Nelson v. Comm'r of Soc. Sec.
Nelson v. Comm'r of Soc. Sec.
Opinion of the Court
Represented by counsel, Plaintiff Jennifer Marie Nelson ("Plaintiff") brings this action pursuant to Title II 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 disability insurance benefits ("DIB"). (Dkt. 1). This Court has jurisdiction over the matter pursuant to
BACKGROUND
Plaintiff protectively filed her application for DIB on December 16, 2013. (Dkt. 7 at 23, 61).
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: obesity, foot problems (callouses and plantar fasciitis ), depression, and anxiety. (Id. ). With respect to Plaintiff's representations that she suffered from numbness and tingling in her right hand, as well as left knee pain, the ALJ concluded that these were not medically determinable impairments. (Id. ).
At step three, the ALJ found that Plaintiff did not have an impairment or combination of impairments that met or medically *365equaled the severity of any Listing. (Id. at 26). The ALJ particularly considered the criteria of Listings 1.02, 12.04, and 12.06, in reaching her conclusion. (Id. at 26-27).
Before proceeding to step four, the ALJ determined that Plaintiff, through the date last insured, retained the RFC:
to lift and carry up to 10 pounds occasionally, and less than 10 pounds frequently; sit 6 hours in an eight-hour workday, stand or walk a total of 2 hours in an eight-hour workday. In addition[,] she requires routine daily tasks which do not significantly change in pace or location on a daily basis. She also requires an occupation which does not require her to talk to the public on the telephone or in person.
(Id. at 27-28). At step four, the ALJ found that through the date last insured, Plaintiff was unable to perform any past relevant work. (Id. at 33).
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 document preparer, addresser, and stem mounter. (Id. at 33-34). Accordingly, the ALJ found that Plaintiff was not disabled as defined in the Act at any time from August 27, 2010, the alleged onset date, through December 31, 2013, Plaintiff's date last insured. (Id. at 34).
II. Remand of this Matter for Further Proceedings is Necessary
Plaintiff asks the Court to reverse or, in the alternative, remand the Commissioner's decision, arguing that: (1) the ALJ improperly evaluated and rejected opinion evidence in the record, resulting in an RFC finding that is not supported by substantial evidence; (2) the ALJ failed to develop the record by obtaining evidence relating to Plaintiff's impairments and limitations existing prior to her date last insured; and (3) the ALJ failed to properly evaluate Plaintiff's credibility. (Dkt. 11-1 at 18-30). 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 relevant to the period of disability at issue, and assessed Plaintiff's RFC based on her own lay interpretation of the medical record. This error necessitates remand for further administrative proceedings.
A. The RFC Finding is Unsupported by Substantial Evidence
Plaintiff argues that the ALJ improperly substituted her own opinion over medical opinions in the record from Dr. Prakash Reddy, Dr. Elizabeth Naumburg,
In deciding a disability claim, an ALJ is tasked with "weigh[ing] all of the evidence available to make an RFC finding that [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),
1. Ms. Dodd's Opinion
The written determination contains a discussion of the opinion evidence in the record, including: (1) the July 15, 2015 opinion of Beverly J. Dodd, LCSW-R, Plaintiff's primary therapist; (2) the March 6, 2016 opinion of Christine Ransom, Ph.D., a consultative physician; and (3) the March 24, 2014 opinion of Thomas Harding, an Administration medical review psychologist. (Dkt. 7 at 26, 31). On July 13, 2015, Ms. Dodd issued an opinion letter relating to Plaintiff's limitations. (Id. at 663). In the letter, Ms. Dodd explained that Plaintiff had been a client since January 2013, and was treated for symptoms of general anxiety disorder, panic disorder, and depressive disorder. (Id. ). Ms. Dodd then opined:
Although she consistently attends both therapy and psychiatric appointments and is being prescribed medication, [Plaintiff's] symptoms often adversely affect her everyday functioning. It is difficult for her to concentrate on everyday activities or deal with stressors, which results in high anxiety and depression. In my clinical assessment, [Plaintiff] would not be able to function in the workplace at this time.
(Id. ). Thereafter, on May 11, 2016, Ms. Dodd issued a second opinion letter. (Id. at 661). In the May 2016 letter, Ms. Dodd referred to the limitations contained in her July 13, 2015 letter, and clarified that "[i]n addition, it is my opinion that these limitations and [Plaintiff's] inability to function in the workplace existed prior to December 31, 2013. If you have additional questions, please do not hesitate to contact me." (Id. ).
Dr. Ransom, a consultative examiner, examined Plaintiff on March 8, 2016. (Id. at 554). Dr. Ransom noted that Plaintiff received treatment at Rochester Rehabilitation Center since 2011. (Id. ). Regarding her current functioning, Plaintiff reported that medication is somewhat effective, but she "continues to feel that she easily becomes *367upset and overwhelmed emotionally. Her energy level fluctuates. She has difficulty concentrating at times." (Id. at 554-55). A mental status exam was mostly normal. (Id. at 555-56). Dr. Ransom opined that Plaintiff:
will have mild difficulty following and understanding simple directions and instructions, perform simple tasks independently, maintain attention and concentration for simple tasks, maintain a simple regular schedule and learn simple new tasks, performing complex tasks, relating adequately with others and appropriately dealing with stress. The results of the evaluation appear to be consistent with mild psychiatric conditions, which will not significantly interfere with the claimant's ability to function on a daily basis.
(Id. at 556). Dr. Harding, one of the Administration's medical review psychologists, found that there was insufficient evidence to adjudicate Plaintiff's claim. (See id. at 65 (Plaintiff's "[a]llegations are partially credible but there exists not enough medical data to substantiate a determination as to severity, frequency or intensity") ). The ALJ noted that other medical evidence received after the date of Dr. Harding's review of the evidence was sufficient to determine that Plaintiff had severe mental impairments prior to her date last insured. (Id. at 26).
The ALJ weighed the opinions of Ms. Dodd and Dr. Ransom in assessing Plaintiff's claim. Regarding Ms. Dodd's opinion that Plaintiff was disabled, the ALJ assigned it no evidentiary weight "because that fact is one for determination by the Commissioner." (Id. at 26). The ALJ considered Ms. Dodd's opinion relating to Plaintiff's limitations for concentration and dealing with stressors only at step two of the disability analysis (i.e. , to assess that Plaintiff's mental impairments were severe), because Ms. Dodd allegedly did not indicate that Plaintiff's limitations were present prior to January 1, 2014, during the relevant period of disability. (See id. at 26 ("Also, while the symptoms were said to cause problems with concentration and dealing with stressors, Ms. Dodd did not indicate if that limited effect was present prior to January 1, 2014") ). Similarly, in weighing the opinion of Dr. Ransom, the ALJ noted that Plaintiff described her symptoms to Dr. Ransom "as they affected her in 2016, at the time of the interview." (Id. at 31-32). Because Dr. Ransom indicated that Plaintiff's limitations were present as of March 8, 2016 (the date of the examination), the ALJ assigned her opinion no evidentiary weight, because it did not relate to the period before December 31, 2013. (Id. at 32).
The ALJ's statement that Ms. Dodd did not indicate that Plaintiff's limitations were present prior to January 1, 2014, is inaccurate. As noted above, on May 11, 2016, two days before the hearing and almost three months prior to the issuance of the written determination, Ms. Dodd reaffirmed her opinion that Plaintiff was precluded from work and clarified that Plaintiff's "limitations and [Plaintiff's] inability to function in the workplace existed prior to December 31, 2013." (Id. at 661). The ALJ failed to address Ms. Dodd's opinion that Plaintiff's disabling limitations existed prior to her date last insured, despite the fact that this opinion was submitted well in advance of the written determination.
2. RFC Assessment
In assessing Plaintiff's RFC, the ALJ acknowledged in the written determination that "[t]he record does not contain any statement of the claimant's physical and mental function-by-function limitation from any treating source issued prior to January 1[,] 2014." (Id. at 32). She then explained how she assessed Plaintiff's RFC:
I have limited the claimant to performing low stress and simple work requiring no more than sedentary exertion. In doing so, I have given evidentiary weight to the claimant's statement regarding what she has remained able to do and have recognized that her obesity has most likely limited her to sedentary work. The limitation concentrating noted by the therapist in 2016, likely was present (although undocumented) during the period prior to the date last insured. I have given the claimant the benefit of the doubt in limiting the claimant in the mental work tasks identified.
(Id. at 32-33). This explanation is insufficient to explain the basis for the ALJ's RFC finding. As acknowledged by the ALJ, the record is devoid of opinion evidence as to Plaintiff's functional limitations, and it is not clear what evidence in the record informed the RFC assessment, other than the ALJ's general statement that she relied on "what [Plaintiff] has been able to do," and "likely" limitations *369due to her obesity. Although the written determination contains a description of Plaintiff's daily activities, the ALJ is not a medical expert, and is not permitted to translate these activities into functional limitations. See Judd v. Berryhill , 17-CV-1188,
B. Plaintiff's Remaining Argument
As set forth above, Plaintiff has identified an additional reason 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 this issue. 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. 11) is granted to the extent that the matter is remanded for further administrative proceedings. Defendant's motion for judgment on the pleadings (Dkt. 14) 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.
Plaintiff's memorandum of law refers to a "Dr. Baumburg." (See Dkt. 11-1 at 25). However, there are no records in this case from any Dr. Baumburg. Instead, it appears that Plaintiff is referring to findings by her primary care physician, Dr. Naumburg. (See Dkt. 7 at 606-54).
Defendant contends that the ALJ considered and adopted Ms. Dodd's May 2016 opinion letter, referring to the portion of the written determination that states, "[t]he limitation concentrating noted by the therapist in 2016, likely was present (although undocumented) during the period prior to the date last insured. I have given the claimant the benefit of the doubt in limiting the claimant in the mental work tasks identified." (See Dkt. 14-1 at 15). This one-sentence statement is insufficient, as it does not contain a discussion of Ms. Dodd's opinion, including her opinion relating to Plaintiff's difficulty dealing with stressors or her opinion that Plaintiff is unable to work. In other words, the ALJ failed to meaningfully consider the May 2016 opinion letter.
The Court further notes that Dr. Reddy, a psychiatrist at Rochester Rehabilitation, assessed Plaintiff with a GAF of 50 (indicating serious symptoms) in January 2014. (Dkt. 7 at 388). Although this assessment was conducted narrowly outside the period of disability, it lends credence to Ms. Dodd's opinion that Plaintiff's impairments existed prior to December 31, 2013.
Reference
- Full Case Name
- Jennifer Marie NELSON v. COMMISSIONER OF SOCIAL SECURITY
- Cited By
- 8 cases
- Status
- Published