SUZANNE H. SEGAL, UNITED STATES MAGISTRATE JUDGE.
Editha Mejia ("Plaintiff") seeks review of the final decision of the Commissioner of the Social Security Administration (the "Commissioner" or the "Agency") denying her application for social security benefits. The parties consented, pursuant to 28 U.S.C. § 636(c), to the jurisdiction of the undersigned United States Magistrate Judge. For the reasons stated below, the
To qualify for disability benefits, a claimant must demonstrate a medically determinable physical or mental impairment that prevents her from engaging in substantial gainful activity and that is expected to result in death or to last for a continuous period of at least twelve months.
To decide if a claimant is entitled to benefits, an ALJ conducts a five-step inquiry. 20 C.F.R. §§ 404.1520, 416.920. The steps are:
The claimant has the burden of proof at steps one through four, and the Commissioner has the burden of proof at step five.
The ALJ employed the five-step sequential evaluation process in evaluating Plaintiff's
At step three, the ALJ found that Plaintiff did not have an impairment or combination of impairments that met or medically equaled one of the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1. (AR 18).
At step four, the ALJ determined that Plaintiff had the RFC to perform a full range of work at all exertional levels but with the following nonexertional limitations: she can have "occasional" interaction with the public; work should not require more than occasional supervision, defined as requiring a supervisor's critical checking of work; work should be limited to simple, routine, repetitive tasks in a work environment not requiring more than occasional production or pace work; and work should involve only simple work-related decisions, with few if any changes in the work place. (AR 19). In making this finding, the ALJ ruled that Plaintiff's statements concerning the intensity, persistence and limiting effects of her symptoms were not entirely credible. (AR 20). The ALJ also discussed the results of a consultative mental status examination performed by Dr. David Starr, Ph.D.; assigned "little weight" to a global assessment of functioning ("GAF") score
At step four, the ALJ determined that Plaintiff could not perform her past relevant work. (AR 23). At step five, the ALJ considered Plaintiff's age, education, work experience, and RFC and concluded that Plaintiff could perform jobs available in significant numbers in the national economy, including dishwasher, potato peeler machine operator, and janitor. (AR 23-24). Accordingly, the ALJ concluded that Plaintiff was not disabled under the Agency's rules. (AR 24).
Under 42 U.S.C. § 405(g), a district court may review the Commissioner's decision to deny benefits. The court may set aside the Commissioner's decision when the ALJ's findings are based on legal error or are not supported by "substantial evidence" in the record as a whole.
"Substantial evidence is more than a scintilla, but less than a preponderance."
Plaintiff alleges that the ALJ erred in four ways. First, Plaintiff contends that the ALJ improperly found that Plaintiff did not meet a listing at step three. (Plaintiff's Memorandum of Points and Authorities ("P. Mem.") at 1, 4-7). Second, Plaintiff contends that the ALJ erred in failing to "evaluate and weigh" the opinion of Dr. Starr. (
For the reasons discussed below, the Court agrees with Plaintiff that this case should be remanded because the ALJ failed to properly evaluate the medical evidence in formulating an RFC and improperly discredited Plaintiff's testimony.
Social Security regulations require the Agency to "evaluate every medical opinion [it] receive[s]," generally giving more weight to evidence from a claimant's treating physician. 20 C.F.R. § 404.1527(c). Where the Agency finds the treating physician's opinion of the nature and severity of the claimant's impairments is well-supported by accepted medical techniques, and consistent with the other substantive evidence in the record, that opinion is ordinarily controlling. 20 C.F.R. § 404.1527(c)(2);
Where a treating source is not given "controlling weight," the Agency must give "good reasons" for the deviation. 20 C.F.R. § 404.1527(c)(2);
Plaintiff argues that the ALJ improperly failed to "evaluate and weigh" Dr. Starr's opinion. (P. Mem. at 1, 7-8). On November 12, 2013, Dr. Starr performed a consultative psychological examination. (AR 430-33). Plaintiff reported "problems with anxiety and depression," occasional panic attacks, hearing voices, some sleep disturbance and nightmares, and suicidal thoughts. (AR 431). Plaintiff reported that she had been prescribed Seroquel, haloperidol, and Loestrin. (AR 431). Dr. Starr examined Plaintiff's appearance, demeanor, and responses to several questions testing her mental status. (AR 431-32). Dr. Starr diagnosed Plaintiff with schizoaffective disorder, depressive type, first episode, currently in remission. (AR 432). Dr. Starr reported that Plaintiff had "problems with mood and thinking," "problems with mood and anxiety with occasional panic attacks," and hallucinations. (AR 432). Dr. Starr found that Plaintiff was "marginally oriented" and had difficulty paying attention and concentrating; her fund of information was "extremely limited"; she did not think abstractly; her judgment was impaired; and she required assistance to manage funds. (AR 432). The ALJ did not assign Dr. Starr's opinion any particular weight, but discussed the examination and stated that Dr. Starr "never opined that [Plaintiff] was precluded from work activity within the confines of the [RFC]." (AR 21-22).
Although the RFC assessed by the ALJ limited Plaintiff's interaction with others and the complexity of Plaintiff's work, (AR 19), the Court disagrees with the ALJ's apparent conclusion that the RFC fully accounts for the limitations and conditions observed by Dr. Starr. For example, the ALJ does not adequately explain how the RFC accounts for Plaintiff's limited fund of information, suicidal thoughts, and hallucinations, (AR 432), or whether these conditions have any effect on Plaintiff's ability to work. The Court therefore agrees with Plaintiff that the ALJ's discussion of Dr. Starr's observations was inadequate.
Plaintiff also alleges that the ALJ erred in assigning "little weight" to a GAF score of 45 assessed by treating physician Dr. David A. Kent, M.D., when Plaintiff was released from psychiatric hospitalization on September 6, 2013. (AR 21, 360). The ALJ gave this score "little weight" because it was "merely a snapshot view" of Plaintiff's functioning "at a particular time" and not reflective of "the entire period at issue." (AR 21). The Court agrees with Plaintiff that the ALJ's opinion overlooks without explanation the GAF score of 45 assessed by treating physician Dr. Michael Millward on October 17, 2013, (AR 517-18), and a GAF score of 29 assessed by Dr. James Piktel at Intermountain Hospital on December 22, 2014. (AR 597). Elsewhere in his evaluation, Dr. Piktel reported that Plaintiff had been involuntarily admitted to Intermountain Hospital due to "overwhelming suicidal ideation and auditory hallucinations." (AR 594). Plaintiff "had a plan to kill herself with a knife, but allegedly her boyfriend took the knife away. In the ER, she was observed hitting herself with a chair." (AR 594).
Defendant argues that a GAF score is not a "medical opinion," and that the ALJ need not have discussed Plaintiff's GAF
Plaintiff also argues that the ALJ erred in assigning "some weight" to the opinions of non-treating, non-examining State agency physicians. (AR 22). The ALJ's opinion acknowledged that the State agency opinions "do not as a general matter deserve as much weight as those of examining or treating physicians," but nevertheless ruled that "those opinions do deserve some weight, particularly in a case like this in which there exist a number of other reasons to reach similar conclusions (as explained throughout this decision)." (AR 22). The ALJ noted that the opinions "supported a finding of `not disabled.'" (AR 22).
The Court agrees that the ALJ's reasons for assigning "some weight" to the opinions of the State agency doctors and relying on them in finding Plaintiff "not disabled" are so vague as to preclude review of his decision on this issue. To the extent that the ALJ relied on these opinions rather than the opinions of treating or examining physicians, he did not provide sufficient reasons for doing so.
For the foregoing reasons, the Court agrees with Plaintiff that the ALJ failed to properly evaluate the medical evidence in formulating an RFC.
Unless there is affirmative evidence showing that the claimant is malingering, the ALJ's reasons for rejecting a claimant's testimony regarding the intensity, persistence and limiting effects of her symptoms must be "clear and convincing."
As Plaintiff observes, the ALJ's only clear statement regarding Plaintiff's credibility was:
(AR 20). The ALJ wholly failed to identify the specific testimony that he found not credible and to link that testimony to specific portions of the record rebutting Plaintiff's testimony. The Court cannot conclude that the ALJ provided clear and convincing reasons for discrediting Plaintiff's testimony.
Defendant nevertheless argues that the ALJ provided appropriate reasons for discrediting Plaintiff's testimony. In analyzing whether Plaintiff's impairments were "severe," the ALJ stated that, although Plaintiff complained of physical pain following a car accident in July 2013, treatment notes in November 2013 stated that Plaintiff was in no "acute distress" and was not in pain. (AR 18). The ALJ also found that, although Plaintiff used a cane at times, there was "never a provider who prescribed a cane as there were no medical findings that she needed assistance with gait." (AR 18). The ALJ also noted that Plaintiff "did well with pain medications" after the accident, and "was quite active with walking and exercising. Thus, the accident was likely not as severe as alleged." (AR 20). Defendant also argues that the ALJ "noted a treatment record showing largely normal physical findings." (D. Mem. at 9 (citing AR 20-21)). With respect to Plaintiff's mental impairments, Defendant argues that the ALJ "showed how Plaintiff's psychological conditions stabilized with medication after treatment in September 2013" and noted a "treatment gap" between May 2014 and January 2015. (D. Mem. at 9-10 (citing AR 21-22)).
A court can only affirm based upon the reasons that the ALJ actually relied upon in his decision.
Moreover, several of the justifications asserted by Defendant are overstated or questionable. For example, although a claimant's failure to seek or follow prescribed medical treatment may suggest that the alleged impairment is not severe or disabling,
Defendant's remaining justifications for the ALJ's decision appear to be based on alleged inconsistencies between the medical evidence and Plaintiff's impairments. However, it is improper to reject subjective testimony based solely on its inconsistencies with the objective medical evidence.
For the foregoing reasons, the Court agrees with Plaintiff that the ALJ failed to provide legally sufficient reasons for discrediting Plaintiff's testimony regarding her limitations.
The Court remands for an award of benefits where "(1) the record has been fully developed and further administrative proceedings would serve no useful purpose; (2) the ALJ has failed to provide legally sufficient reasons for rejecting evidence, whether claimant testimony or medical opinion; and (3) if the improperly discredited evidence were credited as true, the ALJ would be required to find the claimant disabled on remand."
Remand for benefits under
Particularly, the Court observes that the record as a whole leaves no serious doubt that Plaintiff is disabled.
The Court also notes that Plaintiff was granted disability benefits for a subsequent application covering the period after June 16, 2015. (Dkt. No. 19). Although Defendant is correct that the subsequent grant of benefits is not itself determinative of issues in this case, which covers an earlier time period, (D. Mem. at 11-12), it has some impact on the Court's analysis of whether there would be any value in further administrative proceedings.
Accordingly, the Court remands with directions to the Agency to calculate and award benefits to Plaintiff.
For the foregoing reasons, IT IS ORDERED that Judgment be entered REVERSING the decision of the Commissioner and REMANDING this case for the award of benefits. The Clerk of the Court shall serve copies of this Order and the Judgment on counsel for both parties.