ANN AIKEN, Chief Judge.
Plaintiff Freddy Glenn Lee brings this action to obtain judicial review of a final decision of the Commissioner of Social Security ("Commissioner"), denying his application for supplemental security income ("SSI") under Title XVI of the Social Security Act ("Act"). For the reasons set forth below, the Commissioner's decision is affirmed and this case is dismissed.
On June 19, 2009, plaintiff protectively applied for SSI, alleging a disability onset date of February 1, 2002. Tr. 183-85. After his application was denied initially and upon reconsideration, plaintiff timely requested a hearing before an administrative law judge ("ALJ"). Tr. 87-95. The Honorable Marilyn S. Mauer conducted hearings on December 9, 2010 and July 27, 2011. Tr. 29, 77. On November 3, 2011, ALJ Mauer found that plaintiff was not disabled within the meaning of the Act. Tr. 11-22. Plaintiff requested review of the ALJ's decision, which the Appeals Council denied, and subsequently filed a complaint in this Court. Tr. 1-6.
Born on October 11, 1959, plaintiff was 43 years old on the alleged onset date of disability and 51 years old at the time of the hearings. Tr. 183. He attended high school through the eleventh grade and did not receive a GED. Tr. 82-83. Plaintiff has no record of employment, although he performed odd jobs in the construction and mechanics industry, and served as a home caretaker for his mother and brother. Tr. 16, 47-48. Plaintiff alleges disability due to posttraumatic stress disorder, obsessive-compulsive disorder, depression, bipolar disorder, back injuries, osteoarthritis, and a heart condition. Tr. 183, 211.
The court must affirm the Commissioner's decision if it is based on proper legal standards and the findings are supported by substantial evidence in the record.
The initial burden of proof rests upon the claimant to establish disability.
The Commissioner has established a five-step sequential process for determining whether a person is disabled.
At step two, the Commissioner determines whether the claimant has a "medically severe impairment or combination of impairments."
At step three, the Commissioner determines whether the impairment meets or equals "one of a number of listed impairments that the [Commissioner] acknowledges are so severe as to preclude substantial gainful activity."
At step four, the Commissioner determines whether the claimant can still perform "past relevant work." 20 C.F.R. § 416.920(e). If the claimant can work, he is not disabled. If he cannot perform past relevant work, the burden shifts to the Commissioner. At step five, the Commissioner must establish that the claimant can perform other work that exists in the national economy.
The ALJ used the five-step sequential analysis outlined above to determine whether plaintiff was disabled within the meaning of the Act. At step one, the ALJ determined plaintiff had not engaged in substantial gainful activity since April 1, 2009, the SSI application date. Tr. 13. At step two, the ALJ determined plaintiff suffered from the following severe impairments: non-ischemic cardiomyopathy with ejection fraction of 40% to 45%, obesity, major depressive disorder, posttraumatic stress disorder, and right knee pain, status post meniscectomy.
The ALJ determined plaintiff had the RFC to engage in "light work," subject to certain limitations. Tr. 15-15. The ALJ limited plaintiff to work involving simple reasoning that could be learned in 30 days or less and did not involve workplace hazards, public contact, extensive reading or writing, and climbing ladders, ropes, or scaffolds. Tr. 16. The ALJ found that plaintiff could frequently crawl, stoop, crouch, kneel, and climb up ramps or stairs; plaintiff could also occasionally grasp and engage in frequent handling/fingering with his right upper extremity. Id.
At step four, the ALJ concluded that, because plaintiff had no employment history, he was unable perform past relevant work. Tr. 20-21. Finally, at step five, the ALJ determined that there were a significant number of jobs in the national and regional economies that the plaintiff could perform. Tr. 21-22. Therefore, the ALJ found plaintiff not disabled. Tr. 22.
Plaintiff alleges the ALJ erred by: (1) improperly evaluating the medical opinions of Ryan Scott, Ph.D, David Northway, Ph.D, John Allcott, M.D., and Sandi O'Brien, M.A., Q.M.H.P.; and (2) failing to include all of his impairments in the RFC, such that the step five finding was invalid.
Plaintiff argues the ALJ improperly rejected the opinions of his two examining psychologists, Drs. Scott and Northway, as well as the opinions of his treating physician, Dr. Alcott, and treating counselor, Ms. O'Brien.
While only evidence from acceptable medical sources can be used in ascertaining whether plaintiff has a medically determinable impairment, evidence from "other sources" is permissible only when deciding the severity of the impairment. 20 C.F.R. § 416.913(a), (d). "Other sources" include, but are not limited to, medical sources such as nurse-practitioners and mental health counselors.
On November 24, 2010, Ms. O'Brien, a qualified mental health professional, reported plaintiff had an inability to understand short, simple instructions and was "markedly limited" by his mental condition. Tr. 834. Ms. O'Brien also found plaintiff to have moderate limitations in certain social interactions and adaption.
The ALJ rejected Ms. O'Brien's opinion for three reasons. First, the ALJ found that Ms. O'Brien's assessment was not consistent with her observations. Tr. 19. Second, the ALJ determined that the reliability of Ms. O'Brien's findings, which were based on plaintiff's subjective reports, were undermined by the plaintiff's lack of credibility.
The ALJ is not required to accept opinion evidence that is not supported by clinical findings or is based on an uncredible claimant's subjective reports.
In social security cases, there are three categories of medical opinions: those that come from treating, examining, and non-examining doctors.
On November 9, 2009, Dr. Scott conducted a psychodiagnostic examination to evaluate plaintiff's mental impairments. Tr. 604-09. The evaluation was based on plaintiff's comments during the interview and, further, plaintiff was aware the evaluation was for purposes of assessing the existence of a disability. Tr. 604. Due to plaintiff's tangential cognitive processes and difficulty focusing, Dr. Scott found it "somewhat difficult to perform an adequate clinical interview." Tr. 608. Dr. Scott determined plaintiff met the diagnostic criteria for posttraumatic stress disorder, relating to past sexual abuse, and depression.
The ALJ afforded only "partial weight" to Dr. Scott's findings for two reasons. First, the ALJ observed that plaintiff omitted significant facts during the examination, "suggest[ing] a lack of forthrightness in his presentation to Dr. Scott" and, further, plaintiff "was aware that the purpose of [the] examination was to make an assessment with respect to a disability determination," which "undermined the impact of [Dr. Scott's] conclusions." Tr. 19. Second, the ALJ found that Dr. Scott's assessment was inconsistent with Dr. Allcott's recorded observations and "more recent evidence obtained at the hearing level."
An ALJ can consider a doctor's familiarity with information in the record when determining the weight accorded to their medical opinion.
Here, the record before the Court supports the ALJ's conclusion. Plaintiff's treating physician, Dr. Allcott, noted that plaintiff's mental status exams were normal, whereas Dr. Scott found plaintiff to be "highly disorganized cognitively."
Moreover, as the ALJ noted, plaintiff omitted important information during his evaluation with Dr. Scott. Specifically, while plaintiff discussed his work history and the recent death of his mother and brother, he failed to mention that he provided full-time care for his mother and brother until 2009, including bathing them, paying their bills, performing their household chores, and doing their grocery shopping. Tr. 19, 47-53, 604-09. Additionally, Dr. Scott's findings were based upon plaintiff's discredited subjective reports. Tr. 604. Thus, the ALJ gave clear and convincing rationales, supported by substantial evidence, for discrediting Dr. Scott's opinion.
On January 24, 2011, Dr. Northway administered a neuropsychological screening assessment to plaintiff, mainly to evaluate his anxiety and panic attacks. Tr. 857. Prior to evaluating plaintiff, Dr. Northway reviewed Dr. Scott's psychodiagnostic evaluation, as well as numerous treatment notes from Ms. O'Brien and her employer, Options Counseling Services.
When Dr. Northway reviewed plaintiff's medical records, however, he found there were no notes of "cognitive deficits in terms of intellectual functioning." Tr. 861. In fact, he found chart notes from Ms. O'Brien that suggested the opposite: "she noted, `he talked essentially about how he wishes he could see more of his ex-wife' . . . `it is nice to have someone at the same level intellectually to converse with' suggesting [plaintiff] does not have intellectual deficits, at least not at the same level as his brother."
Dr. Northway nonetheless determined that, if plaintiff test results were valid, he would have severe impairments in terms of his intellectual abilities and memory; he also noted that "[t]aken as a whole, it is confusing to reconcile his functioning on the cognitive tests administered for this assessment and his reported level of functioning noted in previous assessments and records." Tr. 861-62. He also opined that plaintiff "would certainly be impaired in social functioning if these test results are valid." Tr. 862. As such, Dr. Northway indicated that "validity measures"
The ALJ agreed with some of Dr. Northway's findings — for example, that plaintiff could only perform tasks involving simple instructions — but gave less weight to the psychologist's conclusion that plaintiff's social skills imposed marked limitations on his ability to work with others because it was not substantiated by the record. Tr. 19-20. The ALJ cited the CDIU investigator's report, which indicated that, when plaintiff is "outside of a clinical setting and mental and physical limitations are not being actively assessed, he demonstrated increased functioning." Tr. 19. Further, the ALJ pointed to Dr. Northway's concession that "plaintiff may have not put forth honest effort." Tr. 20.
The ALJ provided clear and convincing reasons, supported by substantial evidence, for rejecting this portion of Dr. Northway's findings.
Thus, contrary to Dr. Northway's finding of marked limitations in social functioning, the CDUI report "suggest[s] that [plaintiff] retains significant social and cognitive functioning." Tr. 20. In other words, plaintiff's own statements and actions, as observed and reported by to the CDUI investigator, belie Dr. Northway's findings. This, combined with the fact that, as Dr. Northway noted, plaintiff displayed inconsistent levels of functioning in front of various providers and may not have put forth sufficient effort during the evaluation, further undermines Dr. Northway's opinion. Tr. 19-20, 861;
Finally, to the extent plaintiff argues that Dr. Northway's assessment established that he is presumptively disabled under Listing 12.05C, his argument is rejected. Plaintiff bears the burden of establishing that this listing is met and, here, he failed to do so.
On July 7, 2011, Dr. Allcott filled out a questionnaire provided by plaintiff's attorneys, which was accompanied by Dr. Northway's neuropsychological screening assessment report. Tr. 886-88. Dr. Allcott concurred with the opinions expressed by Dr. Northway in his evaluation. Tr. 886. In addition, Dr. Allcott opined that plaintiff has "chronic limitations from back and knee arthritis" and was unable to work. Tr. 888.
The ALJ gave no weight to these conclusions, as they were not accompanied by objective findings and were inconsistent with Dr. Allcott's chart notes. Tr. 18. Further, the ALJ rejected Dr. Allcott's concurrence with Dr. Northway's neuropsychological screening because Dr. Allcott is not a psychologist or mental health specialist.
An ALJ may discredit a doctor's opinion if it is on a check-off questionnaire and is not accompanied by objective explanations.
In fact, Dr. Allcott's opinion was inconsistent with his chart notes, which indicate that plaintiff regularly engaged in activities of daily living and exercise, such as stretching, swimming, and biking.
Finally, plaintiff asserts that the ALJ's step five finding was invalid because the RFC and, by extension, the hypothetical questions posed to the VE, failed to include all of the limitations assessed by Dr. Scott, Dr. Northway, Dr. Allcott, and Ms. O'Brien. As discussed above, however, the ALJ's RFC adequately accounted for all of plaintiff's impairments that were supported by substantial evidence in the record; moreover, the dispositive hypothetical question that the ALJ posed to the VE accurately incorporated all of these limitations. Tr. 116-18. Accordingly, the ALJ's step five finding is supported by substantial evidence and was based upon the proper legal standards.
For the foregoing reasons, the Commissioner's decision is AFFIRMED and this case is DISMISSED.
IT IS SO ORDERED.