JACQUELINE CHOOLJIAN, Magistrate Judge.
On February 9, 2015, Catherine D. Lacy ("plaintiff") filed a Complaint seeking review of the Commissioner of Social Security's denial of plaintiff's applications for benefits. The parties have consented to proceed before the undersigned United States Magistrate Judge.
This matter is before the Court on the parties' cross motions for summary judgment, respectively ("Plaintiff's Motion") and ("Defendant's Motion"). The Court has taken both motions under submission without oral argument.
Based on the record as a whole and the applicable law, the decision of the Commissioner is REVERSED AND REMANDED for further proceedings consistent with this Memorandum Opinion and Order of Remand.
On September 19, 2012, plaintiff filed applications for Supplemental Security Income and Disability Insurance Benefits. (Administrative Record ("AR") 24, 181, 188). Plaintiff asserted that she became disabled on May 1, 2011, due to left ankle injury, stage two cervical cancer, and bipolar disorder (AR 217). The ALJ examined the medical record and heard testimony from plaintiff (who was not represented) and a vocational expert on August 25, 2014. (AR 42-68).
On October 9, 2014, the ALJ determined that plaintiff was not disabled through the date of the decision. (AR 24-33). Specifically, the ALJ found: (1) plaintiff suffered from the following severe impairments: major depressive disorder, generalized anxiety disorder, dysthymic disorder, and status post revision of a left ankle fracture and tears of the posterior tibial tendon and peroneus longus tendon of the distal fibula (AR 26); (2) plaintiff's impairments, considered singly or in combination, did not meet or medically equal a listed impairment (AR 27); (3) plaintiff essentially retained the residual functional capacity to perform sedentary work (20 C.F.R. §§ 404.1567(a), 416.967(a)) with additional limitations
The Appeals Council denied plaintiff's application for review. (AR 5).
To qualify for disability benefits, a claimant must show that the claimant is unable "to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months."
In assessing whether a claimant is disabled, an ALJ is to follow a five-step sequential evaluation process:
The claimant has the burden of proof at steps one through four, and the Commissioner has the burden of proof at step five.
Pursuant to 42 U.S.C. section 405(g), a court may set aside a denial of benefits only if it is not supported by substantial evidence or if it is based on legal error.
Substantial evidence is "such relevant evidence as a reasonable mind might accept as adequate to support a conclusion."
Even when an ALJ's decision contains error, it must still be affirmed if the error was harmless.
A reviewing court may not make independent findings based on the evidence before the ALJ to conclude that the ALJ's error was harmless.
Plaintiff contends that the ALJ inadequately evaluated the credibility of her subjective complaints. (Plaintiff's Motion at 5-11). The Court agrees. As the Court cannot find the ALJ's error harmless, a remand is warranted.
At the hearing plaintiff testified, in pertinent part, to the following: In or about 2011 she fell and hurt her foot. (AR 53). Plaintiff has "a shooting, sharp, burning pain" in her ankle. (AR 62). Despite two surgeries, plaintiff's ankle "still hurts," and doctors said she was going to need additional ankle surgery. (AR 54, 61-62). Plaintiff does not walk well and is unable to "stand very long" (only about 20-30 minutes at a time) because her "legs [] swell up," which hurts "really bad." (AR 53-54, 56). Plaintiff was able to walk into the hearing after being dropped off, but that caused her pain. (AR 56). Plaintiff usually uses a cane, although she did not have it with her at the hearing because it was locked in the apartment from which she and her family were evicted. (AR 53, 56). Doctors instructed plaintiff to use the cane "at all times" because plaintiff would fall "a lot." (AR 55-56). Since the accident, plaintiff has taken "a lot of medication" including hydrocodone and gabapentin (AR 53). Plaintiff had a "bad reaction" to some of her medication. (AR 53-54). Plaintiff has "a really bad nerve condition" and had been hospitalized for her nerves "10 times in . . . three years." (AR 53, 57, 59-60). She "can't concentrate very well," "can't focus," is "real nervous," is "not very good with people," and experienced visual hallucinations (including on the morning of the hearing). (AR 55, 58-59).
In a Function Report dated August 2, 2013, plaintiff stated, among other things, that she was very depressed and nervous; "can't focus"; "can't put hardly any pressure [on her] ankle"; could only walk to the car or an appointment and needed to stop and rest for one hour before she was able to resume walking; could pay attention for "30 minutes"; had been "fired or laid off from a job because of problems getting along with other people"; had problems with completing tasks, concentration, and getting along with others; was "very forgetful"; would lose her balance and fall a lot; had a poor short term memory; and liked to be alone. (AR 277-84).
The ALJ acknowledged in the decision that Social Security regulations required him to follow a "two-step" process to evaluate plaintiff's subjective complaints. (AR 28). Nonetheless, the decision does not specifically state whether the ALJ had, as part of such process, found "an underlying medically determinable physical or mental impairment[] . . . that could reasonably be expected to produce [plaintiff's] pain or other symptoms"; nor does the decision clearly address the credibility of any specific subjective complaint the ALJ found "not substantiated by objective medical evidence[.]" (
When a claimant provides "objective medical evidence of an underlying impairment which might reasonably produce the pain or other symptoms alleged," and there has not been a finding of malingering, the ALJ may discount the credibility of the claimant's subjective complaints only by "offering specific, clear and convincing reasons for doing so."
An ALJ's credibility determination must be specific enough to permit a reviewing court to conclude that the ALJ did not arbitrarily discredit the claimant's subjective complaints.
First, although the ALJ stated that he had generally "considered all symptoms and the extent to which [those] symptoms can reasonably be accepted as consistent with the objective medical evidence," as noted above, the decision does not sufficiently address the credibility of any specific symptom testimony to the extent it was not supported by such evidence. (AR 28-29). For example, the ALJ found "that [plaintiff's] hearing description of left ankle pain and [] difficulty walking support a limitation to sedentary exertion," that plaintiff's mother's statements that plaintiff had "left ankle pain and falls with significant standing" was "generally consistent with the sedentary and other functional limitations [the ALJ] adopted," and that "sedentary functional restrictions also accommodate any lower extremity swelling that [plaintiff] reported with working more than 2 hours since it [sic] allows significant sitting to offset any standing activity." (AR 29) (citing Exhibit 9F at 1 [AR 690]). Such conclusory assertions do not appear to account for all of plaintiff's subjective complaints (e.g., that after walking to a car or an appointment plaintiff needed to stop and rest for an one hour before she could continue walking), much less provide a clear and convincing reason for discounting the credibility of such testimony to the extent the ALJ rejected it. Similarly, the ALJ stated that he had given "some consideration to [plaintiff's] mental symptoms" by limiting plaintiff to "simple routine activities" (as the state agency reviewing physician had found) (AR 31), but the ALJ did not identify which specific mental symptoms he deemed it appropriate not to account for in plaintiff's mental residual functional capacity assessment, why he deemed it appropriate not to account for such symptoms, and the specific evidence in the record which supported doing so.
Second, to the extent, as defendant contends, the ALJ discounted plaintiff's credibility due to lack of objective medical evidence to support the alleged severity of plaintiff's subjective complaints (Defendant's Motion at 3-7;
Finally, since the ALJ's reasons for discrediting plaintiff's subjective complaints were not sufficiently specific, the Court is unable to conduct a meaningful review of the ALJ's credibility determination, and thus cannot conclude that the ALJ's error was harmless.
For the foregoing reasons, the decision of the Commissioner of Social Security is reversed in part, and this matter is remanded for further administrative action consistent with this Opinion.
LET JUDGMENT BE ENTERED ACCORDINGLY.