JOHN D. EARLY, Magistrate Judge.
Plaintiff filed the Complaint herein on August 3, 2016, seeking review of the Commissioner's denial of her application for disability insurance benefits ("DIB"). (Dkt. No. 1.) The parties filed consents to proceed before the undersigned Magistrate Judge. (Dkt. Nos. 22, 23, 24.) Pursuant to the Court's Case Management Order ("CMO"), the parties filed a Joint Stipulation on June 16, 2017, addressing their respective positions. (Dkt. No. 30, "Jt. Stip.") The Court has taken the Joint Stipulation under submission without oral argument. As set forth in the CMO, this decision is made based on the Administrative Record, the pleadings, and the Joint Stipulation of the parties under Rule 12(c) of the Federal Rules of Civil Procedure applying the standards set forth in 42 U.S.C. § 405(g).
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 no less than twelve months. 42 U.S.C. § 423(d)(1)(A);
If the claimant's impairments do not meet or equal a "listed impairment," before proceeding to the fourth step the ALJ assesses the claimant's residual functional capacity ("RFC").
The claimant generally bears the burden at each of steps one through four to show that she is disabled or that she meets the requirements to proceed to the next step, and the claimant bears the ultimate burden to show that she is disabled.
Under 42 U.S.C. § 405(g), this Court reviews the Commissioner's decision denying benefits to determine whether it is free from legal error and supported by substantial evidence in the record as a whole.
Although courts will not substitute their discretion for the Commissioner's, courts 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 ALJ is responsible for determining credibility, resolving conflicts in medical testimony, and for resolving ambiguities."
Lastly, even when legal error is found, the reviewing court will still uphold the decision if the error was harmless, that is, where it is inconsequential to the ultimate non-disability determination, or where, despite the error, the Commissioner's path "may reasonably be discerned," even if the Commissioner explains her decision "with less than ideal clarity."
Plaintiff was born August 3, 1954. (AR 26.) Plaintiff filed an application for disability insurance benefits March 15, 2010. (AR 272-77.) The application was denied on initial review and again on reconsideration, after which Plaintiff requested that her claim be heard before an ALJ. (AR 119-20, 155-60, 161.) An ALJ held a hearing on August 8, 2011, and on October 4, 2011, returned an unfavorable decision. (AR 37-80, 121-138.) On June 19, 2014, the Appeals Council vacated the ALJ's decision and remanded the matter for a new hearing and decision. (AR 143-46.) A remand hearing was held on June 4, 2015. (AR 81-118.) On October 8, 2015, the ALJ again found Plaintiff was not disabled. (AR 12-36.)
The ALJ used the five-step sequential evaluation process to guide the decision. At step one, the ALJ determined that Plaintiff met the insured status requirements through December 31, 2007, and had not engaged in substantial gainful activity since April 24, 2002. (AR 17, 18.) At step two, the ALJ concluded that Plaintiff had the following severe impairments: a history of level 1 anterior cervical spine fusion at C3-4 for a herniated disc in May 2004 with continuing symptomatology; degenerative disc disease with radiculopathy in C6-7 (with stenosis at lower levels); and sensory changes in C8 level, with some evidence of lower cervical spine C7 radiculopathy. (AR 18.)
At step three, the ALJ decided that the impairments did not meet or equal any "listed impairment" (AR 19) and found that through the date last insured Plaintiff retained the RFC to perform light work with the following limitations:
At step four, the ALJ stated that Plaintiff had no past relevant work, had a limited education, and transferable skills was not an issue. (AR 26.)
At step five, based on Plaintiff's age, education, RFC vocational factors, and the VE's testimony, the ALJ found that there were jobs existing in significant numbers in the national economy that Plaintiff could perform, including work as a (1) bakery worker (Dictionary of Occupational Titles ("DOT") 524.687-022); and (2) counter clerk (DOT 249.366-010). (AR 27.) Accordingly, on October 8, 2015 the ALJ determined that Plaintiff was not disabled during the relevant period from the alleged onset date — April 24, 2002 — through the date last insured of December 31, 2007. (AR 35.)
On November 10, 2015, Plaintiff requested that the Appeals Council review the decision by the ALJ. (AR 9-11.) On July 8, 2016, the Appeals Council denied the request for review. (AR 2-8.) This action followed.
Plaintiff contends that the ALJ failed to take into account the work restrictions recommended by Dr. Schilling, a consultative medical examiner who evaluated Plaintiff in 2006. (Jt. Stip. at 4; AR 509.) Dr. Schilling recommended certain neck and head limitations in his assessment. (AR 507.) Plaintiff argues the ALJ impermissibly excluded Dr. Schilling's limitations from the RFC. (Jt. Stip. at 5.) Plaintiff alleges that the VE may not have identified the occupations of bakery worker and counter-clerk photo finisher had the ALJ included Dr. Schilling's physical limitations in the hypothetical presented to the VE. (
The Commissioner contends that Plaintiff failed to raise the vocational issue at either hearing before the ALJ and, therefore, waived the argument by not properly preserving it for appeal. (Jt. Stip. at 9.) Should the Court find that the issues were not waived, the Commissioner argues that the ALJ reasonably limited her hypothetical questions to the VE to the functional limitations that she found were supported by the record. (
The ALJ's RFC is not a medical determination but an administrative finding or legal decision reserved to the Commissioner based on consideration of all the relevant evidence, including medical evidence, lay witnesses, and subjective symptoms.
In determining RFC, the ALJ is required to consider the combined effect of all the claimant's impairments, mental and physical, exertional and non-exertional, severe and non-severe. 42 U.S.C. §§ 423(d)(2)(B), (5)(B). In weighing medical source opinions in Social Security cases, the Ninth Circuit distinguishes among three types of physicians: (1) treating physicians, who actually treat the claimant; (2) examining physicians, who examine but do not treat the claimant; and (3) non-examining physicians, who neither treat nor examine the claimant.
If a treating or examining physician's opinion is uncontradicted, an ALJ may reject it only by offering "clear and convincing reasons that are supported by substantial evidence."
As an initial matter, the Court will address the Commissioner's contention that Plaintiff failed to preserve his challenge to the vocational limitations for appeal by not raising it during the hearings. The Ninth Circuit has held that "at least when claimants are represented by counsel, they must raise all issues and evidence at their administrative hearings in order to preserve them on appeal."
The question for the Court, then, is whether the issue of Dr. Schilling's limitations was sufficiently raised before the ALJ. The Court finds that, although it would have been preferable for the issue to have been raised again more directly during the testimony of the VE, Plaintiff did sufficiently raise the issue of Dr. Schilling's opinion regarding the head, neck and over the shoulder limitations below to preserve it for this appeal. During the administrative hearing held in 2011, Plaintiff's attorney asked the non-examining physician, Dr. Jensen, whether he concurred with certain parts of Dr. Schilling's physical limitation assessment, specifically asking whether Dr. Jensen agreed with the assessment related to no prolonged head posturing and certain limitations in the right upper extremities.
Next, the Court turns to the merits of the parties' arguments on the issue. On April 20, 2006, Dr. Schilling performed an examination of Plaintiff and offered an opinion in which he recommended certain work restrictions to avoid exacerbating Plaintiff's condition. (AR 500-09.) Dr. Schilling recommended that "[Plaintiff] should be limited to no repetitive use of the shoulder and use of right upper extremity. He should not lift more than 10 pounds with the right hand. No over shoulder work. No prolonged head posturing. No power grasping right hand. Limited grip, pinch, torque, push, pull or other similar activities with the right hand." (AR 507.) Dr. Jensen, a non-examining physician, appeared by phone in the 2011 hearing and opined that Plaintiff could reach at or above shoulder level occasionally. (AR 53.) In both decisions, the ALJ stated that Plaintiff was capable of performing light work that would allow for "occasional work at or above shoulder bilaterally. (AR 20, 128.)
While the ALJ made little mention of Dr. Schilling in her 2015 decision, she included references to the results of his examination in her 2011 decision, including the over the shoulder limitations. (AR 129, 130.) In her 2011 opinion, the ALJ stated that she gave considerable weight to the opinion of Dr. Schilling because it was consistent with, and supported by, the objective medical evidence while giving significant weight to Dr. Jensen's opinion. (AR 130.) In her 2015 opinion, the ALJ mentioned Dr. Schilling's opinion briefly without explicitly ascribing it weight while describing Dr. Jensen's conclusions at length and according them "great weight." (AR 22.)
The opinion of an examining physician is generally entitled to greater weight than the opinion of a non-examining physician.
There is a clear difference between the physicians' opinions and the ALJ's RFC demonstrates a preference for Dr. Jensen's opinion over Dr. Schilling's with respect to over the shoulder limitations. Though not explicit, in operation this amounts to the ALJ rejecting the contradicted opinion of an examining physician.
As such, the ALJ was required to provide "specific and legitimate reasons that are supported by substantial evidence" before disregarding Dr. Schilling's opinion.
The Commissioner lodges two arguments to support her position that, in the event the ALJ did err in failing to include certain neck and head limitations, any error was harmless in that Plaintiff has not cited anything in the representative occupations identified by the ALJ that indicates that they required prolonged head posturing. (Jt. Stip. at 11.) Further, the Commissioner contends that even if the ALJ had included neck and head limitations in the RFC, Plaintiff could still perform the occupations identified by the ALJ. (
The Court does not find this error to be harmless as the VE was not presented with a hypothetical that included Dr. Schilling's assessment that Plaintiff maintained serious limitations of the neck and shoulders, including no over the shoulder work.
Plaintiff also argues that the ALJ erred in failing to provide clear and convincing reasons for discounting Plaintiff's subjective symptom testimony. (Jt. Stip. at 14-18.) The Court declines to reach this issue because it finds the ALJ erred as set forth in Section V(1), above, and will remand the case for further proceedings on that issue as discussed further in Section VI, below. Because it is unclear whether the ALJ whether and to what extent the ALJ's apparent rejection of Dr. Schilling's opinion regarding the head/neck and over the shoulder limitations may have played a role in the ALJ's credibility determination of Plaintiff's subjective symptoms, the matter will also be remanded on the issue of Plaintiff's subjective symptom credibility consistent with this opinion.
The decision whether to remand for further proceedings is within this Court's discretion.
Remand is appropriate where outstanding issues must be resolved before a determination of disability can be made and it is not clear from the record that the ALJ would be required to find the claimant disabled if all the evidence were properly evaluated.
Here, remand is appropriate for further consideration and explanation from the ALJ, and, as appropriate, further development of the record consistent with this Order.
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.
LET JUDGMENT BE ENTERED ACCORDINGLY.