JAMES E. GATES, Magistrate Judge.
In this action, plaintiff Carolyn Boone ("plaintiff" or, in context, "claimant") challenges the final decision of defendant Acting Commissioner of Social Security Carolyn W. Colvin ("Commissioner") denying her application for supplemental security income ("SSI") under Title XVI of the Social Security Act ("the Act") on the grounds that she is not disabled. The case is before the court on the parties' respective motions for judgment on the pleadings. (D.E. 25, 27). The motions have been fully briefed.
Plaintiff filed an application for SSI on 14 July 2010, alleging a disability onset date of 2 December 2004. Transcript of Proceedings ("Tr.") 112. The application was denied initially and upon reconsideration, and a request for a hearing was timely filed. Tr. 112. On 9 February 2012, a video hearing ("the 2012 hearing") was held before an administrative law judge ("ALJ"), at which plaintiff and a vocational expert testified. Tr. 38-62. The ALJ issued a decision denying plaintiff's claims on 9 March 2012. Tr. 112-20. Plaintiff timely requested review by the Appeals Council. Tr. 199-202. On 15 April 2013, the Appeals Council allowed the request and remanded the case with instructions that the ALJ further evaluate plaintiff's medically determinable mental impairments, evaluate a 9 May 2011 decision by the North Carolina Department of Health and Human Services ("NCDHHS") allowing plaintiff Medicaid disability benefits ("state Medicaid decision") (Tr. 324-26), and give further consideration to plaintiff's RFC, providing appropriate rationale for it with specific supporting references to evidence of record. Tr. 125-28.
On 5 December 2013, a second hearing ("the hearing") was held before a different ALJ than the one who presided at the 2012 hearing at which plaintiff and a vocational expert testified. Tr. 63-85. On 24 March 2014, the ALJ issued a decision again denying plaintiff's claim for SSI. Tr. 13-24. Plaintiff timely requested review by the Appeals Council. Tr. 7-9. On 25 June 2015, the Appeals Council denied the request for review. Tr. 1-6.
At that time, the decision of the ALJ became the final decision of the Commissioner. 20 C.F.R. § 416.1481. On 31 August 2015, plaintiff commenced this proceeding for judicial review of the ALJ's 24 March 2014 decision, pursuant to 42 U.S.C. § 1383(c)(3). (See In Forma Pauperis ("IFP") Mot. (D.E. 1); Order Allowing IFP Mot. (D.E. 2); Compl. (D.E. 3)).
The Act defines disability as the 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 twelve months." 42 U.S.C. § 1382c(a)(3)(A); Pass v. Chater, 65 F.3d 1200, 1203 (4th Cir. 1995). The Act defines a physical or mental impairment as "an impairment that results from anatomical, physiological, or psychological abnormalities which are demonstrable by medically acceptable clinical and laboratory diagnostic techniques." 42 U.S.C. § 1382c(a)(3)(D). "[A]n individual shall be determined to be under a disability only if his physical or mental impairment or impairments are of such severity that he is not only unable to do his previous 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 . . . ." Id.(a)(3)(B).
The disability regulations under the Act ("Regulations") provide the following five-step analysis that the ALJ must follow when determining whether a claimant is disabled:
20 C.F.R. § 416.920(a)(4)(i)-(v).
The burden of proof and production rests with the claimant during the first four steps of the analysis. Pass, 65 F.3d at 1203. The burden shifts to the Commissioner at the fifth step to show that alternative work is available for the claimant in the national economy. Id.
In the case of multiple impairments, the Regulations require that the ALJ "consider the combined effect of all of [the claimant's] impairments without regard to whether any such impairment, if considered separately, would be of sufficient severity." 20 C.F.R. § 416.923. If a medically severe combination of impairments is found, the combined impact of those impairments must be considered throughout the disability determination process. Id.
Plaintiff was 42 years old on the date she filed her application for SSI and 45 years old on the date of the hearing. See Tr. 22 ¶ 6. The ALJ found that she has at least a high school education. Tr. 22 ¶ 7; see also 20 C.F.R. § 416.964(b)(4) ("High school education and above means abilities in reasoning, arithmetic, and language skills acquired through formal schooling at a 12th grade level or above."); cf. Tr. 18 ¶ 4 (plaintiff "is a 45-year old female . . . with an eighth grade education"); Tr. 43-44 (plaintiff's testimony that she went as far in school as the eighth grade, but attended community college for "my" GED).
Applying the five-step analysis of 20 C.F.R. § 416.920(a)(4), the ALJ found at step one that plaintiff had not engaged in substantial gainful activity since the date of her application. Tr. 15 ¶ 1. At step two, the ALJ found that plaintiff had the following medically determinable impairments that were severe within the meaning of the Regulations: post-laminectomy syndrome, lumbosacral spondylosis, and chronic back pain. Tr. 15 ¶ 2. At step three, the ALJ found that plaintiff's impairments did not meet or medically equal any of the Listings. Tr. 17 ¶ 3.
The ALJ next determined that plaintiff had the RFC to perform a limited range of light work:
Tr. 18 ¶ 4.
Based on her determination of plaintiff's RFC, the ALJ found at step four that plaintiff was not capable of performing her past relevant work. Tr. 22 ¶ 5. At step five, the ALJ accepted the testimony of the vocational expert and found that there were jobs in the national economy existing in significant numbers that plaintiff could perform, including jobs in the occupations of silver wrapper, routing clerk, and advertising material distributor. Tr. 22-23 ¶ 9. The ALJ accordingly concluded that plaintiff was not disabled from the date of her application, 14 July 2010. Tr. 23 ¶ 10.
Under 42 U.S.C. § 1383(c)(3), judicial review of the final decision of the Commissioner is limited to considering whether the Commissioner's decision is supported by substantial evidence in the record and whether the appropriate legal standards were applied. See Richardson v. Perales, 402 U.S. 389, 390, 401 (1971); Hays v. Sullivan, 907 F.2d 1453, 1456 (4th Cir. 1990). Unless the court finds that the Commissioner's decision is not supported by substantial evidence or that the wrong legal standard was applied, the Commissioner's decision must be upheld. See Smith v. Schweiker, 795 F.2d 343, 345 (4th Cir. 1986); Blalock v. Richardson, 483 F.2d 773, 775 (4th Cir. 1972). Substantial evidence is "`such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.'" Perales, 402 U.S. at 401 (quoting Consol. Edison Co. v. NLRB, 305 U.S. 197, 229 (1938)). It is more than a scintilla of evidence, but somewhat less than a preponderance. Perales, 402 U.S. at 401.
The court may not substitute its judgment for that of the Commissioner as long as the decision is supported by substantial evidence. Hunter v. Sullivan, 993 F.2d 31, 34 (4th Cir. 1992) (per curiam). In addition, the court may not make findings of fact, revisit inconsistent evidence, or make determinations of credibility. See Craig v. Chater, 76 F.3d 585, 589 (4th Cir. 1996); King v. Califano, 599 F.2d 597, 599 (4th Cir. 1979). A Commissioner's decision based on substantial evidence must be affirmed, even if the reviewing court would have reached a different conclusion. Blalock, 483 F.2d at 775.
Before a court can determine whether a decision is supported by substantial evidence, it must ascertain whether the Commissioner has considered all relevant evidence and sufficiently explained the weight given to probative evidence. See Sterling Smokeless Coal Co. v. Akers, 131 F.3d 438, 439-40 (4th Cir. 1997). "Judicial review of an administrative decision is impossible without an adequate explanation of that decision by the administrator." DeLoatche v. Heckler, 715 F.2d 148, 150 (4th Cir. 1983).
Plaintiff asserts that the ALJ's decision should be reversed and SSI benefits awarded or, alternatively, that the case should be remanded for a new hearing on the principal grounds that the ALJ erroneously evaluated the state Medicaid decision and erroneously evaluated a workers' compensation settlement into which plaintiff entered on 30 March 2009 (Tr. 343-52) in determining plaintiff's credibility. Because the ALJ's handling of the workers' compensation settlement is dispositive of this appeal, the court will limit its analysis to that issue.
The ALJ's assessment of a claimant's credibility involves a two-step process. Craig, 76 F.3d at 593-96; 20 C.F.R. § 416.929(a)-(c); Soc. Sec. Ruling 96-7p, 1996 WL 374186, at *1 n.1, 2 (2 July 1996). First, the ALJ must determine whether plaintiff's medically documented impairments could cause plaintiff's alleged symptoms. Soc. Sec. Ruling 96-7p, 1996 WL 374186, at *2. Next, the ALJ must evaluate the extent to which the claimant's statements concerning the intensity, persistence, or functionally limiting effects of the symptoms are consistent with the objective medical evidence and the other evidence of record. See id.; see also 20 C.F.R. § 416.929(c)(3) (setting out factors in addition to objective medical evidence in evaluation of a claimant's pain and other symptoms).
Such other evidence includes the claimant's own statements:
Soc. Sec. Ruling 96-7p, at *5.
If the ALJ does not find plaintiff's statements to be credible, the ALJ must cite "specific reasons" for that finding that are "supported by the evidence." Soc. Sec. Ruling 96-7p, 1996 WL 374186, at *2, 4; Jonson v. Colvin, No. 12cv1742, 2013 WL 1314781, at *7 (W.D. Pa. 28 Mar. 2013) ("If an ALJ concludes the claimant's testimony is not credible, the specific basis for such a conclusion must be indicated in his or her decision."); Dean v. Barnhart, 421 F.Supp.2d 898, 906 (D.S.C. 2006).
Here, the ALJ made the finding at the first step of the credibility assessment that plaintiff's "medically determinable impairments could reasonably be expected to cause some of the alleged symptoms." Tr. 19 ¶ 4. At the second step of the assessment, the ALJ found that plaintiff's allegations were not fully credible. She stated that "the claimant's statements concerning the intensity, persistence and limiting effects of these symptoms are not entirely credible for the reasons explained in this decision." Tr. 19 ¶ 4.
The ALJ provided specific reasons for her credibility determination, including her assessment of the workers' compensation agreement. The agreement arose out of an injury to plaintiff's lower back. See Tr. 343-45; see also Tr. 18 ¶ 4. As summarized by the ALJ, the basic terms of the agreement were as follows:
Tr. 21 ¶ 4.
The agreement also contained a provision regarding future medical benefits:
Tr. 348 (emphasis added).
The ALJ deemed the emphasized provision inconsistent with plaintiff's claim of disability:
Tr. 21 ¶ 4. The ALJ does not elaborate on her reasoning for this finding.
As plaintiff contends, the ALJ's ostensible rationale is that Medicare eligibility for plaintiff requires satisfaction of the criteria for disability under the Regulations and that by agreeing she would not likely be Medicare-eligible, she was "conced[ing]" she was not then disabled. But plaintiff's agreement to the Medicare eligibility provision does not necessarily relate at all to whether or not she meets Social Security requirements. While entitlement to a period of disability and disability insurance under Title II of the Act ("DIB") establishes entitlement to Medicare benefits, see 42 U.S.C. § 426(b)(2)(A)(i),
Indeed, the ALJ identifies three prior applications by plaintiff for disability-based Social Security benefits, but they were all for SSI. See Tr. 13. Plaintiff's instant application is, of course, for SSI. See Tr. 13 ("The issue is whether the claimant is disabled under section 1614(a)(3)(A) of the Social Security Act [42 U.S.C. § 1382c(a)(3)(A)]."); 24 ("Based on the application for supplemental security income protectively filed on July 14, 2010, the claimant is not disabled under section 1614(a)(3)(A) of the Social Security Act."). The ALJ nowhere indicates whether she considered this benign interpretation of plaintiff's agreement to the Medicare eligibility provision and, if so, why she rejected it.
The Commissioner agrees that the ALJ was evaluating the Medicare eligibility provision from a DIB perspective and that she erred in doing so. "For the reasons set forth by Plaintiff, the Commissioner concedes that the ALJ's interpretation of the agreement was ill-founded." (Comm'r's Mem. 11).
The Commissioner argues, nonetheless, that the ALJ's error in discounting plaintiff's credibility, in part, on the basis of the provision in the workers' compensation agreement is harmless. She cites to the significant other evidence the ALJ discusses in support of her credibility assessment. While this discussion is admittedly extensive, the court cannot say that the ALJ's error was harmless.
One reason is that the ALJ did not indicate the weight she gave the inconsistency she found between the provision in the workers' compensation agreement and plaintiff's claim of disability. The decision fails to foreclose the possibility that the ALJ's error significantly tainted her view toward plaintiff's credibility and her evaluation of other evidence bearing on plaintiff's credibility.
Moreover, plaintiff's claim of disability relies substantially on her allegations of pain and other limitations resulting from her back impairment. "Because symptoms, such as pain, sometimes suggest a greater severity of impairment than can be shown by objective medical evidence alone, any statements of the individual concerning his or her symptoms must be carefully considered if a fully favorable determination or decision cannot be made solely on the basis of objective medical evidence." Soc. Sec. Ruling 96-7p, 1996 WL 374186, at *3. Thus, the credibility of plaintiff's statements about her pain and other symptoms and their functional effects are of particular importance to the propriety of her disability claim.
The court's concern that the ALJ may have given the concession she erroneously found substantial weight in her credibility analysis is heightened by the questionable judgment the ALJ exhibited in relying on it at all under the circumstances presented in the absence of any stated, plausible justification for doing so. The concession found arose from the purported interrelation of two complex statutory schemes—one governing Social Security disability benefits and the other Medicare benefits. Plaintiff was not, of course, well equipped to understand this purported interrelation. She is not a lawyer and does not have a college degree. As noted, the ALJ found at one point that she had only an eighth grade education. Tr. 18 ¶ 4. While plaintiff expressly represented in the workers' compensation agreement that she "has read and fully understands it" (Tr. 350 ¶ 11), the implicit concession the ALJ found arguably falls outside the scope of simply understanding the agreement. There does not appear to be any evidence showing that plaintiff's lawyer or anyone else explained to her any impact the provision in question could have on a claim by her for Social Security disability-based benefits. The ALJ herself does not appear to have properly understood the statutory interrelation on which she grounded her finding.
Moreover, the agreement itself states that "all parties agree that no rights, other than those arising under the provisions of the Workers' Compensation Act, are compromised or released by the execution of this agreement." Tr. 350 ¶ 8. The ALJ does not address this provision in her decision, including the extent to which, if any, it affects the propriety of using the Medicare eligibility provision against plaintiff in her disability case.
The court concludes that the ALJ committed prejudicial error in her evaluation of plaintiff's credibility. This case should accordingly be remanded for further administrative proceedings.
For the foregoing reasons, IT IS RECOMMENDED that plaintiff's motion (D.E. 25) for judgment on the pleadings be ALLOWED, the Commissioner's motion (D.E. 27) for judgment on the pleadings be DENIED, and this case be REMANDED to the Commissioner pursuant to sentence four of 42 U.S.C. § 405(g) for further proceedings consistent with this Memorandum and Recommendation.
In making this ruling, the court expresses no opinion on the weight that should be accorded any piece of evidence. That is a matter for the Commissioner to decide.
IT IS DIRECTED that a copy of this Memorandum and Recommendation be served on each of the parties or, if represented, their counsel. Each party shall have until 14 June 2016 to file written objections to the Memorandum and Recommendation. The presiding district judge must conduct her own review (that is, make a de novo determination) of those portions of the Memorandum and Recommendation to which objection is properly made and may accept, reject, or modify the determinations in the Memorandum and Recommendation; receive further evidence; or return the matter to the magistrate judge with instructions. See, e.g., 28 U.S.C. § 636(b)(1); Fed. R. Civ. P. 72(b)(3); Local Civ. R. 1.1 (permitting modification of deadlines specified in local rules), 72.4(b), E.D.N.C.
Any response to objections shall be filed within 14 days after the filing of objections.
42 U.S.C. § 426(b)(2)(A)(i).
