Henderson v. Berryhill
Henderson v. Berryhill
Opinion of the Court
Plaintiff Nicole L. Henderson ("plaintiff") brings this action pursuant to Section 205(g) of the Social Security Act (the "Act"),
On July 30, 2012, plaintiff filed an application for a period of disability and DIB under Title II of the Act, alleging disability beginning on October 1, 2008. (Tr. 31).
The plaintiff has moved, and the Commissioner has cross moved, for judgment on the pleadings pursuant to Rule 12(c) of the Federal Rules of Civil Procedure. For the reasons set forth below, plaintiff's motion seeking remand (Dkt. # 10) is granted, the Commissioner's cross motion for judgment dismissing the complaint (Dkt. # 13) is denied, and the matter is remanded for further proceedings.
DISCUSSION
I. Standard of Review
The Commissioner's decision that plaintiff is not disabled must be affirmed if it is supported by substantial evidence, and if the ALJ has applied the correct legal standard. See
"The Court carefully considers the whole record, examining evidence from both sides 'because an analysis of substantiality of the evidence must also include that which detracts from its weight.' " Tejada v. Apfel ,
The same level of deference is not owed to the Commissioner's conclusions of law. See Townley v. Heckler ,
In examining plaintiff's claim, the ALJ applied the familiar five-step analysis applicable to disability determinations. At step one, the ALJ found that plaintiff had not engaged in substantial gainful activity since October 1, 2008, the alleged onset date. (Dkt. # 8 at 33). At step two, the ALJ found that plaintiff had the following severe impairments: degenerative disc disease ; asthma ; fibromyalgia ; chronic pain syndrome; and a history of polysubstance abuse. (Id. ). At step three, the ALJ found that such impairments, alone or in combination, did not meet or medically equal a listed impairment. (Dkt. # 8 at 34).
Next, the ALJ determined that plaintiff retained the RFC to perform sedentary work
DISCUSSION
Plaintiff argues that the Commissioner's decision is not supported by substantial evidence and is based on errors of fact and law.
I. The ALJ's Assessment of Plaintiff's Credibility
Plaintiff's chief argument is that the ALJ made numerous errors in assessing her credibility, and thus improperly rejected plaintiff's testimony concerning the severity of her symptoms, resulting in an erroneous RFC determination.
A plaintiff's allegations of pain and functional limitations are "entitled to great weight where ... [they are] supported by objective medical evidence." Rockwood v. Astrue ,
"When rejecting subjective complaints, and ALJ must do so explicitly and with sufficient specificity to enable the Court to decide whether there are legitimate reasons for the ALJ's disbelief." Rockwood ,
Here, the ALJ concluded that plaintiff's statements as to the intensity and frequency of her symptoms-and specifically her allegations of manipulative limitations and difficulty sitting, standing and walking due to pain-were not fully credible. (Dkt. # 8 at 40). Evidence cited by the ALJ in support of that finding included: (1) examination findings showing intact strength, sensation and reflexes; (2) plaintiff's testimony that she had been "cleaning houses as a part-time job [for a portion of] the period at issue"; and (3) plaintiff's "activities of daily living," including engagement in activities such as personal care, washing dishes, doing laundry, and grocery shopping. (Id. ).
Plaintiff argues-and the Court concurs-that the ALJ's credibility determination was compromised by unsupported interpretations of raw medical evidence, and several mischaracterizations of the record.
First, to the extent that the ALJ found that "intact strength, sensation and reflexes" undermined plaintiff's claims of fibromyalgia-related pain and weakness, it is well settled that an "absence of swelling joints or other orthopedic and neurologic deficits 'is no more indicative that a patient's fibromyalgia is not disabling than the absence of a headache is an indication that a patient's prostate cancer is not advanced.' " Green-Younger v. Barnhart ,
Indeed, even assuming arguendo that a lack of neurological signs (e.g., intact strength, sensation and reflexes) was relevant to the ALJ's analysis in some other manner, the records to which the ALJ cited do not actually evidence a lack of neurological signs. In referring to plaintiff's "intact strength, sensation and reflexes during the period [at issue]," the ALJ cited to Exhibits 2F, 4F, 7F, 10F, 11F, 12F, 14F, 15F, 16F and 18F (Dkt. # 8 at 40, 302-566). However, the bulk of these records include no objective findings concerning plaintiff's strength, sensation and reflexes, and many do not even pertain to a physical examination. (For example, Exh. 2F is an emergency room record describing treatment for a burned arm, 4F describes treatment for a sprained ankle, and 7F is a laboratory report).
Furthermore, to the extent that the ALJ relied on plaintiff's activities of daily living in rejecting her statements concerning the severity of her symptoms, the ALJ described "part-time" work as a housekeeper, and found that the plaintiff can "cook, clean, do laundry, shop, maintain her own care," etc. (Dkt. # 7 at 40). However, the ALJ's characterization overlooks important details. For example, plaintiff's prior work as a housekeeper was significantly less than "part-time": it took place only two hours per week for a period of time, and ended due to plaintiff's symptoms. Plaintiff testified that her participation in *370her own "personal care" such as dressing and showering requires extensive physical assistance from family members, and any housekeeping is limited to light chores such as dish washing, with rest breaks every few minutes. Plaintiff grocery shops only when a neighbor or family member is able to drive her and assist her in the store. (Dkt. # 8 at 65-66).
It is well settled that "[t]here is a critical difference between activities of daily living (which one can do at his own pace when he is able) and keeping a full time job," Harris v. Colvin ,
Here, the ALJ clearly misunderstood or exaggerated the degree to which plaintiff could independently perform daily activities such as housework and personal care, and diminished her credibility findings on that basis in a manner which significantly altered and influenced her RFC finding. Remand is therefore appropriate.
II. The ALJ's Assessment of the Medical Opinion Evidence of Record
The Court also notes that the ALJ gave no more than "little" weight to the medical opinion evidence of record bearing on plaintiff's nonexertional and postural limitations, including the opinion of consulting internist Dr. Harbinder Toor, who was the only acceptable medical source of record who purported to specifically assess those limitations. (Dkt. # 8 at 385-89). The ALJ rejected Dr. Toor's opinion largely on the basis of "vague[ness]," based on his use of terms such as "moderate" and "severe," which the ALJ found insufficient to indicate "what the claimant could or could not do in a work setting." (Dkt. # 8 at 41). The ALJ likewise rejected the "opinion" of plaintiff's treating physician, Dr. Steven Lasser (Dkt. # 8 at 491-92), which took the form of a treatment note which described plaintiff's "severe and disabling" hip, buttock and lower back pain due to severe sacroiliac joint dysfunction syndrome, but failed to meaningfully assess plaintiff's ability to perform the exertional requirements of work. (Id. ). Finally, the ALJ gave no more than "little" weight to the physical RFC assessment of occupational therapist Ms. Maria C. Aguilera (Dkt. # 8 at 574-82), because her findings concerning plaintiff's ability to sit, stand, lift, carry, etc., were more limiting than "any other examination of record," and because Ms. Aguilera is not an "acceptable medical source." (Dkt. # 8 at 41).
Initially, the mere use of terms such as "moderate" and "severe" does not automatically render an opinion "too vague to constitute substantial evidence," particularly where "the examiner conducts a thorough examination and explains the basis for the opinion." O'Bara v. Colvin,
Even assuming that Dr. Toor's opinion was properly characterized as "vague," the ALJ ultimately rejected all of the medical opinion evidence of record as to plaintiff's exertional and postural limitations. Although an ALJ may base an RFC assessment on evidence other than medical opinions, such as treatment notes and activities of daily living, the instant record lacked sufficient evidence to do so. See Monroe v. Commissioner ,
In the absence of the medical opinions rejected by the ALJ, the instant record lacked evidence sufficient for the ALJ to reach an informed decision as to plaintiff's RFC. As such, the ALJ's RFC finding amounted to an improper substitution of her "own expertise or view of the medical proof [in place of] any competent medical opinion," and remand is appropriate. Greek v. Colvin ,
CONCLUSION
For the foregoing reasons, the plaintiff's motion for judgment on the pleadings (Dkt. # 10) is granted, the Commissioner's cross motion for judgment on the pleadings (Dkt. # 13) is denied, and the matter is remanded for further proceedings. On remand, the ALJ is directed to recontact plaintiff's treating and examining physicians, and/or to obtain additional medical opinions specifically assessing plaintiff's exertional and/or postural limitations in specific and quantifiable terms, as well as to engage in a reassessment of plaintiff's credibility in light of such evidence, with specific cites to supporting evidence of record.
IT IS SO ORDERED.
References to page numbers in the Administrative Transcript (Dkt. # 8) utilize the internal Bates-stamped pagination assigned by the parties.
"Sedentary work involves lifting no more than 10 pounds at a time and occasionally lifting or carrying articles like docket files, ledgers, and small tools. Although a sedentary job is defined as one which involves sitting, a certain amount of walking and standing is often necessary in carrying out job duties. Jobs are sedentary if walking and standing are required occasionally and other sedentary criteria are met."
Reference
- Full Case Name
- Nicole L. HENDERSON v. Nancy A. BERRYHILL, Acting Commissioner of Social Security
- Cited By
- 27 cases
- Status
- Published