STEVEN J. McAULIFFE, Chief District Judge.
Pursuant to 42 U.S.C. § 405 (g), Constance Leach moves to reverse the Commissioner's decision denying her application for Disability Insurance Benefits under Title II of the Social Security Act, 42 U.S.C. § 423 (the "Act"). The Commissioner objects and moves for an order affirming his decision.
Claimant's history of both physical and mental impairments is lengthy and substantial. That portion of the parties' joint statement of facts dedicated to summarizing her medical history and the numerous surgical and non-surgical treatments she has undergone spans more than sixty pages, and the administrative record in this case is comprised of nearly 1200 pages. The Administrative Law Judge's decision is correspondingly lengthy and detailed, and it is clear that he devoted substantial time and effort to familiarizing himself with the details of claimant's impairments. But, because the court concludes that the ALJ did not identify a sufficient basis in the record for his decision to discount the opinions and observations of claimant's treating psychotherapist (Dr. Wagner), claimant's daughter (Catherine Leach), and claimant's friend and former housemate (Patricia Enoch), the matter must be remanded for further proceedings.
In 2007, claimant filed an application for both Disability Insurance Benefits ("DIB") and Supplemental Security Income ("SSI") benefits, alleging that she had been unable to work since October 31, 1998. Her application for SSI benefits was approved, with a disability onset date of July 1, 2007. But, her application for DIB was denied, based on the conclusion that she was not disabled prior to her date last insured (June 30, 2004). She requested an administrative hearing, after which the ALJ issued a decision in which he concluded that she was not disabled. Claimant appealed that denial to this court. Subsequently, however, the parties filed an assented-to motion to remand, so the ALJ might more fully evaluate claimant's mental impairments prior to her date last insured. The court granted that motion.
In February of 2011, claimant (represented by counsel), a vocational expert, and one of claimant's friends appeared and testified before the ALJ. A non-examining medical expert testified by telephone. And, because claimant's daughter was unable to attend the hearing, the ALJ allowed her to present her testimony in the form of an affidavit. Five weeks later, the ALJ issued his written decision, concluding that claimant retained the residual functional capacity to perform the physical and mental demands of a range of light work. Admin. Rec. at 12. Although claimant's limitations precluded her from performing her past relevant work as a printing press operator,
Claimant then sought review of the ALJ's decision by the Decision Review Board, which was unable to complete its review during the time allowed. Accordingly, the ALJ's denial of claimant's application for benefits became the final decision of the Commissioner, subject to judicial review. Subsequently, claimant filed a timely action in this court, asserting that the ALJ's decision is not supported by substantial evidence and seeking a judicial determination that she is disabled within the meaning of the Act. She then filed a "Motion for Order Reversing Decision of the Commissioner" (document no. 10). In response, the Commissioner filed a "Motion for Order Affirming the Decision of the Commissioner" (document no. 12). Those motions are pending.
Pursuant to this court's Local Rule 9.1 (d), the parties have submitted a statement of stipulated facts which, because it is part of the court's record (document no. 15), need not be recounted in this opinion. Those facts relevant to the disposition of this matter are discussed as appropriate.
Pursuant to 42 U.S.C. § 405 (g), the court is empowered "to enter, upon the pleadings and transcript of the record, a judgment affirming, modifying, or reversing the decision of the Commissioner of Social Security, with or without remanding the cause for a rehearing." Factual findings and credibility determinations made by the Commissioner are conclusive if supported by substantial evidence.
An individual seeking Social Security disability benefits is disabled under the Act if he or she is unable "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). The Act places a heavy initial burden on the claimant to establish the existence of a disabling impairment.
In assessing a disability claim, the Commissioner considers both objective and subjective factors, including: (1) objective medical facts; (2) the claimant's subjective claims of pain and disability, as supported by the testimony of the claimant or other witnesses; and (3) the claimant's educational background, age, and work experience.
42 U.S.C. § 423 (d) (2) (A).
With those principles in mind, the court reviews claimant's motion to reverse and the Commissioner's motion to affirm his decision.
In concluding that claimant was not disabled within the meaning of the Act, the ALJ properly employed the mandatory fivestep sequential evaluation process described in 20 C.F.R. § 404.1520. Accordingly, he first determined that claimant had not been engaged in substantial gainful employment since her alleged onset of disability: October 31, 1998. Admin. Rec. at 10. Next, he concluded that claimant suffers from the following severe impairments: "left wrist tendinitis and tenosynovitis, and a depressive disorder."
Next, the ALJ concluded that claimant retained the residual functional capacity ("RFC") to perform the exertional demands of a range of light work.
Finally, the ALJ considered whether there were any jobs in the national economy that claimant might perform. Relying upon the testimony of a vocational expert, he concluded that, despite claimant's exertional and non-exertional limitations, she "was capable of making a successful adjustment to other work that existed in significant numbers in the national economy" through the date on which she was last insured.
In support of her motion to reverse the decision of the Commissioner, claimant advances four arguments: (1) the ALJ improperly discounted the opinions of her treating source, Dr. Wagner; (2) the ALJ improperly discounted claimant's credibility; (3) the ALJ's residual functional capacity assessment is not supported by substantial evidence; and (4) the ALJ's determination that claimant could perform other work existing in significant numbers in the national economy is not supported by substantial evidence. The court need only address the first of those arguments, since it is dispositive of the pending motions.
Claimant challenges the ALJ's determination that the opinion of her treating psychologist, Dr. Wagner, "is not supported by his treatment notes or the medical record in general and is entitled to little weight." Admin. Rec. at 18. More specifically, she alleges that Dr. Wagner's numerous treatment notes:
Claimant's Memorandum (document no. 10-1) at 15-16 (citations omitted).
In discussing the weight that will be ascribed to the opinions of "treating sources," the pertinent regulations provide:
20 C.F.R. § 404.1527 (c) (2).
Here, Dr. Wagner began treating claimant in 2001 and saw her, on average, once or twice each month until April of 2003, when she could no longer afford treatment. Claimant resumed treatment with him again in August of 2004. Unfortunately, the treatment notes from each of Dr. Wagner's many sessions with claimant are relatively brief. For that reason, the ALJ concluded that his assessment of claimant's ability to engage in substantial gainful activity was "unsupported by his treatment notes." Admin. Rec. at 18.
In response to the suggestion that his treatment notes did not adequately support his conclusions about claimant's capacity for gainful employment, Dr. Wagner prepared a written statement, in which he noted that:
Admin. Rec. at 1161 (emphasis in original). When Dr. Wagner was specifically asked about claimant's ability to engage in substantial gainful activity, he repeatedly opined that she was not able.
In deciding to afford the opinions of Dr. Wagner "little weight," the ALJ echoed the view espoused by Dr. Kutcher, the non-examining medical expert who testified at claimant's hearing. In short, Dr. Kutcher testified — and the ALJ agreed — that Dr. Wagner's notes were not sufficiently detailed to permit him to conclude that Dr. Wagner's opinions about claimant's abilities were adequately supported.
The problem is this: viewed in its entirety (including the testimony given before the ALJ) the record
Dr. Wagner's conclusions were also fully supported by the testimony of claimant's former roommate, Patricia Enoch (Admin. Rec. at 100-06) and claimant's daughter (Admin. Rec. at 407-08). And, as the Commissioner himself has noted, such testimony can be particularly useful when trying to determine the onset date of progressive impairments, like clamant's.
SSR 83-20,
That claimant's friend and daughter are, as noted by the ALJ, "not acceptable medical sources," Admin. Rec. at 18-19, is not particularly relevant. Their testimony was not offered to establish the existence of a medical impairment. Rather, it was introduced to show the day-to-day effects of claimant's impairments and the side-effects of her many medications. And, their testimony fully supported the conclusions of Dr. Wagner (though the medical expert, Dr. Kutcher, testified that he consciously disregarded such testimony when evaluating whether Dr. Wagner's conclusions were adequately supported by the record evidence. Admin. Rec. at 115).
In concluding that claimant was not disabled at any time prior to the expiration of her insured status, the ALJ afforded "great weight" to the opinions of two physicians: the testifying medical expert, Dr. Kutcher, and the non-examining state agency physician, Dr. Jonathan Jaffe. Admin. Rec. at 17. That was likely an error. First, neither of those physicians examined claimant; both based their opinions exclusively on a review of her medical records. But, when Dr. Kutcher testified before the ALJ, he did not have the benefit of Dr. Wagner's more thorough narrative in which he discussed the medical bases for his various conclusions about claimant's impairments.
And, finally, in reaching their conclusions about claimant's capabilities, both Dr. Kutcher and the ALJ relied upon the opinions expressed by Amy Feitelson, M.D. Dr. Feitelson performed a consultative psychiatric examination of claimant in December of 2002. Admin. Rec. at 424-28. But, the conclusions drawn by Dr. Feitelson are, at a minimum, suspect since she was under the erroneous impression: (1) that claimant had never been administered any psychiatric medications; and (2) that claimant had never acted on her suicidal ideations. In fact, claimant had been treated with psychiatric medications and had (apparently) attempted suicide several times, beginning when she was in high school.
The ALJ afforded only "some" or "little" weight to the testimony of the three people who are likely most familiar with claimant, the combined effects of her physical and mental impairments, her day-to-day behaviors, her capacity to engage in various activities, the side effects of her medications, and her overall credibility in describing the extent (and impact) of her impairments: claimant's adult daughter, claimant's friend and former housemate, and claimant's long-time treating psychologist. While the ALJ is certainly permitted to discount the testimony of witnesses, the court cannot conclude that he adequately explained his decision to do so in this case.
For the foregoing reasons, claimant's motion to reverse the decision of the Commissioner (document no. 10) is granted to the extent she seeks a remand for further proceedings. The Commissioner's motion to affirm his decision (document no. 12) is denied.
Pursuant to sentence four of 42 U.S.C. § 405 (g), this matter is hereby remanded to the ALJ for further proceedings consistent with this order. The Clerk of Court shall enter judgment in accordance with this order and close the case.
