T. LANE WILSON, Magistrate Judge.
This matter is before the undersigned United States Magistrate Judge for a report and recommendation. Plaintiff Mikel L. Peugh seeks judicial review of the Commissioner of the Social Security Administration's decision finding that he is not disabled. As set forth below, the undersigned recommends that the Commissioner's decision denying benefits be
A claimant for disability benefits bears the burden of proving a disability. 42 U.S.C. § 423 (d)(5); 20 C.F.R. §§ 404.1512(a), 416.912(a). "Disabled" is defined under the Act as 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). To meet this burden, plaintiff must provide medical evidence of an impairment and the severity of that impairment during the time of his alleged disability. 20 C.F.R. §§ 404.1512(b), 416.912(b). A disability is a physical or mental impairment "that results from anatomical, physiological, or psychological abnormalities which are demonstrable by medically acceptable clinical and laboratory diagnostic techniques." 42 U.S.C. § 423 (d)(3). "A physical impairment must be established by medical evidence consisting of signs, symptoms, and laboratory findings, not only by [an individual's] statement of symptoms." 20 C.F.R. §§ 404.1508, 416.908. The evidence must come from "acceptable medical sources," such as licensed and certified psychologists and licensed physicians. 20 C.F.R. §§ 404.1513(a), 416.913(a). A plaintiff is disabled under the Act 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 in the national economy." 42 U.S.C. § 423(d)(2)(A).
Social Security regulations implement a five-step sequential process to evaluate a disability claim. 20 C.F.R. §§ 404.1520, 416.920;
In reviewing a decision of the Commissioner, the Court is limited to determining whether the Commissioner has applied the correct legal standards and whether the decision is supported by substantial evidence.
Plaintiff, then a 35-year old male, applied for Title II benefits on April 25, 2011, and Title XVI benefits on May 4, 2011, alleging a disability onset date of October 16, 2010, for purposes of his Title II application. (R. 142-43, 144-49). Plaintiff claimed that he was unable to work due to mild mental retardation, PTSD, hallucination, anxiety, ADD, and dyslexia. (R. 174). Plaintiff's claims for benefits were denied initially on July 7, 2011, and on reconsideration on October 10, 2011. (R. 57-71). Plaintiff then requested a hearing before an administrative law judge ("ALJ"), and the ALJ held the hearing on September 26, 2012. (R.31-56). The ALJ issued a decision on October 22, 2012, denying benefits and finding plaintiff not disabled. (R. 9-30). The Appeals Council denied review, and plaintiff appealed. (R. 1-3, Dkt. 2).
The ALJ found that plaintiff is insured through December 31, 2014, and has not performed any substantial gainful activity since October 16, 2010, his alleged disability onset date. (R. 15). Plaintiff's part-time work as a cook between April and September 2011 (after his alleged disability onset date) does not rise to the level of substantial gainful activity. (R. 15-16). The ALJ found that plaintiff has severe impairments of "learning disorder, anxiety disorder, posttraumatic stress disorder, and schizoaffective disorder." (R. 16). The ALJ considered Listings 12.02, 12.03, and 12.06 and determined that plaintiff does not meet or medically equal a listing.
The ALJ then reviewed plaintiff's testimony and the medical evidence. Plaintiff testified that he uses city buses for transportation because he has never had a driver's license. (R. 18). He sometimes becomes confused when taking the bus and states that his dyslexia causes the words on the bus schedule to appear "jumbled." (R. 19). His girlfriend or the bus driver helps him choose bus routes.
Plaintiff currently works twenty hours a week as a cashier and cook.
Plaintiff has a history of marijuana and methamphetamine use, but he stated that he stopped using drugs three years ago.
Plaintiff lives with his girlfriend, her three children, and their two-year-old daughter. (R. 18-19). He can shop for groceries as long as someone is on the phone with him dictating a list of items. (R. 19). He does household chores.
Plaintiff sought treatment from Associated Centers for Therapy ("ACT") in January 2011, complaining of anxiety and poor thought processes. (R. 20). He reported that he last used methamphetamine a few weeks earlier.
In June 2011, plaintiff underwent a consultative psychological examination with Dr. Minor Gordon. (R. 20). Plaintiff reported that he had attended two therapy sessions at ACT.
Dr. Gordon found that plaintiff was alert and attentive with a calm affect and good eye contact.
Dr. Corine Samwel, an agency psychologist, reviewed plaintiff's records in October 2011 and completed a mental residual functional capacity assessment.
In September 2012, a licensed professional counselor ("LPC") completed a mental status form "under the instruction of Dr. Chris Blaisdeli [sic]."
The ALJ gave great weight to the opinions of Drs. Gordon and Samwel, both of whom found that plaintiff could perform routine work and handle superficial interactions with co-workers. (R. 23). The ALJ found that these opinions "are consistent with and supported by the medical evidence in this case."
The ALJ gave little weight to the mental status form completed by the LPC.
In assessing plaintiff's credibility, the ALJ relied heavily on plaintiff's multiple, inconsistent reports regarding his history of drug abuse. (R. 22). The ALJ also relied on inconsistencies between plaintiff's testimony that he has difficulty focusing and his reports to ACT that he was "doing well" and feeling "great."
The ALJ then weighed and rejected the third-party function report completed by plaintiff's girlfriend. (R. 23). He found the girlfriend's report "not completely truthful" because she stated that plaintiff, who was working as a cashier, could not count change."
The ALJ concluded that plaintiff retained the residual functional capacity to "perform a full range of light and sedentary work, except no climbing of ladders, scaffolds, unprotected heights, and dangerous machinery parts." (R. 17). Plaintiff was also limited to simple instructions and was "able to interact with coworkers and supervisors with routine supervision."
On appeal, plaintiff raises two issues related to the ALJ's consideration of the medical evidence. The undersigned has reviewed the records and included a discussion of those documents below. Otherwise, the ALJ's decision adequately addresses the medical evidence.
In October 2011, agency psychologist Dr. Samwel completed a Mental Residual Functional Capacity Assessment and Psychiatric Review Technique form. (R. 298-315). Dr. Samwel opined that plaintiff has mild limitations in activities of daily living and moderate limitations in social functioning and in concentration, persistence, or pace. (R. 312). In the Mental Residual Functional Capacity Assessment, Dr. Samwel opined that plaintiff was moderately limited in his ability to carry out detailed instructions, maintain attention and concentration for extended periods of time, work near other co-workers without becoming distracted, and perform at a consistent pace. (R. 298-99). In the "Remarks" section of the form, Dr. Samwel stated that plaintiff "should be able to complete simple tasks for 6-8 hours in an eight-hour period at and appropriate pace, and sustain this level across days and weeks." (R. 300).
Dr. Samwel also opined that plaintiff has a moderate limitation in his "ability to interact appropriately with the general public" and that he "[m]ay show limited tolerance for frequent, recurrent contact with the general public."
In September 2012, an LPC at ACT completed a Mental Status Form and Mental Residual Functional Capacity Form. (R. 324-27). The form, completed in the LPC's handwriting, addresses plaintiff's treatment history and progress at ACT and is signed by both the LPC and Dr. Blaisdell, one of plaintiff's treating physicians at ACT.
The Mental Status Form contains statements reflecting plaintiff's own reports to the LPC and other staff, observations of plaintiff's behavior at the time of the initial assessment and during the course of his therapy sessions, and plaintiff's response to his medications. (R. 324-25). When read in conjunction with the treatment notes, the statements in the Mental Status Form can be clearly categorized, leaving no confusion about which statements qualify as opinions from the treating physician, the LPC, and plaintiff.
The Mental Residual Functional Capacity Form rates limitations as follows: "No Significant Limitation," "Moderate Limitation," Marked Limitation," "Severe Limitation," and "Insufficient Evidence." (R. 326-27). The form indicates that plaintiff has a number of marked and severe limitations, particularly with respect to detailed instructions, concentration, and social interaction with co-workers and supervisors.
On appeal, plaintiff raises three points of error: (1) whether the ALJ adequately considered the medical opinion evidence; (2) whether the ALJ erred at steps three through five by failing to find that plaintiff met the requirements of Listing 12.03 or by failing to include all of plaintiff's limitations in the residual functional capacity findings and hypothetical to the vocational expert; and (3) whether the ALJ conducted a proper credibility analysis.
Plaintiff argues that the ALJ failed to properly evaluate the Mental Status Form and Mental Residual Functional Capacity Form completed by the LPC and signed by plaintiff's treating physician, Dr. Blaisdell. (Dkt. 17). Alternatively, plaintiff argues that the ALJ should have evaluated the opinion under SSR 06-03p if he believed that the LPC rendered the opinion.
The Commissioner argues that the ALJ properly evaluated the Mental Status Form and Mental Residual Functional Capacity Form, regardless of whether the ALJ was required to evaluate the opinions as treating physician's opinions or other sources under SSR 06-03p. (Dkt. 21) The Commissioner contends that the ALJ rejected the opinions because they were not consistent with the medical evidence and because they relied heavily on plaintiff's subjective complaints.
Ordinarily, a treating physician's opinion is entitled to controlling weight when it is "well-supported by medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with the other substantial evidence in [the] case record." 20 C.F.R. §§ 404.1527(d)(2), 416.927(d)(2);
The analysis of a treating physician's opinion is sequential. First, the ALJ must determine whether the opinion qualifies for "controlling weight," by determining whether it is well-supported by medically acceptable clinical and laboratory diagnostic techniques and whether it is consistent with the other substantial evidence in the administrative record.
However, even if the ALJ finds the treating physician's opinion is not well-supported by medically acceptable clinical and laboratory diagnostic techniques or is inconsistent with the other substantial evidence in the record, treating physician opinions are still entitled to deference and must be evaluated in reference to the factors enumerated in 20 C.F.R. §§ 404.1527 and 416.927. Those factors are as follows:
In
In this case, the ALJ refused to evaluate the Mental Status Form and Mental Residual Functional Capacity Form signed by Dr. Blaisdell as opinion evidence. (R. 23). The ALJ acknowledged that the LPC completed the forms "under the instruction of" the treating physician but found that the forms were actually the opinion of the LPC who completed them. (R. 21, 23). Rather than weighing these opinions as the opinions of a treating physician, the ALJ speculated that Dr. Blaisdell did not share the opinions expressed in the forms, despite the appearance of his signature on both.
Plaintiff argues that the ALJ erred in giving great weight to the opinions of Dr. Gordon and Dr. Samwel because they are inconsistent with the treating physician's opinion. (Dkt. 17). Plaintiff also argues that, despite giving great weight to Dr. Samwel's opinion, the ALJ did not adopt the limitation that plaintiff could only perform tasks at a proper pace for six hours in an eight-hour day.
Because the undersigned has recommended that the District Court remand the case for the ALJ to consider the treating physician's opinion, the ALJ would need to consider whether the opinions of Dr. Gordon and Dr. Samwel are consistent with the treating physician's opinion. However, the undersigned has also considered the merit of plaintiff's other arguments regarding these medical source opinions.
Regarding Dr. Samwel's opinion, plaintiff's reliance on the limits to plaintiff's concentration is misplaced. Dr. Samwel opined that, even with his limitations, plaintiff would be able to concentrate well enough "to complete simple tasks for 6-8 hours in an eight-hour period at an appropriate pace, and sustain this level across days and weeks." (R. 300). Dr. Samwel's ultimate opinion was that plaintiff retained the residual functional capacity to perform simple, routine tasks on a sustained basis.
Based on Dr. Samwel's opinion, considered in its entirety, and the vocational expert's testimony, the undersigned finds that the ALJ did not err in failing to include an additional limitation on plaintiff's concentration. While the ALJ could have discussed Dr. Samwel's opinion regarding the limits on plaintiff's concentration, the undersigned is able to follow the ALJ's reasoning and does not insist on "technical perfection."
Plaintiff argues that the ALJ erred at steps three through five by failing to find (1) that plaintiff met the requirements of Listing 12.03; (2) that the ALJ made a number of factual mistakes in the residual functional capacity analysis that undermine his findings; and (3) that the ALJ's hypothetical to the vocational expert should have included a limitation on plaintiff's interaction with the public, based on the ALJ's decision to give great weight to Dr. Samwel's opinion. (Dkt. 17).
The Commissioner argues that plaintiff does not meet the requirements of Listing 12.03 because the ALJ found that plaintiff did not have marked limitations in considering the "paragraph B" criteria. (Dkt. 21). The Commissioner also argues that plaintiff misinterprets Dr. Samwel's opinion and that Dr. Samwel did not opine that plaintiff had a functional limitation with respect to public interaction.
Listing 12.03 describes "Schizophrenic, Paranoid and Other Psychotic Disorders." In this case, in order to meet the listing, plaintiff must establish that his medical records document symptoms associated with such disorders, including "[d]elusions or hallucinations," and marked limitations in at least one of the "paragraph B" categories. 20 C.F.R. Pt. 404, Subpt. P, App. 1, Listing 12.03 A and B. Plaintiff argues that the medical records clearly establish the necessary symptoms and that Dr. Blaisdell's opinion establishes the marked limitations in social functioning and in concentration, persistence, or pace. (Dkt. 17). The Commissioner argues that the ALJ found that plaintiff had only mild and moderate limitations in the "paragraph B" categories; therefore, plaintiff cannot meet the requirements for the listing. (Dkt. 21).
Plaintiff challenges the ALJ's findings by arguing that the ALJ should have incorporated the findings of Dr. Blaisdell at step three. The undersigned has addressed the issue of Dr. Blaisdell's opinion, supra, and has recommended that the District Court remand for the ALJ to conduct a proper treating physician's opinion. If, on remand, the ALJ determines that Dr. Blaisdell's opinion is entitled to some weight, the ALJ would then reconsider his findings at step three. However, as the ALJ's findings currently stand, the undersigned finds that plaintiff cannot establish that he meets the requirements of Listing 12.03. For this reason, the undersigned recommends a finding of no error on this issue.
Plaintiff argues that the ALJ included a number of factual mistakes in his residual functional capacity findings that "further indicate a lack of proper consideration of all the evidence and lack of understanding of the case." (Dkt. 17). Specifically, plaintiff contends that the ALJ cited the wrong claimant name, birthdate, and educational history and that the ALJ referred to plaintiff, a male, as "she" and "her."
In the discussion of the ALJ's decision, supra, the undersigned noted that the ALJ's residual functional capacity findings were poorly drafted. After reviewing the ALJ's decision as a whole, however, the undersigned finds that the ALJ's errors are simply scrivener's errors that do not impact the outcome of the case.
Plaintiff argues that the ALJ should have included a limitation on plaintiff's ability to interact with the public because Dr. Samwel included a limitation in her opinion, and the ALJ gave great weight to her opinion. (Dkt. 17). The Commissioner argues that Dr. Samwel noted that plaintiff may have some difficulty interacting with the public but ultimately concluded that the difficulty was not so great that plaintiff's interaction with the public should be limited. (Dkt. 21). The undersigned notes that plaintiff's argument is not a step five argument, but a step four argument because plaintiff is essentially arguing that the ALJ failed to include a limitation on public interaction in his residual functional capacity findings.
In the Mental Residual Functional Capacity Form, Dr. Samwel opined, by checking a box on the form, that plaintiff has a moderate limit in his "ability to interact appropriately with the general public." (R. 299). In her narrative, however, Dr. Samwel explained that plaintiff "[m]ay show limited tolerance for frequent, recurrent contact with the general public" and "[w]ill function best at tasks with modest social demands." (R. 300). Dr. Samwel's final opinion was that plaintiff "can cooperate effectively with public and co-workers in completing simple tasks and transactions."
Plaintiff argues that the ALJ's failure to properly consider the medical evidence also impacted the ALJ's credibility findings. (Dkt. 17). Plaintiff argues that the ALJ erred in finding that plaintiff worked "only sporadically."
The Commissioner argues that the ALJ's credibility findings are supported by substantial evidence. (Dkt. 21). The Commissioner contends that the ALJ relied on the efficacy of plaintiff's treatment, the medical opinion evidence of malingering, the collection of unemployment benefits, plaintiff's activities of daily living, and his part-time work as proof that plaintiff's claims of disability were not credible.
This Court will not disturb an ALJ's credibility findings if they are supported by substantial evidence because "[c]redibility determinations are peculiarly the province of the finder of fact."
In his credibility findings, the ALJ relied on plaintiff's multiple inconsistent reports regarding his history of substance abuse. (R. 22). The ALJ noted that plaintiff was "not entirely truthful," thereby reducing his credibility.
The ALJ was also entitled to rely on plaintiff's collection of unemployment benefits from 2010 through January 2012 as evidence that plaintiff's claim of disability was not credible.
These findings are all proper credibility considerations and are supported by substantial evidence. For this reason, the undersigned recommends a finding of no error on this issue.
For the reasons set forth above, the undersigned
In accordance with 28 U.S.C. §636(b) and Fed. R. Civ. P. 72(b)(2), a party may file specific written objections to this report and recommendation. Such specific written objections must be filed with the Clerk of the District Court for the Northern District of Oklahoma by June 26, 2015.
If specific written objections are timely filed, Fed. R. Civ. P. 72(b)(3) directs the district judge to determine de novo any part of the magistrate judge's disposition to which a party has properly objected. The district judge may accept, reject, or modify the recommended disposition; receive further evidence; or return the matter to the magistrate judge with instructions.