CHARLES J. SIRAGUSA, District Judge.
This is an action brought pursuant to 42 U.S.C. § 405(g) to review the final determination of the Commissioner of Social Security ("Commissioner" or "Defendant"), denying the application of Shawnora Navarro ("Plaintiff") for Social Security Disability Insurance ("SSDI") Benefits and Supplemental Security Income ("SSI") Benefits. Plaintiff claims to be completely disabled due a variety of ailments, including anxiety, post-traumatic stress disorder ("PTSD") and knee pain, but the Commissioner found otherwise. Now before the Court is Plaintiff's motion for judgment on the pleadings (Docket No. [#9]) and Defendant's cross-motion [#13] for the same relief. For the reasons explained below, Plaintiff's application is granted, Defendant's application is denied, and this matter is remanded for further administrative proceedings.
The reader is presumed to be familiar with the facts and procedural history of this action. The Court will briefly summarize the record as necessary for purposes of this Decision and Order.
On April 16, 2015, Plaintiff filed applications for SSI benefits and SSDI benefits, claiming that she became totally disabled on September 2, 2009. Plaintiff had previously filed other applications for benefits that were denied. After the Social Security Administration denied the instant claim initially, a hearing was held before an administrative law judge ("ALJ") on November 14, 2016, at which Plaintiff appeared with her attorney. The ALJ took testimony from Plaintiff and from a Vocational Expert ("VE"). During the hearing, the ALJ identified a gap in the record, and, at his direction, Plaintiff's counsel subsequently obtained and submitted the missing treatment records.
On February 23, 2017, the ALJ issued his decision, denying Plaintiff's applications and finding that she was not disabled at any time between June 29, 2013,
to perform light work as defined in 20 CFR 404.1567(b) and 416.967(b) except:
that she was unable to perform any past relevant work; and that with the RFC described above she was still able to perform several other jobs identified by the VE, including "electronics worker," DOT 726.687-010, "small parts assembler," DOT 706.684-022, and "electrical accessories assembler," DOT 729.687-010.
In making his RFC determination, the ALJ reviewed the medical evidence of record, and, in particular, the opinion evidence from treating psychiatrist Dr. Ronald Spurling, M.D. ("Spurling"), who indicated that Plaintiff was unable to work due to psychological symptoms, and the opinion evidence from a non-treating, non-examining agency psychologist, T. Inman-Dunton, Ph.D. ("Inman-Dunton"), who indicated that Plaintiff was capable of "low stress, unskilled work."
The ALJ indicated that he gave "moderate weight" to Inman-Dunton's opinion, even though, as the ALJ noted, it "pre-date[d] the receipt of a large portion of the evidence available at the hearing levels, in particular, Exhibits 5F through 22F."
On the other hand, the ALJ gave only "limited weight" to Dr. Spurling's opinions. Significantly, the ALJ did so largely because he found that Spurling's opinions were inconsistent with the results of Spurling's own mental status examinations of Plaintiff during office visits. See, Transcript 27 ("[T]he evidence does not demonstrate substantial limitations in the performance of such tasks,
An unusual feature of the administrative record, which may explain the ALJ's heavy reliance on the opinion of Inman-Dunton, who neither treated nor examined Plaintiff, is that the Commissioner did not obtain a consultative psychological (or physical) examination.
In the ALJ's decision, he also found that Plaintiff's statements about the severity of her symptoms were not entirely consistent with the other evidence of record.
After receiving the ALJ's unfavorable ruling, Plaintiff appealed to the Appeals Council. However, the Appeals Council declined to review the ALJ's decision. On March 12, 2018, Plaintiff commenced this action. On November 12, 2018, Plaintiff filed the subject motion [#9] for judgment on the pleadings. Plaintiff contends that the Commissioner's decision should be reversed for the following reasons: 1) the ALJ did not properly apply the treating physician rule to Dr. Spurling's opinions; 2) the ALJ did not properly evaluate Plaintiff's credibility; and 3) the ALJ "failed to determine the severity" of Plaintiff's PTSD condition.
42 U.S.C. § 405(g) states, in relevant part, that "[t]he findings of the Commissioner of Social security as to any fact, if supported by substantial evidence, shall be conclusive." The issue to be determined by this Court is whether the Commissioner's conclusions "are supported by substantial evidence in the record as a whole or are based on an erroneous legal standard." Schaal v. Apfel, 134 F.3d 496, 501 (2d Cir. 1998). Substantial evidence is defined as "more than a mere scintilla. It means such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Id
Plaintiff contends that the ALJ erred at step two of the five-step sequential analysis, because he made no "finding as to whether Ms. Navarro's PTSD was severe."
In considering this argument, the Court observes that the ALJ found that Plaintiff's "anxiety disorder" was a severe impairment, and that PTSD is "an anxiety-related disorder."
The issue, therefore, is whether the ALJ erred by not listing PTSD as a separate impairment at step 2, and by instead including it under the term "anxiety disorder," which he found to be severe. The Court is aware of at least two other similar cases in which courts found no error, because they found that PTSD is included under the term "anxiety disorder." See, Morris v. Astrue, No. CA 11-625S, 2013 WL 1000326, at *12 (D.R.I. Feb. 1, 2013) ("Plaintiff argues that the ALJ erred because, while he found depression and anxiety, he omitted PTSD from his list of severe impairments at Step Two. However, PTSD is a type of anxiety disorder; therefore, the ALJ's finding that Plaintiff's anxiety was a severe impairment necessarily incorporates PTSD. See DSM— IV—TR at 429, 463-67."), report and recommendation adopted sub nom. Morris v. Colvin, No. CA 11-625 S, 2013 WL 997132 (D.R.I. Mar. 13, 2013); see also, Harper v. Berryhill, No. 2:18-CV-02117, 2019 WL 1805003, at *4 (W.D. Ark. Apr. 9, 2019) ("The ALJ determined Plaintiff had the severe impairments of spinal disorders, asthma, migraine headaches, obesity, affective disorders, and anxiety disorders. Plaintiff argues the ALJ erred by not finding [an] additional severe impairment[ ] as it relates to her claim[ ] of Post Traumatic Stress Disorder ("PTSD"). . . [However,] [t]o begin with, PTSD is a type of an affective disorder and anxiety disorder."), report and recommendation adopted, No. 2:18-CV-2117, 2019 WL 1804860 (W.D. Ark. Apr. 24, 2019).
However, in this action the ALJ's failure to list PTSD as a separate impairment, and his decision to evaluate Plaintiff's PTSD symptoms under Listing 12.06 along with her other anxiety symptoms, was erroneous. In that regard, effective January 17, 2017, the Commissioner's listings were changed, in that PTSD, which had formerly been included under Listing 12.06, "Anxiety-Related Disorders," was moved to a new listing, Listing 12.15, "Trauma- and Stressor-Related Disorders." See, Revised Medical Criteria for Evaluating Mental Disorders, 81 FR 66138-01, 2016 WL 5341732 (Sep. 26, 2016). The ALJ in this action did not discuss Listing 12.15.
Nevertheless, Plaintiff's argument is not that the ALJ erred in this regard, but, rather, that he failed to indicate the severity of Plaintiff's PTSD at step 2. That assertion is really not accurate, though, since the ALJ implicitly indicated that the PTSD was severe.
Plaintiff next contends that the ALJ failed to properly apply the treating physician rule to Dr. Spurling's opinion evidence. In particular, Plaintiff contends that the ALJ substituted his own medical judgment for Spurling's, based on his own interpretation of the results of Spurling's mental status examinations. The Court agrees that the ALJ erred by disregarding Spurling's opinions based on his own layman's interpretation of the medical data. In that regard, as discussed earlier, the ALJ repeatedly cited the results of Spurling's mental status examinations as the primary reason for assigning only limited weight to Spurling's opinions concerning Plaintiff's ability to perform various job-related functions.
Under similar circumstances, another Judge of this district recently ruled that an ALJ had impermissibly substituted her own medical expertise for that of a consultative doctor, based on her own interpretation of the medical evidence:
Page v. Berryhill, No. 1:16-CV-0044 (MAT), 2018 WL 2329457, at *5 (W.D.N.Y. May 23, 2018) (Telesca, J.) (emphasis added, citations to record omitted).
Similarly, the Court here finds that the ALJ was not qualified to say that Spurling's opinions were inconsistent with the objective medical evidence, based solely on his own lay opinion. Further, in that regard, the ALJ's decision to give less weight to Spurling's opinion than to the opinion of non-examining agency review psychologist Inman-Dunton was not adequately explained, and is not supported by substantial evidence, particularly since Inman-Dunton's opinion was based on an incomplete record. Additionally, the ALJ should not have rejected Spurling's opinions, about the number of hours that Plaintiff could work, or the number of absences from work that she would have per month, as being unexplained,
Plaintiff also maintains that the ALJ did not properly evaluate her credibility. However, because the Court is remanding the matter for further administrative proceedings that may moot this argument, the Court declines to consider the argument at this time.
The Court notes, however, that there are a number of apparent inconsistencies in Plaintiff's statements that should be explored on remand. For example, when Plaintiff applied for benefits she indicated that she had not received special education in school, but she told the ALJ that she had received special education.
Plaintiff maintains that this action should be remanded solely for the calculation of benefits. However, based on the discussion above, the Court does not find that remand solely for calculation of benefits is clearly warranted. On remand, in addition to properly applying the treating physician rule, the Commissioner may want to further develop the record, such as by seeking clarification from Dr. Spurling on the points mentioned earlier,
For the reasons discussed above, Plaintiff's motion for judgment on the pleadings [#9] is granted, Defendant's motion [#13] is denied, and this matter is remanded to the Commissioner for further administrative proceedings consistent with this Decision and Order. The Clerk of the Court is directed to enter judgment for Plaintiff and close this action.
So Ordered.
