CHARLES A. STAMPELOS, Magistrate Judge.
This is a Social Security case referred to the undersigned United States Magistrate Judge upon consent of the parties and reference by United States District Judge Robert L. Hinkle. Doc. 11. See Fed. R. Civ. P. 73; 28 U.S.C. § 636(c). After careful consideration of the entire Record, the Court reverses the decision of the Commissioner and remands the case for further consideration.
On May 4, 2009, Plaintiff, Wanda Gilchrist, filed a Title II application for a period of disability and Disability Insurance Benefits (DIB) and a Title XVI application for Supplemental Security Income (SIS) alleging disability beginning March 1, 2007. R. 20. (Citations to the Record shall be by the symbol "R." followed by a page number that appears in the lower right corner.) Plaintiff's date last insured, or the date by which his disability must have commenced in order to receive DIB under Title II, is March 31, 2010. R. 20.
Plaintiff's applications were denied initially on September 28, 2009, and upon reconsideration on April 1, 2010. Id. On May 27, 2010, Plaintiff requested a hearing. Id. On May 11, 2011, in Tallahassee, Florida, Plaintiff appeared and testified at a hearing conducted by Administrative Law Judge (ALJ) Michael J. Amendola. R. 20, 32, 43-63, 65-66. Ron C. Mayne, an impartial vocational expert, testified during the hearing. R. 63-65, 138-39 (Resume). During the hearing, Plaintiff amended her alleged onset date to November 8, 2009, the date of Plaintiff's slip and fall. R. 66, 231. Plaintiff was represented by Liz Montefu, a non-attorney representative, who submitted a pre-hearing brief on May 6, 2011. R. 20, 108, 231-37.
On June 3, 2011, the ALJ issued a decision and denied Plaintiff's applications for benefits concluding that Plaintiff was not disabled from November 8, 2009, through the of the ALJ's decision. R. 32. Plaintiff requested review of this decision and filed a brief on March 22, 2012, R. 244-47, which the Appeals Council denied on February 7, 2013. R. 1-5. The ALJ's decision stands as the final decision of the Commissioner.
On April 3, 2013, Plaintiff, by and through present counsel, filed a complaint with the United States District Court seeking review of the ALJ's decision. Doc. 1. Plaintiff filed a motion for summary judgment and memorandum, docs. 15 and 16, and Defendant filed a memorandum, doc.18, which have been considered.
The ALJ made several findings relative to the issues raised in this appeal:
This Court must determine whether the Commissioner's decision is supported by substantial evidence in the record and premised upon correct legal principles. 42 U.S.C. § 405(g);
"In making an initial determination of disability, the examiner must consider four factors: `(1) objective medical facts or clinical findings; (2) diagnosis of examining physicians; (3) subjective evidence of pain and disability as testified to by the claimant and corroborated by [other observers, including family members], and (4) the claimant's age, education, and work history.'"
A disability is defined as a physical or mental impairment of such severity that the claimant is not only unable to do past relevant work, "but cannot, considering his age, education, and work experience, engage in any other kind of substantial gainful work which exists in the national economy." 42 U.S.C. § 423(d)(2)(A). A disability is an "inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months." 42 U.S.C. § 423(d)(1)(A); see 20 C.F.R. §§ 404.1509, 416.909 (duration requirement). Both the "impairment" and the "inability" must be expected to last not less than 12 months.
The Commissioner analyzes a claim in five steps. 20 C.F.R. §§ 404.1520(a)(4)(i)-(v), 416.920(a)(4)(i)-(v).
A positive finding at step one or a negative finding at step two results in disapproval of the application for benefits. A positive finding at step three results in approval of the application for benefits. At step four, the claimant bears the burden of establishing a severe impairment that precludes the performance of past relevant work. Consideration is given to the assessment of the claimant's RFC and the claimant's past relevant work. If the claimant can still do past relevant work, there will be a finding that the claimant is not disabled. If the claimant carries this burden, however, the burden shifts to the Commissioner at step five to establish that despite the claimant's impairments, the claimant is able to perform other work in the national economy in light of the claimant's RFC, age, education, and work experience.
Plaintiff bears the burden of proving that she is disabled, and consequently, is responsible for producing evidence in support of his claim. See 20 C.F.R. §§ 404.1512(a); 416.912(a);
Plaintiff argues the ALJ erred when he did not find Plaintiff's Weschler Intelligence Scale for Children-Revised (WISC-R) score(s) in the 60s, coupled with proven deficits in adaptive functioning and a severe impairment of borderline intellectual functioning, met or equaled the requirements of Listing 12.05C and would have justified a finding of disability. Doc. 16 at 4-13. Plaintiff also argues that the ALJ erred by determining her RFC without adequate consideration of her "additional and significant work-related limitation of function." Doc. 16 at 13-14. In the alternative, Plaintiff argues that the ALJ erred when he did not order a consultative examination, including intelligence testing, "if he had any doubt as to the validity of the IQ scores." As a result, the ALJ did not properly develop the record. Doc. 16 at 15-19.
The Commissioner responds that Plaintiff did not have deficits in adaptive functioning based on the ALJ's findings and the ALJ articulated his rationale for this result; the ALJ was not required to order a consultative examination; and the ALJ did not err in finding that Plaintiff did not have an impairment imposing additional and significant work-related limitation of function. Doc. 18 at 7-17.
Plaintiff's arguments center on whether the ALJ erred in not finding that her mental impairment met or equaled the criteria of Listing 12.05C.
The claimant has the burden of proving that her impairment(s) meet or equal a listed impairment by presentation of specific evidence of medical signs, symptoms, or laboratory test results meeting all of the specified medical criteria.
Listing 12.05C provides in relevant part:
20 C.F.R., Pt. 404, Subpt. P, App. 1, Listing 12.05C.
Generally, the claimant meets the criteria for presumptive disability under section 12.05C when the claimant presents a valid IQ score of 60 through 70 inclusive, and when the claimant presents evidence of an additional mental or physical impairment significantly affecting claimant's ability to work. See
In
Consistent with
Id. at 1355 n.5. Further,
Id. at 1355. As noted in
At step two, the ALJ determined that Plaintiff had one severe impairment— borderline intellectual functioning. R. 22. At step three, the ALJ determined that Plaintiff did not have an impairment or combination of impairments that meets or medically equals one of the listed impairments in 20 C.F.R., Part 404, Subpart P, Appendix 1, including Listing 12.05 (mental retardation). R. 23. In making this determination, the ALJ considered the criteria of Listing 12.05A-D. R.23-26. Relevant here, the ALJ expressly considered the criteria of Listing 12.05C (mental retardation).
The ALJ found that Plaintiff had documented IQ scores of between 60 and 70 when she scored identical scores in the 5th and 8th grades—Full-scale (FSIQ) score of 60, Verbal (VIQ) score of 63, and Performance (PIQ) score of 64. R. 23-24. The ALJ initially cites to Exhibit 7F, pages 18 and 28, and then, after restating the score(s) on the following page, cites to Exhibit 7F, page 18. R. 23-24. (Exhibit 7F are records from the Gadsden School District from 1994 to 2004. R. 301. It appears that almost all of the pages are cut-off, leaving off material on the left-hand side of the page. R. 302-28.) Exhibit 7F, page 2, R. 302, refers to a testing date of September 20, 1994, when Plaintiff was nine years old and in the third grade. Exhibit 7F, page 18, which is not dated, provides test scores and notes that Plaintiff is in the fifth grade. Also noted are test scores (Johnson Psycho-Educational Battery-Revised) from February 25, 1997, when Plaintiff was 12 years old and in the fifth grade. R. 215, 318. IQ scores from May 19, 1992, are listed that include the IQ scores mentioned by the ALJ. R. 318. There are other, non-IQ scores from September 29, 1994. Id. Exhibit 7F, page 28, also undated is a "reevaluation report" indicating that Plaintiff is in the eighth grade and again notes the May 19, 1992, IQ scores, two sets of scores from 1991, and "test of educational achievement (K-TEA)" scores of October 6, 1999. R. 328. It appears Plaintiff has at least one valid set of IQ scores when she was examined on May 19, 1992, and when she was seven years old and in the first grade. (She repeated the first grade. R. 212-13.) On the other hand, the ALJ may have been reading from full-sized documents, unlike the documents in this record, which may have included two sets of IQ scores. Nevertheless, even though no party has raised an issue regarding Plaintiff's IQ scores, on remand, clarification is needed regarding when Plaintiff received IQ testing and the results.
The ALJ found, however, that Plaintiff
R. 24.
Although not specifically at issue here, the ALJ also determined that Plaintiff did not meet the criteria of Listing 12.05D. The findings are relevant, however, because the ALJ discusses Plaintiff's activities of daily living, social functioning, concentration, persistence, or pace, and whether Plaintiff had any extended episodes of decompensation. R. 24-26. (The ALJ made separate a separate RFC assessment. R. 27-30.) After discussing Plaintiff's IQ scores, the ALJ stated:
R. 24.
Id. (referring to but without citation to 20 C.F.R. pt. 404, subpt. P, app. 1, § 12.00C.1.).
The ALJ considered a May 2009 adult function report and Plaintiff's testimony at the hearing reporting her activities of daily living and found that Plaintiff "has no restriction in activities of daily living."
The ALJ provided a definition of social functioning that tracts 20 C.F.R. pt. 404, subpt. P, app. 1, § 12.00C.2., discussed Plaintiff's social functioning, and determined that Plaintiff "has only mild difficulties in the area of social functioning." R. 25. The ALJ also provided a definition of concentration, persistence or pace that tracts 20 C.F.R. pt. 404, subpt. P, app. 1, § 12.00C.3., discussed the evidence relating to this subject, and determined that Plaintiff "has moderate difficulties in concentration, persistence or pace." R. 26.
The ALJ also considered some of Plaintiff's work activities during his step two analysis, when assessing Plaintiff's RFC, and when finding that Plaintiff was unable to perform any past relevant work. R. 25, 29-30. A more detailed review of Plaintiff's early years and work experience is required.
Plaintiff was born in 1984. R. 144, 146. In May 1992, when Plaintiff was seven years old, Plaintiff's school administered the WISC-R to assess her intellectual capacity and to evaluate her continued placement is special education programs for the "educable mentally handicapped." R. 223, 302, 318, 328. This is the only readable IQ score in the record. Plaintiff repeated the first and twelfth grades. R. 212-23, 218. Nevertheless, Plaintiff received her high school diploma in 2005 with the caveat mentioned above. R. 24, 305. Plaintiff has a restricted Florida driver's license—she must have someone else in the car while she is driving. R. 25, 43-44.
Prior to receiving her high school diploma in 2005, Plaintiff briefly worked at the IGA Grocery Store in 2004 as a cashier and earned approximately $136. She "always asked" for help and received help with that job. She got mixed-up when counting money. R. 48, 158. Plaintiff worked at the "state mental hospital" as a "unit treatment rehab specialist" from January 2005 to March 2007. She worked part-time for three days a week, eight hours per day. R. 169. She earned approximately $6,930 in 2005 from this job and approximately $250 from another job (Gadsden Tomato Company) in the same year. R. 158. Plaintiff earned approximately $4,717 in 2006 and $5,557 in 2007 from her job at the state mental hospital. R. 159-60. She had temporary job(s) at Staffco Management Group, Inc., in 2008 and received wages of approximately $72. R. 159, 166, 228.
Plaintiff testified that she helped patients at the state mental hospital "feed themselves." R. 44. She was responsible for documenting the daily activities of, for example, five patients. Staff workers helped her with this job. R. 47. She "got fired over there because no one was helping" her so she went to a different unit, unit one. R. 44, 47. She was working in unit one where she passed out snacks, but did not receive any help. R. 44-45, 47. She was fired at the end of her shift. R. 45.
Plaintiff also worked and continues to work as a volunteer for 30 hours a week at a clothing store as a condition to obtain "cash assistance." R. 25, 29, 61-62. If she does not work, she does not receive any money. R. 61. The store is like a shoe or jewelry store. She does vacuum cleaning and places alarm monitors on the shoes. She also takes plastic off the shirts and puts them on a hanger and makes sure they are arranged correctly, medium to large. Id. The manager (the son of the owner) helps her and gives her "a lot of stuff to do. He'll tell [her she] can sit down or take a break when [she wants] to." She works ten or fifteen minutes and then rests. R. 62. (The ALJ noted that although Plaintiff was fired from her previous job, "she said she has a good relationship with her current supervisor [at the shoe or jewelry store] because he allows her to take frequent breaks, as she needs them." R. 25.) Plaintiff received unemployment compensation benefits for the first and second quarters of 2010. R. 30, 159.
The only work the ALJ described with some specificity was Plaintiff's work as a 30-hour a week volunteer. R. 25, 29-30. The ALJ stated:
R. 29-30. The ALJ also commented on Plaintiff's receipt of unemployment benefits:
R. 30.
The ALJ mentioned Plaintiff's childhood IQ scores and the special education she received in school. R. 23-24. He considered whether Plaintiff had deficits in adaptive functioning, having considered her activities of daily living, social functioning, and concentration, persistence or pace. R. 24-25, 29-30. The ALJ also considered Plaintiff's physical issues following her slip and fall in November 2009. R. 25-29. The ALJ did not, however, thoroughly consider Plaintiff's work activity.
Here, Plaintiff has a valid IQ score of between 60 and 70 creating a rebuttable presumption of mental retardation under Listing 12.05C. Plaintiff completed the 12th grade, albeit with a FCAT waiver and after repeating two grades. She has a restricted driver's license such that she may only drive when accompanied by another. Plaintiff was 25 years old (defined as a younger individual, 18-49) as of November 8, 2009, the amended alleged onset date.
She has not received specialized training in any particular job skill. Plaintiff's jobs were performed on a part-time basis and no job paid her more than $6,930 yearly when she worked at the state mental hospital in 2005. The vocational expert classified her job there as a residential care, assistant, with an SVP of 3 and medium exertional level.
The ALJ considered Plaintiff's medical records when considering Plaintiff's RFC, R. 27-30, and some of the medical records as they pertained to his step two analysis, R. 25-26. Plaintiff was examined and treated by Jeffrey D. Wasserman, D.O., a treating physician at the Gadsden Medical Center from approximately June 2009 to April 2010. R. 25, 29, 356-66. The ALJ referred to Dr. Wasserman's patient note of April 12, 2010, when Plaintiff told him
R. 29, 361. This appears to be Plaintiff's last visit with Dr. Wasserman.
The ALJ also noted that "Disability Determination Service medical and psychological consultants were unable to substantiate the claimant's impairments due to insufficient evidence of record. (Exhibit 2F; 5F; 6F)." R. 29. This finding is borne out by the record. For, example, on September 25, 2009, Shirley Ellis, Ph.D., completed a Psychiatric Review Technique (PRT) and her medical disposition was: "insufficient evidence." R. 265 (Exhibit 2F). Dr. Ellis's consultant's notes state, in part: "Attempts to contact the clt and 3rd party contacts via tc and mail for additional information have been unsuccessful. Therefore, there is insufficient evidence to make a medical determination on this claim." R. 277. On March 31, 2010, Richard K. Lyon, Ph.D., completed a PRT and reached the same conclusion as Dr. Ellis. R. 286 (Exhibit 5F). His consultant's notes state: "The clmt. is a 25 yro female with allegations of being slow. This is a recon case, [sic] the clmt. failed to cooperate at the initial claim and she has not returned her ADL or responded to any letters or calls. There is insufficient MER or ALDs in the file to render a valid medical decision other than insufficient evidence." R. 298. On April 1, 2010, James Patty, M.D., provided a "case analysis" and stated: "The clmt. Is a 25 yro female with mental allegations only, however, at recon she states on her 3341 that she does not hear well. All attempts to contact the clmt. have been unsuccessful and there is not sufficient MER in the file to render a valid medical decision other than insufficient evidence." R. 300 (Exhibit 6F).
Agency worksheets reflect similar findings. See, e.g., R. 68-71, 74-77, 84-89, 92-95. In particular, a September 25, 2009, "report of contact" is signed by a person from the Pensacola area, disability determinations' office, recounting conversations with Plaintiff and her mom regarding scheduled and re-scheduled consultant appointments. R. 189. One such call occurred on September 21, 2009, when it was noted that Plaintiff reported she did not go to her appointment on that date "because she did not feel like it" and Plaintiff was informed "that a decision would be made based on the information currently on file which is insufficient." Id.
Moreover, it does not appear that Plaintiff's representative, albeit a non-lawyer, sent Plaintiff to a consultative examination or requested the ALJ to do so. R. 40-67, 209-10, 231-37, 245-47. In fairness to Plaintiff's representative, she was not retained until on or about September 23, 2010. R. 107-09. Nevertheless, the hearing before the ALJ was held on May 11, 2011, and there appears to have been adequate time to refer Plaintiff or request that she be referred to a medical consultant for a physical and mental examination prior to the hearing. See 20 C.F.R. § 416.1540(b) (providing a claimant's representative must assist in developing the record). At the conclusion of the hearing, the ALJ stated that he would review the medical records and he would "make a decision [in the] next couple of weeks." R. 66. In response, Plaintiff's representative mentioned the amended alleged onset date and did not suggest the record was insufficient. Id. On March 22, 2012, and after the ALJ issued his decision, the representative provided the Appeals Council with a brief, but did not express the need to re-open the record for receiving additional evidence or the need to refer Plaintiff to a medical consultant. R. 245-47.
The ALJ's summary of the medical evidence and Plaintiff's daily and social activities is complete. His analysis of the extent of Plaintiff's paid work was not. The ALJ overemphasized Plaintiff's ability to do simple daily activities, although his findings are supported by substantial evidence. Unfortunately, the record is lacking a medical source assessment of Plaintiff's mental condition as it may relate to her ability to work. Missed appointments with consulting examiners, through no apparent fault of the agency, have been noted herein.
This case falls between
On remand, the ALJ should consider the record anew and open the record for additional evidence in order to make the required findings under the sequential evaluation process. No determination is made regarding whether Plaintiff is disabled and entitled to benefits.
Considering the record as a whole, the ALJ's findings that Plaintiff is not disabled are not based upon substantial evidence in the record and the ALJ incorrectly applied the law in light of the inadequate record. Accordingly, pursuant to the fourth sentence in 42 U.S.C § 405(g), the decision of the Commissioner to deny Plaintiff's applications for Social Security benefits is