KENDALL J. NEWMAN, Magistrate Judge.
Plaintiff, who is represented by counsel, seeks judicial review of a final decision of the Commissioner of Social Security ("Commissioner" or "defendant") denying plaintiff's application for Supplemental Security Income benefits under Title XVI of the Social Security Act ("Act").
In 1998, plaintiff suffered complications from a 1996 gastric bypass surgery, which required a surgical repair and revision. (AT 459.) In 2001, plaintiff suffered at least two broken bones in his thoracic spine and reported suffering severe pain in his pelvis, neck, rib cage and spine. (AT 458). In 2002, plaintiff was diagnosed with emphysematous lungs, severe osteoporosis in his thoracic spine and slight osteoporosis in his cervical spine. (AT 469.) In 2003, plaintiff suffered another compression fracture to his thoracic spine and mild degenerative changes to his lumbosacral spine. (AT 475.)
An apt description of plaintiff's history prior to his application for disability benefits was given in May 2006 by Dr. Medhi, who saw plaintiff regarding a large thyroid mass:
(AT 343.) Plaintiff continued to suffer bone, digestive, seizure, and other ailments from 2006 through 2009.
On March 23, 2006, plaintiff filed a protective application for Supplemental Security Income, which alleged a disability onset date of January 1, 2003. (Admin. Transcript ("AT") 108.) Plaintiff's application was denied initially and on reconsideration (AT 70-74, 76-81.) Plaintiff requested a hearing before an ALJ, and the ALJ conducted a hearing regarding plaintiff's claim on January 8, 2009. (AT 17-59.) Plaintiff was represented by counsel at the hearing and testified. A vocational expert also testified at the hearing.
In a written decision dated June 10, 2009, the ALJ denied plaintiff's application for benefits based on a finding that plaintiff was capable of performing his past relevant work as a mobile home manager and the representative jobs in the national economy of cashier, dispatcher, and order clerk.
The ALJ conducted the required five-step evaluation and concluded that plaintiff was not disabled within the meaning of the Act. At step one, the ALJ found that plaintiff had not engaged in substantial gainful employment since March 23, 2006, the application date. (AT 12.) At step two, the ALJ concluded that plaintiff had the "severe" impairments of: "obesity, seizure disorder, hypertension, anemia, bone disorder, and back disorder." (
Prior to reaching step four of the analysis, the ALJ determined plaintiff's residual functional capacity ("RFC") as follows:
(AT 12.)
In assessing plaintiff's RFC, the ALJ addressed the medical evidence, giving "great weight" to the opinion of consultative examiner Dr. Sharma (AR 14) and giving "significant weight" to the opinion of state non-examining physician Dr. Desouza (
Having assessed plaintiff's RFC, the ALJ found at step four that plaintiff is capable of performing past relevant work as a mobile home manager. (AT 15.) In addition, the ALJ found that "given his age, education, work experience, and [RFC]", there are jobs that exist in significant numbers in the national economy that the claimant can perform. (AT 15-16.) The ALJ relied on the vocational expert's testimony, and found that plaintiff could perform jobs such as cashier, dispatcher, and order clerk. (AT 16.) Based on plaintiff's ability to perform his past work and to perform jobs that exist in significant numbers in the national economy, the ALJ found that plaintiff is "not disabled." (
The court reviews the Commissioner's decision to determine whether it is (1) free of legal error, and (2) supported by substantial evidence in the record as a whole.
"If additional proceedings can remedy defects in the original administrative proceeding, a social security case should be remanded."
Plaintiff first claims that the ALJ erred by rejecting the treating opinions of Drs. Leon and Khambati in favor of the consultative examiner's opinion, which led the ALJ to erroneously conclude: (1) that plaintiff did not suffer nearly complete limitations in his ability to sit/stand/walk in a work setting; and (2) that plaintiff's limitation to doing routine simple tasks was only "slight." (Pl.'s Mot. for Summ. J. at 32-37.) Specifically, plaintiff argues that the ALJ failed to articulate specific and legitimate reasons for not crediting Drs. Leon's and Khambati's assessments of plaintiff's limitations. (
Medical opinions of three types of medical sources are recognized in social security cases: "(1) those who treat the claimant (treating physicians); (2) those who examine but do not treat the claimant (examining physicians); and (3) those who neither examine nor treat the claimant (nonexamining physicians)."
Because the Social Security Administration ("SSA") favors the opinion of a treating physician over non-treating physicians,
Dr. Leon treated plaintiff from 2006-2007. (AT 452-55.) The ALJ gave "little weight" to Dr. Leon's medical opinion because:
(AT 15.)
Plaintiff testified that he prepares meals "maybe twice a day," washes dishes "maybe once a week," sweeps or vacuums "maybe once a month," helps with laundry "maybe once a week," cleans the bathroom "maybe twice a month," goes shopping for groceries once a month, makes his bed daily, changes the bedding once a month, and spends zero time a week at a computer. (AT 29-30.) Plaintiff further testified he spends up to fifteen hours a day in a recliner chair, either watching television or trying to sleep. (AT 31, 43-44.) Plaintiff testified that he does not go anywhere other than to the doctor approximately twice a month and does not a drive a vehicle because his license was revoked due to his seizures. (AT 32-33.)
Dr. Leon opined that, in a work setting, plaintiff could not lift, carry, stand, sit, or walk at all due to his severe osteoporosis with compression fractures. (AT 453.) Dr. Leon further opined that plaintiff would have a "poor"
The sole reason the ALJ provided for rejecting Dr. Leon's medical opinion as to plaintiff's work limitations was the ALJ's view that the limitations conflicted with plaintiff's home activities. However, "[d]isability claimants should not be penalized for attempting to lead normal lives in the face of their limitations." Reddick v. Chater, 157 F.3d 715, 722 (9th Cir. 1998) (citing
Dr. Khambati treated plaintiff throughout 2008. (AT 578.) Dr. Khambati opined that, in a work setting, plaintiff could lift and carry only up to 10 pounds occasionally and could stand, sit, or walk zero to one hours total in an 8-hour workday. (AT 579.) Regarding plaintiff's mental limitations, Dr. Khambati found a "poor" ability to deal with work stress, function independently, and maintain attention and concentration. (AT 581.) Dr. Khambati further assessed that plaintiff would have a "poor" ability to understand, remember, and carry out detailed but not complex job instructions and complex job instructions. (AT 582.) Unlike Dr. Leon, it was Dr. Khambati's opinion that plaintiff would have a "fair" ability to understand, remember and carry out simple job instructions. (
In rejecting Dr. Khambati's opinion, the ALJ summarized only the physical limitations Dr. Khambati placed on plaintiff and then stated: "While Dr. Khambati's assessment is certainly more realistic than Dr. Leon's, greater weight is accorded the consultative examiner's opinion which is more consistent with the treatment record and record of claimant's daily activities." (AT 15.) Not only did the ALJ fail completely to address the mental component of Dr. Khambati's opinion, the ALJ's basis for rejecting Dr. Khambati's opinion lacked the necessary specificity.
This conclusion is not to say that the ALJ must accept Drs. Leon's or Khambati's opinion over that of the CE, but his failure to provide a sufficient basis for rejecting those treating physician opinions requires remand for further proceedings.
Plaintiff next claims that the ALJ erred by finding his testimony regarding his pain and functional limitations not to be credible, on factually inaccurate or legally insufficient bases. While the ALJ is responsible for determining credibility, the ALJ's findings must be supported by specific, cogent reasons.
Here, the ALJ's finding that plaintiff's activities indicate an ability to work is unsupported by the record. The ALJ found:
(AT 13.) As described in the previous section, Plaintiff testified to engaging in some daily life activities, such as preparing the occasional meal and making his bed, but that he spends up to fifteen waking hours a day resting. (AT 29-33, 43-44.) The activities plaintiff described to his doctors, on disability forms, and at his hearing, were fully consistent with his treating physicians' view that plaintiff was severely limited in his ability to sit/stand/walk in a work setting. His activities were sporadic and punctuated with long periods of rest in a recliner chair. As discussed above in regards to the ALJ's rejection of plaintiff's treating physicians' medical opinions, plaintiff's home activities do not necessarily transfer to a work setting and the test for whether a claimant is disabled does not require the claimant to vegetate in a dark room and give up on attempts at engaging in normal life activities.
The ALJ based his adverse credibility as to plaintiff on three other reasons, all of which are factually or legally insufficient. First, the ALJ found plaintiff not credible because plaintiff testified he was prescribed a wheelchair but the ALJ stated he did not find anything in the treatment record that support this claim. (AT 13.) This is simply incorrect. Although the record does not contain a copy of plaintiff's prescription for his wheelchair, there is a clear reference to plaintiff's wheelchair in a 2008 Sales, Service and Rental Agreement from Apria Healthcare which requested an exchange of foot rest on plaintiff's wheelchair. (AT 632.)
Second, the ALJ stated that "there does not appear to be any records" to support plaintiff's testimony that he has three seizures a month and has been hospitalized for four times in the last twelve months. (AT 13.) To the contrary, there are numerous documented hospitalizations in the record, including a three and half month inpatient stay when plaintiff was in a coma. (See AT 306-09; 514; 519-20; 535; 547-60; 566; 563; 573.) Moreover, aside from a single notation in July of 2006 that plaintiff's seizures were under "good control," all other notations reflected seizure activity, and the last entry in plaintiff's medical record reflected that plaintiff was experiencing three to five seizures a month lasting at least several minutes each with resultant confusion sometimes for approximately fifteen minutes. (AT 246; 267; 422; 486; 503; 584; 586; 588; 670.)
Lastly, the ALJ based his adverse credibility finding on plaintiff's "generally unpersuasive appearance and demeanor while testifying at the hearing." Because the ALJ's other three bases for finding plaintiff not credible are error, this final justification is legally insufficient on its own. See Gallant v. Heckler, 753 F.2d 1450, 1455 (9th Cir. 1984); Morgan v. Apfel, 169 F.3d 595, 600 (9th Cir. 1999);
Plaintiff also claims the ALJ erred by failing to credit the testimony of the VE in response to hypothetical questions that reflected the functional limitations provided by Drs. Leon and Khambati. Because the court holds that the ALJ erred by rejecting the medical opinions of plaintiff's treating physicians without providing specific and legitimate reasons for so doing, and because the ALJ relied on a hypothetical RFC to the VE that did not encompass the limitation posed by plaintiff's treating physicians, on remand the ALJ will need to reassess the plaintiff's RFC and reconsider the VE's testimony or possibly obtain further VE testimony.
By remanding this matter for further proceedings, the undersigned does not mean to suggest that the ultimate outcome should or should not be different. Instead, the matter is remanded because the ALJ's decision is legally deficient for the reasons set forth herein.
For the foregoing reasons, IT IS HEREBY ORDERED that:
1. Plaintiff's motion for summary judgment (Dkt. No. 20) is granted;
2. Defendant's cross-motion for summary judgment (Dkt. No. 21) is denied; and
3. The Clerk is directed to enter a judgment in favor of plaintiff pursuant to sentence four of 28 U.S.C. § 405(g) and remand this matter to the Social Security Administration for further proceedings.
The claimant bears the burden of proof in the first four steps of the sequential evaluation process.