PAUL L. ABRAMS, Magistrate Judge.
Plaintiff filed this action on March 25, 2015, seeking review of the Commissioner's denial of her application for Disability Insurance Benefits ("DIB"). The parties filed Consents to proceed before the undersigned Magistrate Judge on May 5, 2015, and December 10, 2015. Pursuant to the Court's Order, the parties filed a Joint Stipulation on December 7, 2015, that addresses their positions concerning the disputed issues in the case. The Court has taken the Joint Stipulation under submission without oral argument.
Plaintiff was born on July 31, 1949. [Administrative Record ("AR") at 38, 144.] She has past relevant work experience as a financial solutions coach, senior marketing executive, sales marketing support manager, and sales representative. [AR at 22 (citation omitted).]
On December 14, 2012, plaintiff protectively filed an application for a period of disability and DIB, alleging that she has been unable to work since August 30, 2010. [AR at 13, 144.] After her application was denied initially and upon reconsideration, plaintiff timely filed a request for a hearing before an Administrative Law Judge ("ALJ"). [AR at 13, 98.] A hearing was held on July 23, 2014, at which time plaintiff appeared represented by an attorney, and testified on her own behalf. [AR at 13, 28-63.] After the hearing, the ALJ determined that he needed the opinion of an impartial medical expert and propounded interrogatories on Paul Grodan, M.D. [AR at 13, 225-30, 884-97.] On September 15, 2014, the ALJ proffered Dr. Grodan's responses to plaintiff, advising that she could "comment on the answers to the interrogatories, submit more evidence, ask [the ALJ] to submit cross interrogatories to the expert, and request a supplemental hearing." [AR at 13, 231.] Plaintiff did not provide a response. [AR at 13.] On October 17, 2014, the ALJ issued a decision concluding that plaintiff was not under a disability from August 30, 2010, the alleged onset date, through October 17, 2014, the date of the decision. [AR at 13-23.] Plaintiff requested review of the ALJ's decision by the Appeals Council. [AR at 5-8.] When the Appeals Council denied plaintiff's request for review on January 21, 2015 [AR at 1-3], the ALJ's decision became the final decision of the Commissioner.
Pursuant to 42 U.S.C. § 405(g), this Court has authority to review the Commissioner's decision to deny benefits. The decision will be disturbed only if it is not supported by substantial evidence or if it is based upon the application of improper legal standards.
"Substantial evidence means more than a mere scintilla but less than a preponderance; it is such relevant evidence as a reasonable mind might accept as adequate to support a conclusion."
Persons are "disabled" for purposes of receiving Social Security benefits if they are unable to engage in any substantial gainful activity owing to a physical or mental impairment that is expected to result in death or which has lasted or is expected to last for a continuous period of at least twelve months. 42 U.S.C. § 423(d)(1)(A);
The Commissioner (or ALJ) follows a five-step sequential evaluation process in assessing whether a claimant is disabled. 20 C.F.R. §§ 404.1520, 416.920;
At step one, the ALJ found that plaintiff had not engaged in substantial gainful activity since August 30, 2010, the alleged onset date.
[AR at 16 (citations omitted).] At step three, the ALJ determined that plaintiff does not have an impairment or a combination of impairments that meets or medically equals any of the impairments in the Listings. [
[AR at 17.] At step four, stating that he "accept[ed] the vocational expert's description of [plaintiff's] past work," the ALJ concluded that plaintiff is capable of performing her past relevant work as a senior marketing executive (Dictionary of Occupational Titles ("DOT") No. 189.117-014), a position he described as sedentary and skilled. [AR at 22-23.] Accordingly, the ALJ determined that plaintiff was not disabled at any time from the alleged onset date of August 30, 2010, through October 17, 2014, the date of the decision. [AR at 32.]
Plaintiff contends that the ALJ erred when he (1) determined that plaintiff was capable of performing her past relevant work as a senior marketing executive; (2) evaluated plaintiff's subjective symptom statements; and (3) discounted the medical opinion of plaintiff's treating cardiologist, Jeffrey Dell, M.D. [Joint Stipulation ("JS") at 5, 13, 23.]
As set forth below, the Court agrees with plaintiff, and remands for further proceedings.
The ALJ determined that plaintiff could perform her past relevant work as a senior marketing executive as actually and generally performed. [AR at 22 (citing DOT No. 189.117-014).] He also specifically stated that he "accept[ed] the vocational expert's description of [plaintiff's] past work," in making that finding. [AR at 23.]
Plaintiff contends, and defendant concedes, that the ALJ erred (1) when he stated that he relied on the testimony of a vocational expert, as no vocational expert was called to testify; and (2) when he evaluated plaintiff's past relevant work and determined that plaintiff's description of her job duties matched the DOT's description of the position of senior marketing executive at DOT No. 189.117-014. [JS at 7-12, 30-32.] Defendant also states that "[b]ecause no vocational expert testified at the hearing" and "[b]ased . . . on the fact that the Dictionary code the ALJ relies on does not match Plaintiff's actual work, this case should be remanded to the ALJ to evaluate Plaintiff's past relevant work properly, and if necessary, to obtain the assistance of a vocational expert." [JS at 32 (citation omitted).]
Remand is warranted on this issue.
The ALJ noted in his decision that plaintiff alleged "difficulty engaging in physical activity, that she cannot exert herself for more than five minutes, . . . [that] she has difficulty walking (up to five feet), climbing stairs, and lifting (no more than five pounds)[,] [and] also alleges experiencing fatigue as a side effect to her medication." [AR at 21 (citations omitted).] He stated that plaintiff "alleges greater physical limitations than [he] allowed for" in the RFC, and that he gave her "allegations of disabling symptoms little weight." [AR at 21, 22.] Plaintiff contends the ALJ failed to articulate legally sufficient reasons for rejecting plaintiff's subjective symptom testimony. [JS at 13-23, 38-39.]
"To determine whether a claimant's testimony regarding subjective pain or symptoms is credible, an ALJ must engage in a two-step analysis."
Where, as here, plaintiff has presented evidence of an underlying impairment, and the ALJ did not find "affirmative evidence" of malingering [
Here, in discounting plaintiff's credibility, the ALJ specifically found the following: (1) the record contained no evidence that plaintiff complained of fatigue to her treating doctors; (2) there is no evidence that plaintiff's doctors adjusted her medication in response to any complaint of fatigue; (3) there is no evidence of any difficulties in performing daily activities; (4) plaintiff did not show any difficulty in focusing or concentrating when providing answers to questions or in volunteering information at the hearing; (5) the objective evidence fails to support plaintiff's allegations; (6) plaintiff has a "limited recent history of treatment" with no evidence of surgical procedures since her alleged onset date to treat her cardiac conditions, and no emergency room visits or hospitalizations for her asthma; (7) there is no evidence of physical therapy, pain relief injections, or surgical intervention to treat plaintiff's osteopenia; and (8) plaintiff's daily activities are not consistent with the alleged degree of impairment and suggest that she "has a better physical capacity than she has stated in the record." [AR at 21-22.]
Plaintiff argues, and defendant concedes, that the ALJ erred when he found that the record contained no evidence that plaintiff complained of fatigue to her treating doctors. [JS at 15, 35.] Defendant argues, however, that the error was harmless because the ALJ provided several legitimate reasons which, "standing alone, were sufficient to support the ALJ's credibility finding." [JS at 35.]
Because the Court concludes, as discussed below, that the ALJ failed to provide any specific, clear and convincing reasons for discounting plaintiff's credibility, the error was not harmless.
The ALJ found that there was no evidence in the record that plaintiff's doctors adjusted her medication in response to any complaint of fatigue. [AR at 21.] Plaintiff notes that despite her repeated complaints of fatigue to her treating physicians, the medical expert, Dr. Grodan, who validated plaintiff's symptom of fatigue [AR at 894], and whose opinion the ALJ gave "greater weight," also opined that plaintiff's treatment was appropriate. [JS at 18.] She argues, therefore, that "there is no support for ALJ James D. Goodman's finding that Plaintiff's medications warranted adjustment." [JS at 18.] Defendant does not address this reason for discounting plaintiff's credibility.
Because the ALJ erred in finding that the record contained no evidence of plaintiff's fatigue, the ALJ's "related" finding that none of her doctors adjusted her medication in response to any complaints, especially in light of Dr. Grodan's opinion that her treatment was appropriate, is not a specific, clear and convincing reason for discounting plaintiff's credibility.
The ALJ found that there was "no evidence that [plaintiff] has any difficulties in performing her daily activities," and that plaintiff's activities of daily living were not consistent with her alleged degree of impairment:
[AR at 21, 22 (citations omitted).]
An ALJ may discredit testimony when plaintiff reports participation in everyday activities indicating capacities that are transferable to a work setting.
Plaintiff contends that the ALJ misrepresented the evidence and did not take into account that she suffers from shortness of breath, is occasionally light-headed and dizzy, and "she cannot do much" because of the shortness of breath. [JS at 20.] Here, the ALJ identified daily activities that he found demonstrated a "better physical capacity" than plaintiff stated in the record. [AR at 22.] However, the amount of involvement plaintiff described in those activities was minimal [
Thus, these were not specific, clear and convincing reasons for discounting plaintiff's credibility.
The ALJ also found that the objective evidence does not support plaintiff's subjective symptom allegations. [AR at 21.] Specifically, he stated that "there is simply not enough evidence of debilitating impairments to make the allegations readily believable . . . and the objective findings in the record and the findings of Dr. Sedgh [the State Agency consultative examiner] support the [RFC]." [
While a lack of objective medical evidence supporting a plaintiff's subjective complaints cannot provide the
Here, however, the ALJ reviewed the medical evidence, stated his conclusion that plaintiff's testimony was not credible to the extent it was inconsistent with his RFC assessment, and then stated his finding that the objective findings in the record "[a]s discussed above," also supported his RFC determination and did not support plaintiff's allegations. [AR at 21.] As the Ninth Circuit recently held, "an ALJ's `vague allegation' that a claimant's testimony is `not consistent with the objective medical evidence,' without any `specific finding in support' of that conclusion, is insufficient."
Thus, this was not a specific, clear and convincing reason for discounting plaintiff's credibility.
The ALJ also discounted plaintiff's allegations because other than medications to treat her impairments, she had a "limited recent history of treatment" with respect to her cardiac conditions, no emergency room visits or hospitalizations for her asthma, and no evidence of physical therapy, pain relief injections, or surgical intervention to treat her osteopenia, thus suggesting that she is not as limited as she alleges. [AR at 21-22.]
An ALJ may properly rely on the fact that only routine and conservative treatment has been prescribed.
However, the ALJ failed to articulate what, if any, other treatment was currently recommended or available for plaintiff's physical impairments. Although he noted that plaintiff had not undergone any surgical procedures since the alleged onset date for her cardiac condition, or for her osteopenia, he points to no evidence in the record that surgery had been recommended for plaintiff or was warranted for her conditions. Additionally, the ALJ failed to point to anything in the record to show that any specific treatment, other than the medication plaintiff was receiving, is a standard method for treating individuals with the type of pain or other limitations caused by plaintiff's physical impairments. Indeed, the medical expert opined that plaintiff's treatment was "appropriate." [AR at 893.]
Thus, this was not a specific, clear and convincing reason for discounting plaintiff's credibility.
The ALJ found that plaintiff did not exhibit any difficulty in focusing or concentrating when testifying at the hearing. [AR at 21.] Plaintiff counters that her treating cardiologist, Dr. Dell, stated in an RFC questionnaire that plaintiff's cardiac symptoms "often" interfere with attention and concentration. [JS at 23-24 (citing AR at 865).]
Although they may not form the sole basis for discrediting a claimant's subjective symptom testimony, an ALJ may properly consider his own observations at the hearing as part of the credibility analysis.
As the Court finds that none of the other reasons given by the ALJ for discounting plaintiff's credibility was legally sufficient, even if this was a specific, clear and convincing reason to discount plaintiff's credibility it would be the only such reason, which is not sufficient to support the ALJ's adverse credibility determination.
Based on the foregoing, the ALJ's credibility determination was not "sufficiently specific" to allow this Court to conclude that the ALJ rejected plaintiff's testimony on permissible grounds and did not arbitrarily discredit her testimony regarding pain and fatigue.
Plaintiff argues that the ALJ failed to properly consider the opinion of her treating cardiologist, Dr. Dell, who treated her for more than six years — from January 2008 to the time of the hearing. [JS at 23 (citing AR at 864).] On July 16, 2014, Dr. Dell completed a Residual Functional Capacity Questionnaire in which he found the following: plaintiff has marked limitations in physical activity; stress brings on bronchospasm; she is incapable of even a low stress job; her physical problems cause emotional difficulties that in turn contribute to the severity of her symptoms and limitations; her cardiac symptoms interfere with her attention and concentration; she can walk less than a block without having to rest; she can stand or walk less than two hours in an eight-hour workday and sit about five hours in an eight-hour workday with the need to take unscheduled breaks every two hours for about 45 minutes; and she would be absent from work more than three times a month. [AR at 864-67.]
Observing that Dr. Dell provided no diagnostic or objective evidence to support his "limiting assessment," and his report "contains little to establish a causal connection among the objective findings, if any, and the limitations he opines," the ALJ stated that he gave "greater weight" to the opinion of the medical expert, Dr. Grodan, "as the record is more consistent with the sedentary [RFC] offered by Dr. Grodan." [AR at 20.] The ALJ also stated that "Dr. Grodan, a designated medical expert, has superior medical credentials [to the State Agency medical consultants and the consultative examiner, Dr. Sedgh,] in the matters giving rise to the claimant's allegations." [AR at 19.]
Plaintiff notes that the ALJ is not medically trained and, therefore, not qualified to address whether there is a connection between Dr. Dell's RFC opinion and the medical findings, and the ALJ's rejection of Dr. Dell's opinion "amounts to nothing more than a statement of [the ALJ's] conclusion." [JS at 27.] Plaintiff also notes that Dr. Grodan — whose opinion the ALJ gave "greater weight" — testified that plaintiff experiences "fatigue," yet the ALJ did not include this limitation in his RFC determination. [JS at 28.] Finally, plaintiff notes that although the ALJ found that Dr. Dell provided no diagnostic or objective evidence to support his assessment
Defendant argues that the ALJ "must provide good reasons supported by substantial evidence for rejecting a treating source's opinion," and that the ALJ did so in rejecting Dr. Dell's opinion in favor of Dr. Grodan's opinion. [JS at 36 (citing 20 C.F.R. § 404.1527(c)(2)).] Simply providing a "good reason," however, is not the correct legal standard. An "ALJ may only reject a treating or examining physician's uncontradicted medical opinion based on clear and convincing reasons."
The Court finds that the ALJ did not provide specific and legitimate reasons supported by substantial evidence of record for rejecting the opinions of plaintiff's cardiologist in favor of the opinions of the non-examining consultant. Remand is warranted on this issue.
The Court has discretion to remand or reverse and award benefits.
In this case, there are outstanding issues that must be resolved before a final determination can be made. In an effort to expedite these proceedings and to avoid any confusion or misunderstanding as to what the Court intends, the Court will set forth the scope of the remand proceedings. First, because the ALJ failed to provide specific and legitimate reasons for discounting the opinions of Dr. Dell and for giving the opinions of Dr. Grodan greater weight, the ALJ on remand shall reassess the medical opinions of record. In assessing the medical opinion evidence of all of the doctors, the ALJ must explain the weight afforded to each opinion and provide legally adequate reasons for any portion of the opinion that the ALJ discounts or rejects, including a legally sufficient explanation for crediting one doctor's opinion over any of the others. Second, because the ALJ failed to provide specific, clear and convincing reasons, supported by substantial evidence in the case record, for discounting plaintiff's subjective symptom testimony, the ALJ on remand shall reassess plaintiff's subjective allegations and either credit her testimony as true, or provide specific, clear and convincing reasons, supported by substantial evidence in the case record, for discounting or rejecting any testimony. Finally, the ALJ shall reassess plaintiff's RFC and determine at step four, with the assistance of a vocational expert if necessary, whether plaintiff is capable of performing any of her past relevant work. If she is not so capable, then the ALJ should proceed to step five and determine, with the assistance of a vocational expert if necessary, whether there are jobs existing in significant numbers in the regional and national economy that plaintiff can still perform.
Plaintiff's request that the new hearing be held before a different ALJ and that time limits be imposed on the hearing and decision date is