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") under Title II of the Social Security Act ("Act").
For the reasons that follow, the court recommends that plaintiff's motion for summary judgment be GRANTED IN PART, the Commissioner's cross-motion for summary judgment be DENIED, and the action be remanded for further proceedings pursuant to sentence four of 42 U.S.C. § 405(g).
Plaintiff was born on November 22, 1960; has a GED; can speak, understand, read, and write in English; and previously worked primarily as a cement mason. (Administrative Transcript ("AT") 37-39, 130.) On August 11, 2011, plaintiff applied for DIB, alleging that she was unable to work as of August 1, 2008, due to frequent staph infections, plantar fasciitis, bilateral knee pain, back pain, neck pain, limited range of motion in the left shoulder, and depression. (AT 11, 60-61, 113, 131.) After the Commissioner denied plaintiff's application initially and on reconsideration, plaintiff requested a hearing before an administrative law judge ("ALJ"), which took place on October 11, 2012, and at which plaintiff (represented by a non-attorney representative) testified. (AT 11, 33-52.) At that hearing, plaintiff amended her alleged disability onset date to May 14, 2007. (AT 11, 50.)
In a decision dated November 15, 2012, the ALJ determined that plaintiff had not been under a disability, as defined in the Act, at any time from May 14, 2007, plaintiff's amended alleged disability onset date, through December 31, 2008, plaintiff's date last insured. (AT 11-21.) The ALJ's decision became the final decision of the Commissioner when the Appeals Council denied plaintiff's request for review on March 27, 2014. (AT 2-4.) Thereafter, plaintiff filed this action in federal district court on May 28, 2014, to obtain judicial review of the Commissioner's final decision. (ECF No. 1.)
On appeal, plaintiff raises the following issues: (1) whether the ALJ erroneously rejected the opinion of one of plaintiff's treating physicians; (2) whether the ALJ improperly discounted the credibility of plaintiff and her husband; (3) whether the ALJ's residual functional capacity ("RFC") assessment was erroneous and unsupported by substantial evidence; and (4) whether the ALJ erred in not obtaining vocational expert testimony for purposes of making a determination at step five of the sequential disability evaluation process.
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 pursuant to the Commissioner's standard five-step analytical framework.
Before proceeding to step four, the ALJ found that, through the date last insured, plaintiff had the RFC to perform the full range of light work as defined in 20 C.F.R. § 404.1567(b). (AT 15.) At step four, the ALJ determined that plaintiff was unable to perform any past relevant work through the date last insured. (AT 20.) However, at step five, the ALJ held, 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 have performed through the date last insured. (
Therefore, the ALJ concluded that plaintiff had not been under a disability, as defined in the Act, at any time from May 14, 2007, plaintiff's amended alleged disability onset date, through December 31, 2008, plaintiff's date last insured. (AT 21.)
The weight given to medical opinions depends in part on whether they are proffered by treating, examining, or non-examining professionals.
To evaluate whether an ALJ properly rejected a medical opinion, in addition to considering its source, the court considers whether (1) contradictory opinions are in the record; and (2) clinical findings support the opinions. An ALJ may reject an uncontradicted opinion of a treating or examining medical professional only for "clear and convincing" reasons.
In this case, one of plaintiff's treating physicians, Dr. James Gonzalez, in a July 21, 2011 treatment note stated that:
(AT 746.) The ALJ essentially rejected Dr. Gonzalez's opinion, reasoning that it was vague, ambiguous, and conclusory; it failed to provide any specific functional limitations; and it was not clear whether Dr. Gonzalez was familiar with the definition of disability under the Act. (AT 19.)
To be sure, Dr. Gonzalez's July 21, 2011 note is vague, ambiguous, and conclusory. It fails to set forth any meaningful functional limitations to be potentially incorporated into the RFC. Furthermore, as the ALJ suggested, it is far from clear whether Dr. Gonzalez opined that plaintiff was disabled as that term is understood in the social security context. Indeed, Dr. Gonzalez's discussion of plaintiff's previous work and the requirements of that work may at least plausibly suggest that he used the term permanently disabled to mean that plaintiff was permanently unable to perform her previous heavy work. Nevertheless, although an ALJ may generally reject a conclusory, minimally supported opinion by a treating physician, the court concludes, for the reasons outlined below, that the ALJ should have further developed the record under the circumstances of this case.
As an initial matter, although Dr. Gonzalez's July 21, 2011 note is conclusory, the record contains copious treatment records by Dr. Gonzalez and other treating physicians, which documented plaintiff's multiple surgeries, chronic wound infections, home health care by visiting nurses, abdominal hernias, headaches, and plantar fasciitis during the relevant period. Additionally, another physician, Dr. Tamas Vidovszky, who plaintiff consulted for a second opinion on November 1, 2011, documented that plaintiff at that time had a large, moderately symptomatic abdominal wall hernia. (AT 848.)
Additionally, the court finds it significant that the ALJ in this case did not obtain an opinion from a consultative expert who personally examined plaintiff. Instead, the ALJ relied on the opinion of a non-examining state agency physician to conclude that plaintiff was capable of performing the full range of light work. (AT 19.) Even though the opinion of a non-examining medical expert can constitute substantial evidence when it is consistent with other independent evidence in the record, the record evidence here is too ambiguous to permit such reliance on the non-examining opinion.
Accordingly, the court concludes that the case should be remanded for further development of the medical opinion evidence, as discussed below.
The court declines plaintiff's invitation to remand the case for an award of benefits. Generally, if the court finds that the ALJ's decision was erroneous or not supported by substantial evidence, the court must follow the "ordinary remand rule," meaning that "the proper course, except in rare circumstances, is to remand to the agency for additional investigation or explanation."
As noted above, Dr. Gonzalez's July 21, 2011 note is ambiguous and thus insufficient in itself to establish plaintiff's disability without further development of the record.
Additionally, the record contains other conflicting evidence at least potentially casting doubt on plaintiff's claims of extended disability. For example, on July 1, 2008, two weeks after plaintiff's last surgery, one of plaintiff's treating physicians observed that she was "doing well without any problems or complications" and was discharged from his care. (AT 611.) The record contains no further significant medical records prior to December 31, 2008, the date last insured, until a later visit on February 18, 2009, when plaintiff was noted to have an encrusted lesion on the navel, but with the remainder of the wound having healed well and no abdominal tenderness. (AT 224.) On November 19, 2009, one of plaintiff's treating physicians indicated that plaintiff was doing well, she had an abdominal hernia but no abdominal tenderness, and he recommended that she ride her bike for exercise. (AT 219-20.)
Finally, the court notes that the record contains numerous references to plaintiff's heavy alcohol use (at times, at least 7 alcoholic drinks per day), including suggestions by treating physicians that plaintiff's alcohol use and withdrawal significantly impacted her treatment and recovery from surgery. (
Therefore, in light of the ambiguities and conflicts in the record, as well as the issue of materiality of plaintiff's substance abuse, the court finds it appropriate to follow the ordinary remand rule and remand for further proceedings.
More specifically, on remand, the ALJ shall obtain a consultative examination of plaintiff by a physician who has
Importantly, the court expresses no opinion regarding how the evidence should ultimately be weighed, and any ambiguities or inconsistencies resolved, on remand. The court also does not instruct the ALJ to credit any particular opinion or testimony. The ALJ may ultimately find plaintiff disabled from May 14, 2007 through the present; may find plaintiff eligible for some type of closed period of disability benefits; or may find that plaintiff was never disabled during the relevant period—provided that the ALJ's determination complies with applicable legal standards and is supported by substantial evidence in the record as a whole.
In light of the court's conclusion that the case should be remanded for further development of the medical opinion evidence, the court declines to address plaintiff's remaining issues. On remand, the ALJ will have an opportunity to reconsider his findings concerning credibility and the RFC based on the developed record, if appropriate, and seek vocational expert testimony, if necessary. The court expresses no opinion concerning those issues at this juncture.
For the foregoing reasons, IT IS HEREBY RECOMMENDED that:
1. Plaintiff's motion for summary judgment (ECF No. 16) be GRANTED IN PART.
2. The Commissioner's cross-motion for summary judgment (ECF No. 22) be DENIED.
3. The action be remanded for further proceedings pursuant to sentence four of 42 U.S.C. § 405(g).
4. Judgment be entered for plaintiff.
These findings and recommendations are submitted to the United States District Judge assigned to the case, pursuant to the provisions of 28 U.S.C. § 636(b)(1). Within fourteen (14) days after being served with these findings and recommendations, any party may file written objections with the court and serve a copy on all parties. Such a document should be captioned "Objections to Magistrate Judge's Findings and Recommendations." Any reply to the objections shall be served on all parties and filed with the court within fourteen (14) days after service of the objections. The parties are advised that failure to file objections within the specified time may waive the right to appeal the District Court's order.
IT IS SO RECOMMENDED.
The claimant bears the burden of proof in the first four steps of the sequential evaluation process.
