Benman v. Comm'r of Soc. Sec.
Benman v. Comm'r of Soc. Sec.
Opinion of the Court
INTRODUCTION
Represented by counsel, Plaintiff India Benman ("Plaintiff") brings this action pursuant to Titles II and XVI of the Social Security Act (the "Act"), seeking review of the final decision of the Commissioner of Social Security (the "Commissioner," or "Defendant") denying her applications for disability insurance benefits ("DIB") and supplemental security income ("SSI"). (Dkt. 1). This Court has jurisdiction over the matter pursuant to
BACKGROUND
Plaintiff protectively filed her applications for DIB and SSI on February 19, 2014. (Dkt. 8-3 at 34-3 5).
LEGAL STANDARD
I. District Court Review
"In reviewing a final decision of the [Social Security Administration ("SSA") ], this Court is limited to determining whether the SSA's conclusions were supported by substantial evidence in the record and were based on a correct legal standard." Talavera v. Astrue ,
II. Disability Determination
An ALJ follows a five-step sequential evaluation to determine whether a claimant is disabled within the meaning of the Act. See Bowen v. City of New York ,
At step three, the ALJ examines whether a claimant's impairment meets or medically equals the criteria of a listed impairment in Appendix 1 of Subpart P of Regulation No. 4 (the "Listings").
The ALJ then proceeds to step four and determines whether the claimant's RFC permits the claimant to perform the requirements of his or her past relevant work.
DISCUSSION
I. The ALJ's Decision
In determining whether Plaintiff was disabled, the ALJ applied the five-step sequential evaluation set forth in
*256At step two, the ALJ found that Plaintiff suffered from the severe impairments of diabetes, chronic kidney disease, gastroparesis, depressive disorder, anxiety disorder, posttraumatic stress disorder, and borderline personality disorder. (Id. at 24-25). The ALJ further found that Plaintiff's medically determinable impairments of cannabis use, alcohol use, hypertension, left foot pain, and lower back pain were non-severe. (Id. at 25-26).
At step three, the ALJ found that Plaintiff did not have an impairment or combination of impairments that met or medically equaled the severity of any Listing. (Id. at 26). The ALJ particularly considered the criteria of Listings 6.03, 9.00, 1.00, 2.00, 4.00-6.00, 8.00, 11.00, 12.00, 12.04, 12.06, and 12.08 in reaching his conclusion. (Id. at 26-27).
Before proceeding to step four, the ALJ determined that Plaintiff retained the RFC to perform light work as defined in
lifting and/or carrying 20 pounds occasionally and ten pounds frequently, standing and/or walking for six hours in an eight-hour workday, and sitting for six hours in an eight-hour workday. [Plaintiff] can occasionally stoop, kneel, crouch, crawl, and balance, but should avoid climbing ropes, ladders, and scaffolds. Mentally, [Plaintiff] retains the ability to understand and follow simple instructions and directions; perform simple tasks with supervision; maintain attention/concentration for simple tasks; regularly attend to a routine and maintain a schedule; relate to and interact with others to the extent necessary to carry out simple tasks; and handle simple work-related stress.
(Id. at 27). At step four, the ALJ found that Plaintiff had no past relevant work. (Id. at 31).
At step five, the ALJ considered the Medical-Vocational Guidelines to conclude that, considering Plaintiff's age, education, work experience, and RFC, there were jobs that exist in significant numbers in the national economy that Plaintiff could perform. (Id. at 31-32). Accordingly, the ALJ found that Plaintiff was not disabled as defined in the Act. (Id. at 32-33).
II. Remand of this Matter for Further Proceedings is Necessary
Plaintiff asks the Court to reverse or, in the alternative, remand this matter to the Commissioner, arguing: (1) the ALJ's assessment of Plaintiff's physical RFC did not rely on any medical opinion evidence, and he therefore substituted his own judgment for a competent medical opinion; (2) the ALJ failed to account for Plaintiff's stress-related limitations in assessing her mental RFC; (3) the ALJ's step five finding was not supported by substantial evidence, because he failed to consult a vocational expert; (4) the ALJ failed to consider the impact of Plaintiff's chronic hospitalizations on her ability to work; and (5) the ALJ improperly held Plaintiff's noncompliance with treatment against her, without considering the reasons for her noncompliance. (Dkt. 10-1 at 18-24). For the reasons set forth below, the Court finds that the ALJ erred in failing to obtain any opinion evidence from an acceptable medical source, and decided the physical portion of Plaintiff's RFC based on his own interpretation of the medical record. This error necessitates remand for further administrative proceedings.
A. The RFC Finding is Unsupported by Substantial Evidence
In deciding a disability claim, an ALJ is tasked with "weigh[ing] all of the evidence available to make an RFC finding *257that [is] consistent with the record as a whole." Matta v. Astrue ,
An ALJ is prohibited from 'playing doctor' in the sense that 'an ALJ may not substitute his own judgment for competent medical opinion.... This rule is most often employed in the context of the RFC determination when the claimant argues either that the RFC is not supported by substantial evidence or that the ALJ has erred by failing to develop the record with a medical opinion on the RFC.
Quinto v. Berryhill , No. 3:17-cv-00024 (JCH),
In this case, the only opinion evidence considered by the ALJ in assessing Plaintiff's physical RFC was a May 2014 consultative exam by Harbinder Toor, M.D. (Dkt. 8-2 at 28; see also Dkt. 8-7 at 218-21). Dr. Toor's report notes that he observed the following: Plaintiff was in moderate pain; she had an abnormal gait with slight limping to her left side; her heel-to-toe walking declined; her squatting was 20 percent full; her station was normal; she did not need help changing for her exam; she had difficulty getting off and on the examination table; and she had difficulty getting out of the chair. (Dkt. 8-7 at 219). Plaintiff reported that her participation in the activities of cooking, cleaning, and laundry varies; that she does not do any shopping; and that she showers, bathes, cares for her child, and dresses daily. (Id. ).
Dr. Toor's musculoskeletal exam revealed full flexion, extension, and rotary movement of the cervical spine, but limited flexion, extension, and lateral flexion of the lumbar spine. (Id. at 220). Plaintiff's straight leg raise tests were positive both sitting supine and bilaterally. (Id. ). Plaintiff had a full range of motion in her shoulders, elbows, forearms, wrists, hips, and knees. (Id. ). Her left ankle plantar flexion and dorsiflexion were limited, but she had a full range of motion in her right ankle. (Id. ). Plaintiff's joints were stable and non-tender. (Id. ). A neurologic exam revealed tingling and numbness in both of Plaintiff's feet, and 5/5 strength in her upper and lower extremities. (Id. ). Similarly, an examination of Plaintiff's extremities revealed tenderness in her feet. (Id. ). Based on all of this information, Dr. Toor opined that Plaintiff had "moderate to severe" limitations in standing, walking, bending, lifting, or squatting. (Id. ). He further opined that Plaintiff had moderate limitations sitting for a long time, and that her pain interfered with her physical routine and balance. (Id. at 221).
The ALJ allocated "some weight" to the postural and lifting limitations identified by Dr. Toor "based on his programmatic expertise." (Dkt. 8-2 at 28). However, the ALJ rejected the remainder of Dr. Toor's assessment, because it was inconsistent with other evidence in the record. (Id. ). Specifically, the ALJ found that Dr. Toor's opinion was based in part on the claimant's lower back disorder, left foot pain, and hypertension, which the ALJ determined were not "severe" impairments. (Id. ). The *258ALJ also found that Plaintiff was "not fully compliant with taking her medications for her diabetes, her abdominal pain was out of proportion to clinical findings, and she recently reported ... improvement in her blood sugar levels." (Id. ). The ALJ then assessed that Plaintiff retained the RFC to perform light work, in that she: can lift and/or carry 20 pounds occasionally and ten pounds frequently; stand and/or walk for six hours in an eight-hour workday, and sit for six hours in an eight-hour workday; and occasionally stoop, kneel, crouch, crawl, and balance, but should avoid climbing ropes, ladders, and scaffolds. (Id. at 27). The assessed RFC is at odds with Dr. Toor's opinion relating to Plaintiff's physical limitations.
As an initial matter, the Court recognizes that Dr. Toor's opinion, which is based on a one-time consultative examination, is not entitled to any special weight. See Hamm v. Colvin , No. 16cv936 (DF),
(1) the frequency of examination and length, nature, and extent of the treatment relationship,
(2) the evidence in support of the physician's opinion,
(3) the consistency of the opinion with the record as a whole,
(4) whether the opinion is from a specialist, and
(5) whatever other factors tend to support or contradict the opinion.
See Crawford v. Astrue , No. 13-cv-6068P,
The ALJ purportedly rejected Dr. Toor's opinions because they were "inconsistent with the evidence in record." (Dkt. 8-2 at 28). The ALJ's first reason for rejecting Dr. Toor's opinion - that Plaintiff's lower back pain, left foot pain, and hypertension were not severe - is self-serving and does not address any of the factors enumerated above. Moreover, it is well-established that an ALJ is required to consider functional limitations that arise from non-severe impairments. See Parker-Grose v. Astrue ,
The ALJ's second reason for rejecting Dr. Toor's opinion refers to other evidence in the record relating to Plaintiff's diabetes, i.e. , that Plaintiff is not compliant in taking her diabetes medications, that her abdominal pain was out of proportion to her clinical findings, and that she recently *259reported improvement in her blood sugar levels. (Id. ). However, the ALJ does not explain how these facts contribute to his discrediting Dr. Toor's assessed physical limitations. The ALJ's failure to adequately explain his reasoning is particularly significant in this case, where Dr. Toor's evaluation is the only medical opinion in the record as it relates to Plaintiff's physical limitations.
Moreover, and as Plaintiff correctly argues, in rejecting the remaining portions of Dr. Toor's opinion, the ALJ did not rely on any opinion evidence from an acceptable medical source, and therefore determined Plaintiff's RFC based on his own interpretation of the medical record. (Dkt. 10-1 at 18). The Commissioner argues in response that the ALJ is not required to base his RFC finding on a medical opinion that mirrors that finding and, in fact, an ALJ is not required to base his RFC on a medical opinion at all. (Dkt. 13-1 at 13). In support of this argument, the Commissioner cites to a recent, unpublished Summary Order issued by the Second Circuit Court of Appeals, Monroe v. Comm'r of Soc. Sec. ,
In reply to Defendant's argument that the Second Circuit's holding in Monroe is controlling, Plaintiff argues that the line of case law allowing an ALJ to rely on solely medical evidence, in absence of a medical opinion, is limited, and that courts have distinguished Monroe where the ALJ does not discuss treatment notes with any vocational or functional relevance when assessing the RFC. (Dkt. 14 at 1-2). Defendant's brief does not address this issue, nor does it point to specific evidence with vocational or functional relevance in the record from which the ALJ could have assessed Plaintiff's physical RFC.
The Court agrees with Plaintiff that Monroe is distinguishable here. "While in some circumstances, an ALJ may make an RFC finding without treating source opinion evidence, the RFC assessment will be sufficient only when the record is 'clear' and contains 'some useful assessment of the claimant's limitations from a medical source.' " Muhammad v. Colvin , No. 6:16-cv-06369(MAT),
Having reviewed the record, the Court finds that it is neither clear nor complete and does not contain a useful assessment of Plaintiff's physical limitations. Unlike the physician in Monroe , Dr. Toor did not have a lengthy treatment history with Plaintiff. As a consultative physician, Dr. Toor examined Plaintiff on one occasion, and issued a four-page report memorializing his opinion. (See Dkt. 8-7 at 218-21). Dr. Toor does not have any treatment notes on which the ALJ could rely in formulating Plaintiff's physical RFC. In other words, aside from Dr. Toor's May 2014 report, the record does not contain medical opinion evidence with vocational or functional relevance for Plaintiff's physical limitations.
In rejecting the opinion of Dr. Toor - the only medical opinion in the record relating to Plaintiff's physical limitations - the ALJ substituted his own medical opinion for Plaintiff's physical limitations. See Rodriguez v. Colvin , No. 13cv07607 (DF),
B. Plaintiff's Remaining Arguments
As set forth above, Plaintiff has identified additional reasons why she contends the ALJ's decision was not supported by substantial evidence. However, because the Court has already determined, for the reasons previously discussed, that remand of this matter for further administrative proceedings is necessary, the Court declines to reach these issues. See, e.g., Bell v. Colvin , No. 5:15-CV-01160 (LEK),
CONCLUSION
For the foregoing reasons, Plaintiff's motion for judgment on the pleadings (Dkt. 10) is granted to the extent that the matter is remanded for further administrative proceedings. Defendant's motion for judgment on the pleadings (Dkt. 13) is denied. The Clerk of Court is directed to enter judgment and close this case.
SO ORDERED.
When referencing the page number(s) of docket citations in this Decision and Order, the Court will cite to the CM/ECF-generated page numbers that appear in the upper righthand corner of each document.
Reference
- Full Case Name
- India BENMAN v. COMMISSIONER OF SOCIAL SECURITY
- Cited By
- 48 cases
- Status
- Published