Medina v. Comm'r of Soc. Sec.
Medina v. Comm'r of Soc. Sec.
Opinion of the Court
INTRODUCTION
Represented by counsel, Plaintiff Grizel Colon Medina ("Plaintiff") brings this action pursuant to Title 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 application for supplemental security income ("SSI"). (Dkt. 1). This Court has jurisdiction over the matter pursuant to
BACKGROUND
Plaintiff protectively filed her application for SSI on July 2, 2014. (Dkt. 8-2 at 16; Dkt. 8-3 at 16).
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 Parker 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
At step two, the ALJ found that Plaintiff suffered from the severe impairments of degenerative disc disease and obesity. (Id. ). The ALJ further found that Plaintiff's *300medically determinable impairments of asthma, seizure disorder, sleep apnea, gastroesophageal reflux disease, hand dysfunction, and affective disorder, were non-severe. (Id. at 18-21).
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 21). The ALJ particularly considered the criteria of Listing 1.04 in reaching his conclusion, as well as considering the effect of Plaintiff's obesity as required by Social Security Ruling ("SSR") 02-1p. (Id. ).
Before proceeding to step four, the ALJ determined that Plaintiff retained the RFC to perform a range of light work as defined in
cannot climb ladders, ropes, or scaffolds. She frequently can balance and stoop; [Plaintiff] occasionally can kneel, crouch, crawl, and climb ramps and stairs. [Plaintiff] must be able to sit for five minutes after standing for 30 minutes, or stand for 5 minutes after sitting for 30 minutes, but she can continue working in either position. [Plaintiff] cannot work in a job where she is isolated from co-workers. She cannot work around unprotected heights or moving mechanical equipment. [Plaintiff] cannot operate motorized equipment as part of the job. She must avoid concentrated exposure to dust, odors, fumes, and pulmonary irritants. [Plaintiff] can work only in jobs that require minimal ability to speak English.
(Id. at 22). At step four, the ALJ found that Plaintiff has no past relevant work. (Id. at 25).
At step five, the ALJ relied on the testimony of a vocational expert ("VE") 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, including the representative occupations of produce weigher, racker, and inspector and hand packager.
II. Remand of this Matter for Further Proceedings is Necessary
Plaintiff asks the Court to remand this matter to the Commissioner, arguing that (1) the ALJ erred by failing to incorporate hand limitations assessed by Harbinder Toor, M.D. in the RFC finding without explanation; and (2) the ALJ erred in weighing other medical opinions in the case, including by collectively weighing five separate opinions, some of which were issued by treating sources, and giving conclusory reasons for rejecting the opinions of Kristina Luna, Psy. D. and Erica Hahn, LMSW, Plaintiff's therapist. (Dkt. 10-1). For the reasons set forth below, the Court finds that the ALJ erred in evaluating the opinions of Plaintiff's treating sources, and that this error necessitates remand for further administrative proceedings.
A. Assessment of Treating Source Opinion Evidence
The requirements for evaluating medical opinion evidence (for claims filed before March 27, 2017) are found at
Because Plaintiff's claim was filed before March 27, 2017, the ALJ was required to apply the treating physician rule. Accordingly, for the treating source opinions not afforded controlling weight, the ALJ was required to "consider various factors to determine how much weight to give to the opinion." Halloran v. Barnhart ,
(i) the frequency of examination and the length, nature and extent of the treatment relationship; (ii) the evidence in support of the treating physician's opinion; (iii) the consistency of the opinion with the record as a whole; (iv) whether the opinion is from a specialist; and (v) other factors brought to the Social Security Administration's attention that tend to support or contradict the opinion.
Whatever weight the ALJ assigns to the treating physician's opinion, he must "give good reasons in [his] notice of determination or decision for the weight [he gives to the] treating source's medical opinion."
The record is comprised of the following medical opinion evidence: (1) a November 7, 2014 evaluation by agency consultant I. Seok, M.D. (Dkt. 8-3 at 2-15, Ex. 1A); (2) a May 8, 2014 physical assessment by Aharon Wolf, M.D. (Dkt. 8-7 at 161-65, Ex. 18F); (3) a May 8, 2014 psychological assessment by Adam Brownfeld, Ph.D. (id.
*302at 167-72, Ex. 19F); (4) an August 26, 2014 physical assessment by Michael M. Henderson, M.D., a treating physician (id. at 174-78, Ex. 20F); (5) an October 9, 2014 internal medicine examination by Dr. Toor (id. at 78-83, Ex. 7F); (6) an October 24, 2014 psychiatric evaluation by Dr. Luna (id. at 87-91, Ex. 9F); (7) an October 24, 2014 physical assessment by Dr. Henderson (id. at 92-96, Ex. 10F); (8) a March 4, 2015 physical assessment by nurse practitioner Susan Szczepanski ("NP Szczepanski") (id. at 223-26, Ex. 23F); (9) an August 27, 2015 physical assessment by NP Szczepanski (id. at 126-34, Ex. 16F); (10) a March 31, 2016 psychological assessment by LMSW Hahn, Plaintiff's therapist (id. at 313-16, Ex. 27F); (11) a May 6, 2016 physical assessment by Hirushi Weerasinghe, M.D., a treating physician (id. at 325-28, Ex. 28F); (12) a June 10, 2016 physical assessment by Dr. Weerasinghe (id. at 423-27, Ex. 35F); and (13) a June 18, 2016 physical assessment by Eun Ha Lee, M.D. (Dkt. 8-9 at 449-53, Ex. 41F).
Rather than considering most of the medical opinion evidence separately - save for the opinions of Dr. Toor, Dr. Seok, Dr. Luna, Dr. Brownfeld, and LMSW Hahn - the ALJ collectively explained his reasoning for affording "limited weight" to several sources, including opinions from Plaintiff's treating physicians, Drs. Henderson and Weerasinghe:
I give limited weight to the collective medical source statements offered from multiple sources, as scattered throughout the record (Ex. 10F; 16F; 18F; 19F; 28F; 41F). Some of these reports are vague, checklist-type appraisals, while others (such as the medical source statement provided by Eun Ha Lee, M.D.) clearly state that the content was based on the claimant's 'verbal report' and was not assessed based on objective measures (Ex. 41F/2). Therefore, whether these were checkmark-type opinions generated in connection with the work requirements of the local jurisdiction, or just subjective assessments relying substantially on the claimant's self-reports, they do not apply the same standards as the Social Security Administration's disability processes. Furthermore, the opinions in some instances offer starkly different assessments, which highlights the difficulty in relying on these types of checklist forms as opposed to narrative-based explanations.
(Dkt. 8-2 at 24).
The Court finds that the ALJ's collective consideration of these many medical opinions was error. As an initial matter, the ALJ failed to specifically mention the names of several of the sources of these medical opinions (save for Dr. Lee), and rather referred to exhibit numbers to identify the opinions. Missing from the laundry list of exhibits ("Ex. 10F; 16F; 18F; 19F; 28F; 41F") are the Exhibit numbers corresponding with the June 10, 2016 opinion by Dr. Weerasinghe (Ex. 35F) and the August 26, 2014 opinion by Dr. Henderson (Ex. 20F), which indicates that the ALJ did not even consider these opinions by Plaintiff's treating physicians. In fact, there is no mention of these opinions anywhere in the written determination.
Moreover, because the ALJ assessed these opinions in a collective fashion, it is not clear to the Court which opinions - aside from the opinion of Dr. Lee - the ALJ discounted based on vagueness, and which opinions were discounted because they were based on Plaintiff's subjective complaints. This also constitutes error requiring remand. See Tobey v. Comm'r of Soc. Sec. , No. 1:16-CV-00937 (MAT),
Finally, Drs. Henderson and Weerasinghe were Plaintiff's treating physicians and therefore, their opinions were entitled to controlling weight if well-supported by and not inconsistent with the other medical evidence of record. As noted above, the ALJ failed to discuss the August 26, 2014 opinion by Dr. Henderson and the June 10, 2016 opinion by Dr. Weerasinghe. He did cite to the October 24, 2014 physical assessment by Dr. Henderson and the May 6, 2016 physical assessment by Dr. Weerasinghe, at Exhibits 10F and 28F. (See Dkt. 8-2 at 24). The ALJ assigned only "limited weight" to these opinions; accordingly, pursuant to the regulations, the ALJ was required to consider: "(i) the frequency of examination and the length, nature and extent of the treatment relationship; (ii) the evidence in support of the treating physician's opinion; (iii) the consistency of the opinion with the record as a whole; (iv) whether the opinion is from a specialist; and (v) other factors *304brought to the Social Security Administration's attention that tend to support or contradict the opinion." Halloran ,
Defendant argues that although the ALJ discounted medical opinions in the record "as a group," this was proper because the "form, cursory opinions warranted the analysis the ALJ provided." (Dkt. 12-1 at 24). However, "[e]ven if [a treating source's] opinions do not merit controlling weight, the ALJ must explain what weight [he] gave those opinions and must articulate good reasons for not crediting the opinions of a claimant's treating physician." Perez v. Astrue , No. 09-CV-958 (DLI),
While the Court is cognizant that "[a]n ALJ does not have to explicitly walk through [all the relevant] factors, so long as the Court can conclude that the ALJ applied the substance of the treating physician rule," see Scitney ,
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),
*305CONCLUSION
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. 12) 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.
The vocational expert also testified that the following sedentary jobs would be available: a final assembler, a lens inserter, and a bench hand. (Dkt. 8-2 at 27).
The ALJ also failed to consider the March 4, 2015 physical assessment by NP Szczepanski (Ex. 23F).
The August 26, 2014 opinion by Dr. Henderson did not assess any functional limitations (see Dkt. 8-7 at 175, 177); accordingly, had the ALJ considered this opinion, it likely would not have changed the assessed RFC.
Reference
- Full Case Name
- Grizel COLON MEDINA v. COMMISSIONER OF SOCIAL SECURITY
- Cited By
- 11 cases
- Status
- Published