KENDALL J. NEWMAN, Magistrate Judge.
Plaintiff seeks judicial review of a final decision by the Commissioner of Social Security ("Commissioner") denying plaintiff's application for Supplemental Security Income ("SSI") under Title XVI of the Social Security Act ("Act").
After carefully considering the parties' written briefing, the court's record, and the applicable law, the court DENIES plaintiff's motion, GRANTS the Commissioner's cross-motion, and AFFIRMS the final decision of the Commissioner.
Plaintiff was born on May 12, 1972, completed the eleventh grade and later obtained a GED, and is able to communicate in English. (Administrative Transcript ("AT") 64, 69, 506, 683.)
The new hearing was scheduled for June 12, 2007; however, plaintiff failed to appear and the ALJ issued a notice to show cause based on that failure. (AT 378-79, 476-81.) On August 10, 2007, the ALJ issued a decision dismissing plaintiff's case because plaintiff failed to provide good cause for her failure to appear at the hearing. (AT 380-83.) Plaintiff requested review of that decision before the Appeals Council, which granted review, and issued an order on May 3, 2008, that vacated the ALJ's decision of dismissal and directed the ALJ to conduct another hearing. (AT 433-35.)
An ALJ held another hearing on July 8, 2008, at which plaintiff and a vocational expert ("VE") testified. (AT 369.) The ALJ issued a decision dated February 26, 2009, determining that plaintiff had not been under a disability, as defined in the Act, from her application date, through the date of that decision. (AT 369-77.) The ALJ's decision became the final decision of the Commissioner when the Appeals Council denied plaintiff's request for review on May 24, 2011. (AT 354-57.) Plaintiff again filed an action in federal district court for review of the ALJ's decision pursuant to 42 U.S.C. § 405(g), and the court remanded the case for further proceedings at the Commissioner's request because a transcript of the hearing held on July 8, 2008, could not be prepared. (AT 520-23.) Accordingly, on December 20, 2012, the Appeals Council vacated the ALJ's February 29, 2009 decision and remanded for a further hearing before an ALJ. (
An ALJ held a third hearing in this matter on July 17, 2013, at which plaintiff, represented by counsel, and a VE testified. (AT 661-723.) The ALJ issued a decision dated October 25, 2013, determining that plaintiff had not been under a disability, as defined in the Act, from her application date, through the date of that decision. (AT 496-507.) The ALJ's decision became the final decision of the Commissioner when the Appeals Council denied plaintiff's request for review on September 23, 2015. (AT 482-85.) Plaintiff filed this action in federal district court on September 23, 2015, to obtain judicial review of the Commissioner's final decision. (ECF No. 1.)
On appeal, plaintiff raises the following issues: (1) whether the ALJ's residual functional capacity ("RFC") determination with regard to plaintiff's physical functioning was supported by substantial evidence in the record; (2) whether the ALJ erred in considering the medical opinions of Dr. Marshall and Dr. Kalman when rendering his RFC determination; (3) whether the ALJ erred in determining that plaintiff's pain and symptom testimony was not credible; and (4) whether the ALJ erred in relying on the VE's testimony to determine at step five of the sequential analysis that there were other jobs within that national economy that plaintiff could perform given her RFC.
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 SSI pursuant to the Commissioner's standard five-step analytical framework.
Before proceeding to step four, the ALJ assessed plaintiff's RFC as follows:
(AT 500.)
At step four, the ALJ found that plaintiff was unable to perform her past relevant work. (AT 506.) At step five, the ALJ found 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. (
First, plaintiff argues that the ALJ erred in finding that plaintiff has the physical RFC to perform medium work because that determination is not supported by any medical opinion evidence in the record. More specifically, plaintiff argues that all of the opinion evidence in the record is with regard to the extent of plaintiff's mental limitations; no physician has opined on plaintiff's physical limitations. Plaintiff contends that this means that the ALJ must have rendered his determination that plaintiff can perform medium work based off nothing more than his own lay opinion and the record was inadequate to allow the ALJ to properly evaluate the medical evidence regarding plaintiff's physical impairments. Plaintiff argues that the ALJ committed prejudicial error in rendering his physical RFC determination on such a basis, therefore, this action should be remanded so the ALJ can obtain an opinion from one of plaintiff's treating physicians, or order a consultative examination regarding the extent of plaintiff's physical impairments. The court finds plaintiff's argument lacks merit.
The evidence in the record regarding plaintiff's physical impairments consists primarily of plaintiff's own complaints regarding stomach, hand, and back issues, and headaches, which plaintiff claims caused disabling levels of pain. (
Plaintiff contends, however, that the sparse medical evidence in the record regarding plaintiff's physical impairments still does not support the ALJ's determination that plaintiff could perform the specific functional requirements of medium work, such as an ability to stand and/or walk 6 hours in an 8-hour workday. However, even assuming arguendo that there was not substantial evidence in the record to support the ALJ's specific finding that plaintiff could perform medium work, any such error was harmless because plaintiff's medical records regarding her physical impairments clearly demonstrate that plaintiff did not have a debilitating physical impairment. If anything, the ALJ actually gave plaintiff the benefit of the doubt in finding that her physical RFC rendered her capable of medium work given the fact that the objective medical evidence in the record shows that plaintiff had physical impairments that were mostly temporary and no more than mild in nature. (
Plaintiff also argues that the lack of medical evidence in the record regarding plaintiff's physical impairments means that the ALJ was required to further develop the record. "An ALJ's duty to develop the record further is triggered only when there is ambiguous evidence or when the record is inadequate to allow for proper evaluation of the evidence."
20 C.F.R. § 416.912(a). Plaintiff failed to proffer sufficient evidence that she had a debilitating physical impairment; it was not the ALJ's duty to take steps to rectify that failure.
Second, plaintiff argues that the ALJ erred in considering and weighing the medical opinion evidence in the record regarding plaintiff's mental impairments. Specifically, plaintiff argues that the ALJ erred by assigning "good weight" to the opinion of Dr. Marshall, a consultative examining psychologist, but failing to fully capture the limitations opined by that physician within his RFC determination. Plaintiff also argues that the ALJ erred by assigning "little weight" to the opinions of Dr. Kalman, a consultative examining psychiatrist, without providing proper reasons for doing so that were supported by substantial evidence in the record.
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.
Dr. Marshall conducted a complete psychiatric evaluation of plaintiff on August 25, 2002, which consisted of a review of plaintiff's medical records, an interview with plaintiff, and an independent mental status examination. (AT 122-28.) Based on this examination, Dr. Marshall provided an assessment of plaintiff's workplace limitations stemming from her mental impairments. (AT 128.) In that assessment, Dr. Marshall opined that plaintiff has no impairment in the ability to carry out simple job instructions, but "may be impaired" in the ability to understand, remember, or complete complex commands. (
The ALJ assigned "good weight" to Dr. Marshall's opinion because her opinion was "supported by objective findings including observations upon mental status testing as well as being consistent with the evidence of record as a whole." (AT 502.) Plaintiff argues that the ALJ's RFC determination failed to properly incorporate into his RFC determination the limitations Dr. Marshall opined with regard to plaintiff's ability to interact with supervisors and coworkers and in adapting to work-place stressors, which plaintiff contends constitutes prejudicial error as those limitations should also have been included in the ALJ's RFC determination. The court finds plaintiff's argument unpersuasive.
In addition to assigning "good weight" to Dr. Marshall's opinion, the ALJ also assigned "great weight" to the opinion of Dr. Gottschalk, another examining psychiatrist. (AT 502-03.) Dr. Gottschalk completed a mental residual functional capacity assessment after an examination of plaintiff on April 10, 2003. (AT 191-93.) Dr. Gottschalk opined that plaintiff is not significantly limited in the ability to remember locations and work-like procedures; understand, remember, and carry out very short and simple instructions; sustain an ordinary routine without special supervision; make simple work-related decisions; ask simple questions or request assistance; maintain socially appropriate behavior and to adhere to basic standards of neatness and cleanliness; respond appropriately to changes in the work setting; be aware of normal hazards and take appropriate precautions; and travel in unfamiliar places or use public transportation. (AT 191-92). He opined further that plaintiff is "moderately limited" in the ability to understand, remember, and carry out detailed instructions; maintain concentration and attention for extended periods; perform activities within a schedule, maintain regular attendance, and be punctual within customary tolerances; work in coordination with or proximity to others without being distracted by them; complete a normal workday and workweek without interruptions from psychologically based symptoms and perform at a consistent pace without an unreasonable number and length of rest periods; interact appropriately with the general public; accept instructions and respond appropriately to criticism from supervisors; get along with coworkers or peers without distracting them or exhibiting behavioral extremes; and set realistic goals and make plans independently of others. (
By assigning "great weight" to Gottschalk's opinion, the ALJ determined that it more closely reflected plaintiff's actual mental RFC than the opinion of Dr. Marshall, who the ALJ found to be only somewhat less persuasive. (AT 502-03.) The ALJ reasonably reflected this determination in his mental RFC determination that plaintiff can rarely have face-to-face interaction with the public; frequently have face-to-face interaction with coworkers and supervisors; occasionally understand remember, and carry out complex or detailed job instructions; and work at jobs that have weekly or daily, but not hourly goals or quotas. (AT 500.) Indeed, these limitations contained in the ALJ's RFC determination reflected a synthesis of both Dr. Marshall's and Dr. Gottschalk's opinions, with a slight favorability given to the limitations opined by Dr. Gottschalk's opinion when the two physicians' opinions differed.
The ALJ is "not required to adopt or rely on any medical source opinion in making [his] residual functional capacity assessment[.]"
Dr. Kalman conducted two consultative psychiatric examinations of plaintiff. The first examination occurred on August 4, 2003. (AT 265-73.) After this examination, Dr. Kalman diagnosed plaintiff with a schizoaffective disorder and schizophrenia, chronic paranoid type, rule out borderline personality disorder; and assessed Plaintiff with a global assessment of functioning ("GAF") score of 50. (AT 267.) Dr. Kalman opined that plaintiff is unable to get along with the public or her family; is emotionally labile with rapid speech; is unable to relate and interact with coworkers and supervisors; is unable to interact with the public; is able to understand, remember, and execute simple one- and two-step job instructions; has a decreased ability to maintain attention and concentration; has a limited ability to withstand stress and pressures associated with daily work activities; and is not competent to handle her own funds. (
Dr. Kalman also completed a medical source statement regarding the extent of the limitations caused by plaintiff's mental impairments. (AT 270-73.) Therein, Dr. Kalman opined that plaintiff is not significantly limited in the ability to understand, remember, and carry out very short (one to two step) instructions or tasks, and was mildly limited in her ability to remember locations and work-like procedures, make simple work-related decisions, maintain socially appropriate behavior and adhere to basic standards of neatness and cleanliness, and be aware of normal hazards and take appropriate precautions. (AT 270-72.) Dr. Kalman opined further that plaintiff is moderately limited in the ability to understand, remember, and carry out detailed (three or more step) instructions, which may or may not be repetitive; maintain attention and concentration for extended periods (approximately two-hour segments between arrival and first break, lunch, second break, and departure) with four such periods in a workday; perform activities within a schedule, maintain regular attendance, and be punctual within customary tolerances; sustain an ordinary routine without special supervision; work in coordination with or proximity to others without being unduly distracted by them; complete a normal workday and workweek without interruptions from psychologically based symptoms; perform at a consistent pace without an unreasonable number and length of rest periods; interact appropriately with the general public or customers; ask simple questions or request assistance from supervisors; respond appropriately to expected or unexpected changes in the work setting; travel in an unfamiliar place or use public transportation; and set realistic goals or to make plans independently of others. (
Dr. Kalman conducted his second psychiatric examination of plaintiff and rendered a second opinion regarding the extent of plaintiff's mental impairments on June 30, 2008. (AT 452-61.) After this second examination, Dr. Kalman diagnosed plaintiff with a generalized anxiety disorder, depressive disorder, not otherwise specified, and borderline intellectual functioning; and assessed plaintiff with a GAF score of 55. (AT 455.) Dr. Kalman also completed a second medical source statement regarding the extent of limitations caused by plaintiff's mental impairments. (AT 458-61.) Unlike his first opinion, Dr. Kalman found that plaintiff is not markedly limited in any area of mental functioning. (
The ALJ provided the following assessment with regard to Dr. Kalman's opinions:
(AT 505.) These were specific and legitimate reasons for discounting Dr. Kalman's opinions that were supported by substantial evidence in the record.
First, the ALJ properly determined that Dr. Kalman's earlier opinion was based more on plaintiff's own subjective complaints regarding the extent of her mental limitations, rather than the objective medical findings reflected in plaintiff's examination, including his own findings. Indeed, it was reasonable for the ALJ to determine that the more limiting aspects of Dr. Kalman's 2003 opinion were based primarily on plaintiff's complaints as they were not corroborated by any other examination or physicians' opinion in the record, including Dr. Kalman's later examination and opinion. (
Second, the ALJ also properly determined the fact that Dr. Kalman opined in his second opinion that plaintiff was less restricted in many areas of mental functioning than what he opined in his initial assessment, thus indicating that plaintiff's mental impairments actually improved over the course of the roughly five years between Dr. Kalman's two examinations. Indeed, in his 2008 opinion, Dr. Kalman found that plaintiff had either mild or moderate mental limitations in all areas of mental functioning. (AT 458-60.) This opinion contrasted with his opinion in 2003, where he found that plaintiff primarily had moderate mental limitations in most areas of mental functioning with marked limitations in some others, and clearly demonstrated that plaintiff's mental condition improved between the two examinations. (AT 270-71.) As the ALJ noted in his decision, the fact that the record shows that plaintiff was not taking psychotropic medications nor attending any therapy or counseling for her mental impairments at the time of Dr. Kalman's 2008 opinion emphasizes the fact that plaintiff improved without treatment, and that the more restrictive limitations contained in Dr. Kalman's earlier opinion did not accurately reflect plaintiff's mental functioning throughout the course of the relevant period.
Finally, the ALJ also properly determined that the inconsistencies between certain details contained in Dr. Kalman's earlier and later examination notes, coupled with the fact that both of his medical source statements were cursory in nature, undermined the reliability of those opinions.
In sum, the ALJ provided multiple specific and legitimate reasons for discounting Dr. Kalman's opinions that were supported by substantial evidence in the record. Accordingly, the ALJ did not err in his assessment of that physician's opinions.
Third, plaintiff argues that the ALJ erred in finding plaintiff's testimony less than fully credible because the ALJ's reasons for discounting that testimony were not clear and convincing reasons supported by substantial evidence.
In
"The ALJ must specifically identify what testimony is credible and what testimony undermines the claimant's complaints."
Here, the ALJ found plaintiff's testimony regarding the extent of the pain and limitations stemming from her mental and physical impairments to be less than fully credible based on the following rationale:
(AT 502.) This rationale provided clear and convincing reasons to support the ALJ's adverse credibility determination that were supported by substantial evidence in the record.
First, the ALJ properly determined that plaintiff's claims of disabling symptoms stemming from her impairments was belied by the objective medical evidence in the record. Although a lack of medical evidence cannot form the sole basis for discounting plaintiff's subjective symptom testimony, it is nevertheless a relevant factor for the ALJ to consider.
Indeed, the ALJ also properly concluded that the evidence in the record of plaintiff's inconsistent statements undermined the credibility of her testimony regarding the extent of her symptoms. First, the record shows that while plaintiff noted in her disability report that she obtained her GED, she told Dr. Kalman that she had only completed the eleventh grade. (AT 76, 453.) Plaintiff later clarified during the administrative hearing that she had only completed the eleventh grade, but then later obtained her GED, therefore indicating that her statement to Dr. Kalman regarding her education did not inherently conflict with her statement in her disability report. (AT 683.) However, the ALJ reasonably noted in his decision that plaintiff's omission of the fact that she has a GED to Dr. Kalman may have influenced that physician's opinion that plaintiff had borderline intellectual functioning, therefore negatively impacting plaintiff's credibility had the omission been purposeful. (AT 502.)
More importantly, the ALJ properly discounted plaintiff's credibility because she gave inconsistent statements about her drug and alcohol history.
In sum, the ALJ provided multiple permissible grounds for his adverse credibility determination with regard to plaintiff's testimony that were supported by substantial evidence from the record.
Finally, plaintiff argues that the ALJ erred in rendering his step-five determination based on the testimony provided by the VE because the ALJ's hypothetical based on his RFC determination failed to fully encompass all of plaintiff's limitations supported by the evidence in the record, therefore meaning that the VE's testimony did not constitute substantial evidence. Specifically, plaintiff contends that the ALJ's hypothetical based on his RFC determination failed to incorporate certain mental limitations opined by Dr. Marshall despite the fact that the ALJ gave that physician's opinion "good weight." However, as discussed above, the ALJ properly considered and weighed Dr. Marshall's opinion and based the limitations contained in his RFC determination on substantial evidence from the record.
The ALJ posed a hypothetical to the VE that incorporated all of the limitations included in the ALJ's RFC determination, to which the VE responded that there existed several jobs within the national economy that plaintiff could perform. (AT 718-20.) The ALJ properly relied on this testimony to support his step five determination that there existed jobs in significant numbers within the national economy that plaintiff could perform given her RFC.
In sum, 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:
1. Plaintiff's motion for summary judgment (ECF No. 14) is DENIED.
2. The Commissioner's cross-motion for summary judgment (ECF No. 21) is GRANTED.
3. The Commissioner's final decision is AFFIRMED, and judgment is entered for the Commissioner.
4. The Clerk of Court shall close this case.
The claimant bears the burden of proof in the first four steps of the sequential evaluation process.