JAMES R. KLINDT, Magistrate Judge.
Eric Hawkins ("Plaintiff") is appealing the Commissioner of the Social Security Administration's final decision denying his claims for disability insurance benefits ("DIB"). Plaintiff's alleged inability to work is a result of "[h]yperactivity," "bipolar," "depression," "ptsd," and "anxiety." Transcript of Administrative Proceedings (Doc. No. 8; "Tr." or "administrative transcript"), filed February 10, 2015, at 322 (capitalization and emphasis omitted). On April 2, 2012, Plaintiff protectively filed an application for DIB, alleging an onset disability date of May 10, 2010. Tr. at 178-80 (DIB). Plaintiff's "protective filing date" is listed elsewhere in the administrative transcript as March 27, 2012.
On October 28, 2013, an Administrative Law Judge ("ALJ") held a hearing during which the ALJ heard testimony from Plaintiff, who was represented by counsel, from Plaintiff's wife, Arlene Hawkins, and a vocational expert ("VE"). Tr. at 39-60. On January 31, 2014, the ALJ issued a Decision finding Plaintiff not disabled and denying Plaintiff's claim. Tr. at 21-30. Plaintiff then requested review by the Appeals Council, Tr. at 7-8, and submitted evidence to the Council in the form of a brief authored by his attorney representative and a Mental Medical Source Statement from Michael Sorna, M.D. Tr. at 5; see Tr. at 384-85 (representative's brief), 1758-61 (records from Dr. Sorna). On October 22, 2014, the Appeals Council denied Plaintiff's request for review, Tr. at 1-3, thereby making the ALJ's Decision the final decision of the Commissioner. On November 28, 2014, Plaintiff commenced this action under 42 U.S.C. § 405(g), by timely filing a Complaint (Doc. No. 1), seeking judicial review of the Commissioner's final decision.
Plaintiff raises two issues on appeal: whether "the ALJ properly consider[ed] the fact that [Plaintiff] was given a service connected 100% disability rating by the [Veterans Administration (VA)] and found to be incompetent to control or manage his own affairs"; and whether "[t]he ALJ adequately evaluate[d] the medical opinion evidence as to the severity of [Plaintiff's] mental impairments and his resulting functional limitations that were offered by a VA examining physician[.]"
After a thorough review of the entire record and consideration of the parties' respective filings, the undersigned finds that the Commissioner's final decision is due to be affirmed for the reasons stated herein.
When determining whether an individual is disabled,
Here, the ALJ proceeded through step four of the five-step inquiry, where her inquiry ended based on her step four finding.
The ALJ determined Plaintiff has the following residual functional capacity ("RFC"):
Tr. at 25 (emphasis omitted). At step four, the ALJ found, with the assistance of the VE, that Plaintiff "is capable of performing past relevant work as an order picker and housekeeping cleaner. This work does not require performance of work-related activities precluded by [Plaintiff's] RFC." Tr. at 29 (emphasis and citation omitted). Because the ALJ found Plaintiff capable of performing his past relevant work, the ALJ was not required to and did not proceed to step five. Accordingly, the ALJ concluded that Plaintiff "has not been under a disability . . . from May 10, 2010, through the date of th[e D]ecision." Tr. at 30 (emphasis and citation omitted).
This Court reviews the Commissioner's final decision as to disability pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3). Although no deference is given to the ALJ's conclusions of law, findings of fact "are conclusive if . . . supported by `substantial evidence' . . . ."
In his first argument, Plaintiff contends that "the ALJ's lack of any substantive discussion of the VA's 100% disability rating results in an inadequate decision that cannot withstand judicial review." Pl.'s Mem. at 6. In a related argument, Plaintiff contends that the ALJ failed to consider all the medical evidence and specifically failed to explain why she rejected the opinions of Dr. Sumerall, whose opinions regarding Plaintiff's mental impairment functional limitations were the basis for the VA finding Plaintiff to be 100% disabled. Id. at 15-18. The issues are addressed in turn.
Plaintiff argues that the ALJ only mentioned one time the VA's finding that he was totally disabled. Pl.'s Mem. at 6. Plaintiff contends that the ALJ was obligated to attribute great weight to the VA's 100% disability rating, and that the ALJ's lack of any substantive discussion regarding the VA rating constitutes reversible error. Id. at 6-13. In response, Defendant argues that the ALJ appropriately considered the VA disability rating. Def.'s Mem. at 10 . According to Defendant, the ALJ was not required to state the weight given the rating provided "the record shows that [s]he expressly considered" the VA's finding.
"`Although the V.A.'s disability rating is not binding on the [Commissioner of the Social Security Administration], it is evidence that should be given great weight.'"
In a letter dated December 9, 2010, the VA advised Plaintiff that "[t]he information contained in your VA examination dated November 6, 2010, showed that you are not able to manage your personal affairs to include disbursement of funds." Tr. at 1545. The letter indicates Plaintiff "was not competent for VA purposes." Tr. at 1545. In a July 8, 2011 letter, the VA certified that Plaintiff has a "service connected disability rating of 100% and received an honorable discharge." Tr. at 1544. The 100% disability rating was based on Plaintiff's disabilities of "PTSD with bipolar affective disorder, attention deficit hyperactivity disorder, and substance abuse." Tr. at 1544. As noted by Defendant, the VA's certification of 100% disability in the July 2011 letter included "no report of decision, report of examination or statement of medical findings." Def. Mem. at 3.
Upon review of the ALJ's Decision, the undersigned finds that the ALJ clearly considered and thoroughly discussed and scrutinized the VA records throughout her Decision. Accordingly, the undersigned declines to accept Plaintiff's argument that the disability rating should have been more thoroughly discussed.
The ALJ made one specific reference to the VA disability rating of Plaintiff in her Decision, stating as follows:
Tr. at 26. Elsewhere in the Decision, the ALJ considered and made a number of specific references to the VA records, but did not always refer to them by name; rather, she referred to exhibit numbers. The VA records make up the bulk of the medical evidence in the administrative transcript and can be found in Exhibits 1F (Tr. at 386-425); 2F (Tr. at 426-1397); 3F (Tr. at 1398-1528); 6F (Tr. at 1544-49); 10F (Tr. at 1574-1637); 11F (Tr. at 1638-1713); 13F (Tr. at 1717-44); and 14F (Tr. at 1745-53). The ALJ discussed exhibits 1F, 2F, 3F, 10F, 11F, 13F, and 14F at her step two finding. Tr. at 23-24. At step three, the ALJ referenced the VA records in exhibit 10F and a September 2010 VA record. Tr. at 24. And, in her assessment of Plaintiff's RFC, the ALJ included a lengthy discussion of the VA records contained in exhibits 1F, 2F, 6F, 10F, 13F, and 14F. Tr. at 26-28.
As referenced above, the ALJ concluded at step two that Plaintiff had severe impairments of "cognitive disorder, NOS; attention deficit hyperactivity disorder (ADHD); bipolar disorder; and anxiety disorder (PTSD); and polysubstance dependency in reported remission." Tr. at 23 (emphasis and citation omitted). In making this finding, it is apparent the ALJ thoroughly considered the VA records. In that regard, the ALJ noted:
Tr. at 23-24.
In determining whether Plaintiff's mental impairments meet a listing, the ALJ appropriately considered whether the "paragraph B" criteria were satisfied. Tr. at 24. In so doing, the ALJ generally discussed a 2010 VA record which indicate evidence of a cognitive disorder, but then the ALJ noted that in the September 2011 consultative examination, "Dr. [Peter] Knox[, M.Ed., Psy.D.] reported [Plaintiff] had intact memory and understanding, adequate mental activities (IQ), and no significant issues in the area of concentration and persistence." Tr. at 24 (citation omitted). In discussing Plaintiff's activities of daily living, the ALJ also referenced a September 2011 visit to the VA for a psychological assessment in which Plaintiff was capable of caring for his two-year old granddaughter whom he brought to the appointment with him. Tr. at 24 (referring to Exhibit 10F/42).
In making her RFC assessment, the ALJ considered the testimony of Plaintiff and his wife. Tr. at 26. Additionally, the ALJ discussed in detail Plaintiff's treatment with the VA. Tr. at 26-27. The ALJ noted that "[t]he medical evidence clearly documents [Plaintiff's] extensive history for his diagnosed conditions." Tr. at 26. However, the ALJ went on to conclude that based upon the objective evidence, Plaintiff is not as limited as claimed. Tr. at 26. In reaching this conclusion, she noted that Plaintiff's "mental health symptoms are generally controlled when [Plaintiff] is compliant with treatment recommendations, including the consistent use of prescribed psychotropic medications and abstinence from polysubstance abuse." Tr. at 26.
The undersigned finds that the ALJ in her Decision thoroughly considered and scrutinized the VA records, identifying both consistencies and inconsistencies between the VA records and the record as a whole. The ALJ noted Plaintiff's "history of not going to appointments and stopping his medications." Tr. at 27 (referring to Exhibit 2F/421);
The ALJ discussed Plaintiff's testimony "that [Plaintiff] felt unable to work because of difficulty getting along with others," but then the ALJ noted how this testimony was not corroborated by the medical records, which "fail to indicate significant social conflict in regular attendance at group therapy sessions." Tr. at 27. The ALJ also noted, "the record indicates that [Plaintiff] maintained relationships with family members, went on yearly cruises with his wife, shopped and traveled alone." Tr. at 28. And, the ALJ observed that in February 2011, Plaintiff "told a healthcare provider that he was enjoying retirement and reported hobbies including bowling and fishing." Tr. at 28 (referring to Exhibit 1F/36); see Tr. at 421.
While the ALJ did not articulate the weight attributed to the VA disability rating, she discussed in detail, and referenced throughout her opinion, the VA records. As recognized by both parties, the VA's disability rating is not binding on the Commissioner. See 20 C.F.R. § 404.1504. Here, the ALJ discussed and closely analyzed the VA records and articulated specific reasons, supported by substantial evidence, for finding Plaintiff not disabled. Accordingly, the ALJ's Decision is due to be affirmed on this issue.
In his second argument, Plaintiff posits that an ALJ is obligated to state with particularity the weight given to different medical opinions and the reasons therefor, and he argues "it was reversible error for the ALJ to completely ignore [the] opinions [of Dr. Sumerall]." Pl.'s Br. at 18. In response, Defendant disputes that the ALJ ignored the opinions of Dr. Sumerall, and argues to the contrary that "[t]he ALJ's finding of severe impairments appear to have been copied directly from Dr. Sumerall's November 6, 2010 report." Def.'s Mem. at 15 (referring to Tr. at 23, 885). While Defendant concedes that the ALJ does not specifically reference Dr. Sumerall by name, Defendant contends that "the ALJ's [D]ecision clearly shows she considered his report . . . and incorporated Dr. Sumerall's findings into her RFC assessment."
Plaintiff saw Dr. Sumerall on November 6, 2010 for a neuropsychological evaluation. Tr. at 882-86. Upon exam,
Tr. at 884. A number of tests were administered during his evaluation. Tr. at 884-85. The Axis I diagnoses included "Cognitive Disorder NOS," "ADHA," "Bipolar Disorder," "PTSD," and "Substance abuse." Tr. at 885. Dr. Sumerall concluded,
Tr. at 885-86.
An ALJ is required to consider every medical opinion. See 20 C.F.R. §§ 404.1527(c), 416.927(c) (stating that "[r]egardless of its source, we will evaluate every medical opinion we receive"). While "the ALJ is free to reject the opinion of any physician when the evidence supports a contrary conclusion,"
In this Circuit, the ALJ must state with particularity the weight given to different medical opinions and the reasons therefor."
It is clear here that the ALJ did not mention Dr. Sumerall by name or identify the weight attributed to his opinions. As noted by Defendant, however, the ALJ's listing of Plaintiff's severe impairments was identical to Dr. Sumerall's diagnoses.
In making her RFC assessment, the ALJ determined Plaintiff was capable of a "full range of work at all exertional levels, but is limited to simple routine tasks in a work environment with only occasional changes, and with no exposure to the public." Tr. at 25 (emphasis omitted). By limiting Plaintiff's RFC to require only "simple, routine tasks," it appears the ALJ has taken Dr. Sumerall's opinions into account that Plaintiff "will have significant difficulty recalling new information without reminders[,] . . . will struggle with tasks requiring concentration and remaining attentive to tasks[, and] . . . will frequently forget instructions." Tr. at 886.
Although the ALJ did not specifically discuss Dr. Sumerall by name or state the weight she attributes to his opinions, the undersigned finds that any error in this instance is harmless as a remand would not likely produce a different result. Here, it is evident the ALJ considered the entire record as a whole, including the voluminous VA records, and adequately stated the basis for her RFC finding.
In support of her Decision, the ALJ considered not only the lengthy medical record, but also Plaintiff's testimony that he is able to drive, travels independently to medical appointments, is capable of caring for his two-year old step-granddaughter, attends church three times per week, takes yearly cruises with his wife, shops, and is able to maintain relationships with family members. Tr. at 24, 28. Additionally, the ALJ noted "[m]edical treatment records indicate [Plaintiff's] mental health symptoms are generally controlled when [Plaintiff] is compliant with treatment recommendations, including the consistent use of prescribed psychotropic medications and abstinence from polysubstance abuse." Tr. at 26.
Further, as noted by Defendant, the ALJ cited and afforded significant weight to the opinions of four State Agency consultants. Def.'s Mem. at 16-17 (referring to Tr. at 28, 73, 86, 1543, 1558). The Agency consultants reviewed and analyzed the extensive VA records, including Dr. Sumerall's records and his diagnosis of Cognitive Disorder NOS, in rendering their opinions. Tr. at 70, 83, 1530, 1539, 1572. Jill Rowan, Ph.D., opined that Plaintiff is
Tr. at 73 (capitalization omitted). Consultant, Theodore Weber, Psy.D., reported similar findings. Tr. at 86. Consultants, Deborah Doxsee, Ph.D., and Nancy Dinwoodie, M.D., opined that Plaintiff can understand and follow instructions, can sustain an ordinary routine, and is capable of socially appropriate behavior. Tr. at 1543, 1558.
Given the above factors, the undersigned finds that the ALJ's decision is supported by substantial evidence. Accordingly, any error in the ALJ's failure to mention Dr. Sumerall specifically by name or to state the weight attributed to his opinions would be harmless.
Based on a thorough review of the administrative transcript, and upon consideration of the respective arguments of the parties, the Court finds that the ALJ's Decision is supported by substantial evidence.
In accordance with the foregoing, it is hereby
1. The Clerk of Court is directed to enter judgment pursuant to sentence four of 42 U.S.C. § 405(g)
2. The Clerk is directed to close the file.