KENDALL J. NEWMAN, Magistrate Judge.
Plaintiff seeks judicial review of a final decision of the Commissioner of Social Security ("Commissioner") denying plaintiff's application for Disability Insurance Benefits ("DIB") and Supplemental Security Income ("SSI") under Titles II and XVI, respectively, of the Social Security Act ("Act").
For the reasons that follow, the court denies plaintiff's motion for summary judgment, grants the Commissioner's cross-motion for summary judgment, and enters judgment for the Commissioner.
Plaintiff was born on May 7, 1961; has a GED; is able to communicate in English; and previously worked as a general laborer.
Subsequently, on March 17, 2009, plaintiff requested a hearing before an administrative law judge ("ALJ"). (AT 91-92.) However, after a hearing was scheduled for April 9, 2010 (AT 100-05), plaintiff's former counsel on April 2, 2010, filed a request to withdraw the prior hearing request. (AT 121.) Consequently, on April 26, 2010, the ALJ dismissed plaintiff's request for hearing, noting that the January 29, 2009 reconsideration determination remained in effect. (AT 74.) Thereafter, on May 27, 2010, plaintiff, at that time proceeding without counsel, filed a request for the Appeals Council to review the order of dismissal. (AT 122.) Plaintiff explained that "my attorney advised me I did not have a case and to drop my case. I did not understand I could attend my hearing without an attorney." (
An administrative hearing was eventually conducted on September 15, 2011, at which plaintiff (proceeding without counsel), plaintiff's mother, and a vocational expert ("VE") testified. (AT 42-66.) In a subsequent decision dated September 19, 2011, the ALJ determined that plaintiff had not been under a disability, as defined in the Act, from April 2, 2008, plaintiff's alleged disability onset date, through the date of the ALJ's decision. (AT 28-36.) The ALJ's decision became the final decision of the Commissioner when the Appeals Council denied plaintiff's request for review, prepared with the assistance of plaintiff's present counsel, on March 27, 2013. (AT 1-7.) Thereafter, plaintiff filed this action in federal district court on April 19, 2013, to obtain judicial review of the Commissioner's final decision. (ECF No. 1.)
Plaintiff has raised the following issues: (1) whether the ALJ failed to properly develop the record; (2) whether the ALJ improperly discounted the testimony of plaintiff and plaintiff's mother; (3) whether the ALJ's residual functional capacity assessment was not supported by substantial evidence; (4) whether the ALJ erroneously relied on the Grids to find plaintiff not disabled; and (5) whether the evidence presented to the Appeals Council warrants remand.
The court reviews the Commissioner's decision to determine whether (1) it is based on proper legal standards pursuant to 42 U.S.C. § 405(g), and (2) substantial evidence in the record as a whole supports it.
The ALJ evaluated plaintiff's entitlement to DIB and SSI pursuant to the Commissioner's standard five-step analytical framework.
Before proceeding to step four, the ALJ assessed plaintiff's residual functional capacity ("RFC") as follows:
(AT 32-33.) At step four, the ALJ found that plaintiff was unable to perform any past relevant work. (AT 34.) Finally, at step five, the ALJ determined, in reliance on the Grids, that considering plaintiff's age, education, work experience, and RFC, there were jobs that existed in significant numbers in the national economy that plaintiff could perform. (AT 35.)
Accordingly, the ALJ concluded that plaintiff had not been under a disability, as defined in the Act, from April 2, 2008, plaintiff's alleged disability onset date, through the date of the ALJ's decision. (AT 35.)
Plaintiff contends that the ALJ failed to fully and fairly develop the record, especially in light of plaintiff's unrepresented status at the time. That argument is unpersuasive.
"The ALJ always has a `special duty to fully and fairly develop the record and to assure that the claimant's interests are considered . . . even when the claimant is represented by counsel.'"
In this case, the ALJ carefully explained plaintiff's options regarding representation and offered a postponement of the hearing to provide plaintiff with an opportunity to obtain counsel, but plaintiff instead voluntarily elected to proceed. (AT 45-46.) Moreover, the record does not reveal any prejudice or unfairness in the administrative proceedings. Plaintiff had at least a GED and did not claim to suffer from any mental impairments rendering him unable to understand or participate in the proceedings. Apart from questioning plaintiff, the ALJ permitted plaintiff's mother to testify on plaintiff's behalf, and at the end of the hearing, the ALJ also gave plaintiff an opportunity to add any additional information that plaintiff wanted to bring to the ALJ's attention. (AT 65.) Furthermore, prior to the hearing, the Commissioner appropriately developed the record by requesting medical records from plaintiff's health care providers and ordering a consultative evaluation by a physician who personally examined plaintiff, as well as two evaluations by non-examining state agency physicians. Although plaintiff suggests that these assessments were somewhat dated at the time of the ALJ's decision, the record evidence does not demonstrate that plaintiff's condition significantly changed after these assessments were performed.
To the extent that plaintiff claims that the ALJ failed to obtain all of plaintiff's relevant medical records, any such potential error was harmless, because plaintiff's present counsel, who started representing plaintiff at the Appeals Council level, had an adequate opportunity to present additional pertinent records for consideration by the Appeals Council. However, for the reasons discussed below, the court concludes that the records submitted to the Appeals Council would not plausibly have changed the ALJ's prior decision. As such, they were inconsequential to the ultimate non-disability determination.
In
"The ALJ must specifically identify what testimony is credible and what testimony undermines the claimant's complaints."
As an initial matter, the court notes that the ALJ did not entirely discredit plaintiff's subjective allegations. Indeed, in light of plaintiff's obesity and complaints of pain and shortness of breath with exertion, the ALJ assessed a more restrictive RFC than the functional assessments of both the consultative examiner and the state agency physicians. (AT 33-34.) Nevertheless, to the extent that the ALJ discounted plaintiff's testimony regarding the degree of his symptoms and functional limitations, the ALJ provided specific, clear, and convincing reasons for doing so.
The ALJ found that the record before him did not contain any opinions from treating or examining physicians indicating that the claimant was disabled or had limitations greater than those incorporated into the RFC. (AT 34.) That finding is supported by substantial evidence.
The record before the ALJ did not include a functional assessment from a treating physician. However, on August 27, 2008, plaintiff was evaluated by consultative examiner Dr. Frank Chen, who personally examined plaintiff and reviewed plaintiff's records. (AT 291-93.) Plaintiff's chief complaints were listed as deafness of the left ear, coronary artery disease, chronic low back pain, numbness of the right hand and right foot, and chronic pain in the neck. (AT 291.) Dr. Chen noted plaintiff's bypass surgery in January of 2008, as well as placement of a stent in August of 2008 with improvement of chest pain. (
Thereafter, on September 30, 2008, and January 27, 2009, the non-examining state agency physicians respectively reviewed plaintiff's records and determined that plaintiff was essentially capable of performing medium work. (AT 306-11, 352-53.) Those assessments were thus largely consistent with Dr. Chen's opinion.
Even though the ALJ ultimately gave plaintiff the benefit of the doubt and limited plaintiff to light work, the assessments of the consultative examiner and state agency physicians certainly undermine plaintiff's allegations of disabling functional limitations. Moreover, the assessments are consistent with results from objective testing conducted by plaintiff's treating providers. For example, although the treatment records document plaintiff's complaints of constant chest pain and shortness of breath, related imaging studies revealed largely normal findings. On June 25, 2008, a chest x-ray noted plaintiff's prior coronary artery bypass surgery, but showed no acute findings. (AT 285.) Subsequent December 22, 2008 and May 12, 2009 chest x-rays were likewise normal, also revealing no acute lung disease. (AT 340, 385.) Further cardiac diagnostic studies performed on September 9, 2011, indicated that the mitral valve structures, aortic valve structures, left and right ventricular chamber size, and left atrial chamber size were normal; there was no pericardial effusion; and the ejection fraction was 66%, with only mild mitral and tricuspid regurgitation. (AT 427.) Another study on September 11, 2011, showed normal perfusion with no evidence of stress induced ischemia; global left ventricular ejection fraction within normal limits at 53-57%; and normal wall motion. (AT 426.) Likewise, although plaintiff complained of debilitating back pain, a December 13, 2010 x-ray of the lumbar spine revealed essentially normal findings, and a subsequent June 22, 2011 MRI of the lumbar spine showed only "[m]inor annulus bulging with the lowest 3 lumbar levels without evidence of a significant degree of spinal or foraminal stenosis and without significant progression of any abnormality when compared to [previous MRI of] 06/03/2009." (AT 561, 564.)
To be sure, "after a claimant produces objective medical evidence of an underlying impairment, an ALJ may not reject a claimant's subjective complaints based solely on a lack of medical evidence to fully corroborate the alleged severity" of the symptoms.
In discounting plaintiff's credibility, the ALJ also rationally observed that, apart from the initial bypass surgery in January 2008 (prior to the alleged disability onset date), plaintiff did not receive the type of treatment one would expect for a totally disabled individual. (AT 34.) Indeed, the record reveals that plaintiff on several occasions failed to comply with his treatment regimen, and that some of his own treating physicians expressed doubts about his credibility.
Additionally, the ALJ pointed to some inconsistency in plaintiff's statements at the hearing: "The claimant said that he experiences shortness of breath if he walks too far; he said "too far" was fifteen feet but then said that he walks two blocks to walk his daughter to school — and one would assume he walks two blocks back to his home." (AT 33, 55, 57.) The inconsistency is plausibly indicative of some exaggeration on plaintiff's part. Although this single, limited inconsistency may not be sufficient by itself to discredit plaintiff, it is consistent with other evidence of potential exaggeration and excessive complaints, such as the notations of treating cardiologist Dr. Jones, discussed above. As such, the ALJ properly considered it as part of the credibility analysis.
Finally, the ALJ noted plaintiff's testimony that he last worked full time in 2001 or 2002, and that plaintiff's work history showed only sporadic employment prior to the alleged disability onset date of April 2, 2008, "which raises a question as to whether the claimant's continuing unemployment is actually due to medical impairments." (AT 33-34, 47.)
In light of the above, the court concludes that the ALJ provided several specific, clear, and convincing reasons for discounting plaintiff's credibility. The record may well contain some contrary evidence that plaintiff could point to in an attempt to bolster his credibility. However, it is the function of the ALJ to resolve any ambiguities, and the court finds the ALJ's assessment to be reasonable and supported by substantial evidence. As the Ninth Circuit explained:
Plaintiff further argues that the ALJ improperly discounted the testimony of plaintiff's mother. "[C]ompetent lay witness testimony cannot be disregarded without comment" and "in order to discount competent lay witness testimony, the ALJ must give reasons that are germane to each witness."
Here, the ALJ referenced the testimony of plaintiff's mother, clearly indicating that he had considered the information for purposes of assessing plaintiff's RFC. As discussed above, the ALJ provided specific, clear, and convincing reasons for discounting plaintiff's testimony. Several of those reasons (particularly the weight of the medical evidence, plaintiff's failure to comply with his treatment regimen, and plaintiff's work history) are equally germane to the testimony of plaintiff's mother, which largely echoed plaintiff's own testimony. Any error in not explicitly re-stating or linking the reasons given for discounting plaintiff's testimony with respect to discounting plaintiff's mother's testimony was harmless, and remand is not warranted on that basis.
Plaintiff contends that the ALJ's RFC is not supported by substantial evidence, because plaintiff's testimony that he could walk no more than 15 feet before becoming out of breath is inconsistent with a light work RFC, which involves standing and walking up to 6 hours in an 8-hour workday. However, for the reasons discussed above, the ALJ provided specific, clear, and convincing reasons for discounting plaintiff's credibility, and as such, the ALJ was not required to incorporate a 15-feet walking limitation into the RFC.
In addition to limiting plaintiff to light work, the ALJ found that plaintiff had non-exertional limitations related to left ear hearing loss. (AT 32-33.) A June 20, 2008 audiometric evaluation indicated that plaintiff had speech discrimination of 80% at 75 decibels in the right ear and 56% at 100 decibels in the left ear. (AT 268.) Plaintiff contends that the ALJ erroneously relied on the Grids in finding plaintiff not disabled, and instead should have obtained testimony from the VE concerning plaintiff's non-exertional hearing limitation.
The "Grids" take administrative notice of the numbers of unskilled jobs that exist throughout the national economy at various functional levels. 20 C.F.R. Part 404, Subpart P, Appendix 2, § 200.00(b). "The ALJ can use the grids without vocational expert testimony when a non-exertional limitation is alleged because the grids provide for the evaluation of claimants asserting both exertional and non-exertional limitations. But the grids are inapplicable when a claimant's non-exertional limitations are sufficiently severe so as to significantly limit the range of work permitted by the claimant's exertional limitations."
In this case, the record indicates that plaintiff's hearing limitation would not significantly limit the range of work permitted by plaintiff's exertional limitations. Plaintiff informed consultative examiner Dr. Chen that he had been deaf in his left ear since birth, but that he was able to hear with a hearing aid. (AT 291.) Because plaintiff had previously worked full time as a general laborer despite his hearing impairment (AT 47), it stands to reason that his longstanding hearing impairment would not significantly erode the range of light work plaintiff could perform. Additionally, the transcript from the administrative hearing also reasonably suggests that plaintiff had minimal, if any, difficulty understanding and responding to the ALJ's questions. Therefore, remanding for vocational expert testimony is unnecessary.
Finally, plaintiff argues that the Appeals Council erred in denying plaintiff's request to review the ALJ's decision in light of the additional evidence that was submitted to the Appeals Council. That argument lacks merit.
Technically, federal courts "do not have jurisdiction to review a decision of the Appeals Council denying a request for review of an ALJ's decision, because the Appeals Council decision is a non-final agency action. When the Appeals Council declines review, the ALJ's decision becomes the final decision of the Commissioner, and the district court reviews that decision for substantial evidence, based on the record as a whole. . . ."
Thus, the court construes plaintiff's argument as contending that the Commissioner's final decision is not supported by substantial evidence in the record as a whole when the Appeals Council evidence is considered along with the other record evidence. Plaintiff specifically points to a functional capacity questionnaire submitted to the Appeals Council, which was completed by nurse practitioner Maricel Fernandez Cabanlit on February 21, 2012, and endorsed by a treating physician, Dr. Arun Anand on April 18, 2012. (AT 565-69.) According to that questionnaire, plaintiff had numerous disabling limitations, including that plaintiff could only sit for 20 minutes at a time; stand for 10 minutes at a time; sit and stand/walk for less than 2 hours total in an 8-hour workday; never lift even less than 10 pounds; rarely twist; never stoop/bend, crouch/squat, or climb ladders or stairs; and would be absent from work more than four days per month. (AT 567-68.) Even though the questionnaire was prepared in 2012, it states that the limitations assessed were present at least as of May 18, 2009, the date on which plaintiff started treatment with Dr. Anand, and the questionnaire thus plausibly relates to the period prior to the ALJ's September 19, 2011 decision.
Nevertheless, remand for further consideration of Dr. Anand's opinion is not warranted, because the opinion is conclusory and minimally supported.
Because substantial evidence in the record as a whole supports the ALJ's decision, even when the additional Appeals Council evidence is considered, remand is inappropriate.
For the foregoing reasons, the court finds that the ALJ's decision was free from prejudicial error and supported by substantial evidence in the record as a whole. Accordingly, IT IS HEREBY ORDERED that:
The claimant bears the burden of proof in the first four steps of the sequential evaluation process.