities at the hearing" was improper.
Fourth, the ALJ's statement that Plaintiff's testimony was not credible because her "claim of fatigue from medication is not supported by the record" was also improper because, as stated above, the absence of objective medical evidence for Plaintiff's symptoms and limitations cannot, by itself, support the adverse credibility finding. Moreover, although Plaintiff did testify that she gets tired when she takes her medicines, especially Vicodin (
The decision whether to remand for further proceedings or order an immediate award of benefits is within the district court's discretion.
Since the ALJ failed to properly assess Plaintiff's credibility, remand is appropriate. Because outstanding issues must be resolved before a determination of disability can be made, and "when the record as a whole creates serious doubt as to whether the [Plaintiff] is, in fact, disabled within the meaning of the Social Security Act," further administrative proceedings would serve a useful purpose and remedy defects.
For the foregoing reasons, the decision of the Commissioner is reversed, and the matter is remanded for further proceedings pursuant to Sentence 4 of 42 U.S.C. § 405(g).
LET JUDGMENT BE ENTERED ACCORDINGLY.