KENDALL J. NEWMAN, Magistrate Judge.
Plaintiff seeks judicial review of a final decision by the Commissioner of Social Security ("Commissioner") denying plaintiff's applications 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 GRANTS IN PART plaintiff's motion for summary judgment, DENIES the Commissioner's cross-motion for summary judgment, and remands the case for further proceedings under sentence four of 42 U.S.C. § 405(g).
Plaintiff was born on May 8, 1962, has no formal education, and primarily communicates in Mien with little to no ability to communicate in English. (Administrative Transcript ("AT") 182, 186-87.)
On appeal, plaintiff raises the following issues: (1) whether the ALJ improperly rejected the opinions of consultative examining psychologists Drs. Ewing and Stiles; and (2) whether the ALJ improperly rejected the opinion of plaintiff's treating physician Dr. Marzano.
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 15.)
At step four, the ALJ determined that plaintiff was capable of performing past relevant work as a laundry sorter and fruit cutter. (AT 20.) Thus, the ALJ concluded that plaintiff had not been under a disability, as defined in the Act, from January 25, 2011, through the date of the ALJ's decision. (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.
While a treating professional's opinion generally is accorded superior weight, if it is contradicted by a supported examining professional's opinion (supported by different independent clinical findings), the ALJ may resolve the conflict.
Here, the ALJ discussed three medical opinions regarding plaintiff's limitations based on her mental impairments
Dr. Ewing's opinion was based on an examination of plaintiff on October 24, 2011, performed at the request of the Commissioner. (AT 373.) On that date, Dr. Ewing reviewed plaintiff's medical records and had the assistance of an interpreter. (
Nearly nine months after Dr. Ewing's opinion, on July 16, 2012, Dr. Stiles examined the plaintiff at the request of the Commissioner and issued an opinion. (AT 394.) Dr. Stiles had the services of an interpreter and reviewed plaintiff's medical records. (AT 394-96.) Dr. Stiles diagnosed plaintiff with "major depression, severe with psychotic symptoms." (AT 398.) Dr. Stiles opined that plaintiff could perform one or two step simple repetitive tasks, but was unable to perform complex tasks because of her intellectual impairments. (
For the reasons discussed below, the ALJ failed to provide specific and legitimate reasons for discounting these opinions.
The ALJ discounted the opinions' clinical findings that plaintiff had impairments to attention and concentration because such findings were "possibly due to language barrier." (AT 17.) However, both consultative examiners had the assistance of an interpreter. Even though Dr. Stiles noted that the section of her exam dealing with proverbs "does not translate," that simply demonstrates that Dr. Stiles was able to note that linguistic barriers interfered with a specific portion of the exam. (AT 373-78.) Given the complete absence of any other references to linguistic difficulties in the opinion, there is simply no basis for asserting that a language barrier affected the clinical findings regarding attention or concentration.
The ALJ also discounted the opinions as "based primarily" on plaintiff's subjective and self-reported psychotic symptoms, such as auditory hallucinations, which the ALJ found not credible. (AT 373, 394). However, irrespective of the credibility of plaintiff's auditory hallucinations, Drs. Ewing and Stiles specifically based their assessed limitations on their clinical findings regarding plaintiff's attention, concentration, and memory. (AT 377, 398.) Furthermore, both doctors explicitly stated that their respective opinions were "[b]ased on the results of the requested mental status exam and clinical interview, including personal history and accompanying documents. . . ." (
The ALJ further alluded to an inconsistency between plaintiff's daily activities and the opinions of Drs. Ewing and Stiles. (AT 19.) However, the mental limitations assessed by Drs. Ewing and Stiles are not obviously inconsistent with plaintiff being independent in basic activities of daily living, not requiring assistance in preparing meals, being able to make change at the store, and spending the day walking. (AT 19, 375, 396). Without further explanation by the ALJ, conclusions at this level of generality simply cannot constitute a specific and legitimate reason for discounting the consultative examiners' opinions.
The ALJ also appears to rely on his finding of an inconsistency between the assessed mental limitations and plaintiff's treatment recommendations. (AT 20.) The ALJ references two specific treatment recommendations: Dr. Nguyen's recommendation that the plaintiff start a mild exercise plan (AT 470) and the Wellness and Recovery Center's ("WRC") Annual Service Plan, which recommended that plaintiff attend a WRC support group. (AT 484.) However, Dr. Nguyen is not a psychiatrist or psychologist, and his recommendations were issued to help plaintiff treat her physical impairments. Furthermore, the WRC's recommendation was based on an explicit finding that plaintiff's ability to socialize was impaired and was intended to help build plaintiff's social skills in a highly structured environment. (AT 484.) The ALJ does not articulate how those treatment recommendations were inconsistent with the mental limitations assessed by the consultative examiners.
Therefore, the court concludes that the ALJ has not provided specific and legitimate reasons to discount the opinions of the consultative examiners. Remand for further consideration of those opinions is warranted.
Plaintiff contends that the ALJ also erred by discounting the opinion of Dr. Marzano, plaintiff's treating physician. At least at an initial glance, Dr. Marzano's opinion appears to be a checklist with minimal clinical findings or medical rationale in support of its conclusions. (AT 434-36.) Furthermore, Dr. Marzano's treatment records are very sparse. (AT 482-98.) Nevertheless, because the court concludes that remand is necessary to further consider the opinions of the consultative examiners, the ALJ will have an opportunity to reconsider Dr. Marzano's opinion, if appropriate, and explain the ultimate weight accorded to that opinion.
On remand, the ALJ shall further consider the opinions of the consultative examiners. The ALJ is also free to develop the record in other ways, as needed. 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. Nevertheless, the ALJ's decision shall comply with applicable legal standards and be supported by substantial evidence in the record as a whole.
For the foregoing reasons, IT IS HEREBY ORDERED that:
1. Plaintiff's motion for summary judgment (ECF No. 14) is GRANTED IN PART.
2. The Commissioner's cross-motion for summary judgment (ECF No. 17) is DENIED.
3. The Commissioner's final decision is REVERSED and the action is REMANDED for further proceedings consistent with this order pursuant to sentence four of 42 U.S.C. § 405(g).
4. Judgment is entered for plaintiff.
The claimant bears the burden of proof in the first four steps of the sequential evaluation process.