Dye v. Comm'r of Soc. Sec.
Dye v. Comm'r of Soc. Sec.
Opinion of the Court
Represented by counsel, Plaintiff Adam Franklin Dye ("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 his 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 his applications for DIB and SSI on February 3, 2014. (Dkt. 7 at 31, 113-14).
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
*390At step two, the ALJ found that Plaintiff suffered from the severe impairments of: "cervical and lumbar degenerative disc disease ; arthrosis of the right wrist and thumb; intermittent explosive disorder ; antisocial personality disorder ; depression with anxiety; and history of substance abuse." (Id. at 34). The ALJ further found that Plaintiff's medically determinable impairment of obesity was non-severe. (Id. ). With respect to Plaintiff's representation that he suffers from a learning disability, the ALJ concluded that this was not a medically determinable impairment. (Id. ).
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 34). The ALJ particularly considered the criteria of Listings 1.02(a), 1.04, 12.04, 12.08, and 12.09 in reaching her conclusion. (Id. at 35-37).
Before proceeding to step four, the ALJ determined that Plaintiff retained the RFC to perform a range of sedentary work as defined in
occasional climb ramps or stairs; never climb ladders, ropes, or scaffolds; occasional balance, stoop, crouch, kneel, crawl; frequent handling objects, this is gross manipulation with the right, dominant hand; frequent fingering objects, that is fine manipulation with the right, dominant hand; occasional exposure to moving mechanical parts; occasional operating a motor vehicle; occasional exposure to unprotected heights; able to perform simple, routine, repetitive tasks; have no interaction with the public; and only occasional, superficial interaction with co-workers and supervisors.
(Id. at 37). At step four, the ALJ found that Plaintiff was unable to perform any past relevant work. (Id. at 52).
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 table clerk, document preparer, and printed circuit board assembly touch up screener. (Id. at 53-54). Accordingly, the ALJ found that Plaintiff was not disabled as defined in the Act. (Id. at 55).
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 that (1) the ALJ rejected all opinion evidence relating to Plaintiff's physical limitations, and therefore assessed the physical RFC based on her lay interpretation of the evidence; (2) the ALJ assessed Plaintiff's mental RFC in the absence of opinion evidence; and (3) the ALJ improperly diminished Plaintiff's credibility. (Dkt. 8-1 at 17-30). For the reasons set forth below, the Court finds that the RFC is not supported by substantial evidence because the ALJ assessed Plaintiff's mental RFC in the absence of opinion evidence. 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 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),
At the administrative hearing, Plaintiff testified that he was diagnosed with "manic depressive bipolar, ADHD, post traumatic stress disorder and OCD," and that these conditions made him "[q]uite moody. Obviously, I get depressed a lot, cry sometimes, working - like even when I was younger, I couldn't really work with a lot of people. My mood would go way off, hence, how many jobs I've had." (Dkt. 6 at 74). Plaintiff explained that he was nervous working around people and had "problems dealing with ... other people telling me what I can and can't do and it just doesn't make me feel very good." (Id ). Plaintiff recounted an incident when he was suspended due to an altercation with another individual at work. (Id. at 75). Plaintiff explained that he attended therapy at Wayne Behavioral Health every month for "anger management, one-on-one counseling and men's alternative to violence," but that he had not been to an appointment in two months, due to his feeling overwhelmed by his divorce and caring for his children. (Id. at 83).
The ALJ found that Plaintiff had multiple severe impairments, including several severe mental impairments. (See id. at 34 (assessing Plaintiff with the severe impairments of cervical and lumbar degenerative disc disease ; arthrosis of the right wrist and thumb; intermittent explosive disorder ; antisocial personality disorder ; depression with anxiety; and history of substance abuse) ). At step three, the ALJ found that Plaintiff had either mild or marked limitations in several areas of mental functioning. (See id. at 35-36 (Plaintiff has mild restriction in activities of daily living; moderate difficulties in social functioning; moderate difficulties in concentration, persistence, or pace; and no episodes of decompensation) ). The ALJ included limitations relating to Plaintiff's mental impairments in the RFC, including that Plaintiff perform simple, routine, repetitive tasks; have no interaction with the public; and only occasional, superficial interaction with co-workers and supervisors. (Id. at 37).
In explaining how she assessed Plaintiff's mental RFC, the ALJ discussed Plaintiff's mental health treatment, noting that his mental impairments"were not as limiting as alleged and do not preclude him from all work." (Id. at 46). The ALJ focused specifically on the fact that Plaintiff did not receive formal mental health treatment from 2011 through 2014 and, when he received treatment, the record revealed that he was not as limited as he alleged. (Id. at 47-48). Notably missing from the ALJ's discussion is an assessment of opinion evidence for work-related limitations caused by Plaintiff's severe mental impairments *392. This is because there is no such evidence in the record.
Rather than relying on opinion evidence - which generally contains information relevant to specific functional limitations - to assess Plaintiff's mental RFC, the ALJ used her own lay judgment to evaluate Plaintiff's mental health treatment history. For example, the ALJ states that "[t]he record supports the claimant remains capable of performing simple, routine, and repetitive tasks." (Id. at 48). In arriving at this conclusion, the ALJ discussed the following: Plaintiff did not receive formal mental health treatment until 2015; prior to that time, Plaintiff was prescribed medications to treat his mental health conditions; doctor's observations of Plaintiff's mental state; Plaintiff's ability to care for his children, with the help of his parents; and Plaintiff's collecting rent in the trailer park where he lived. (Id. ). Similarly, the ALJ explained that the RFC accommodates Plaintiff's "allegations that he angers easily and has increased irritability," "objective findings of a constricted, guarded, and anxious mood and affect," as well as Plaintiff's "subjective allegations of irritability with difficulty controlling his anger and subsequent physical violence." (Id. ). In explaining how she arrived at these accommodations - which include no interaction with the public and only occasional, superficial interaction with co-workers and supervisors - the ALJ discussed that Plaintiff had a good response to Cymbalta ; Plaintiff presented as calmer after one physical therapy session; and Plaintiff did not continue with mental health treatment at Wayne Behavioral Health. (Id. ). The ALJ concluded that because Plaintiff did not continue with treatment, "he remains capable of occasional, superficial interaction with co-workers and supervisors." (Id. ).
In the absence of opinion evidence, the ALJ's equating this type of information - treatment notes, observations by Plaintiff's providers, Plaintiff's medications and response to treatment, and activities of daily living -to specific functional capacities, was improper. Where the record primarily discusses a plaintiff's impairments, symptoms, and treatment, but does not shed light on the plaintiff's limitations, the ALJ may not rely on the record in determining the plaintiff's RFC. See Trippett v. Comm'r of Soc. Sec. , No. 16-CV-908-MJR,
The Court is cognizant that where the record reflects only minor impairments, the ALJ may, in her discretion, assess an RFC in the absence of opinion evidence. See Wilson ,
Defendant argues that "a mental medical source opinion was not required to assess Plaintiff's RFC because the ALJ assessed his RFC based on the record as a whole." (Dkt. 12-1 at 26). In support of this contention, Defendant highlights the ALJ's observations that Plaintiff did not seek formal mental health treatment until 2015, as well as that Plaintiff was inconsistent taking medication and did not follow through on treatment. (Id. at 26-27). Defendant also contends that Plaintiff did not originally allege disability based on mental impairment and therefore "[did] not appear to have viewed his own mental impairments as disabling."
Defendant also argues that Plaintiff's mental status examinations are consistent with the ability to perform unskilled work, that he performed work at a pizza shop (which he quit based on his physical impairments, but required mental skills beyond those required by the RFC), and that he performed childcare for his children (semi-skilled work). (Dkt. 12-1 at 26-27). The Court rejects these arguments for several reasons. First, defense counsel, like the ALJ, is not a medical professional and may not interpret Plaintiff's mental status examinations to assess a functional capacity of unskilled work. Second, Defendant's articulations regarding Plaintiff's performance of the pizza shop job and, more specifically, the assumption that he could handle the mental aspects of that job, are absent from the ALJ's opinion. Defendant's after-the-fact explanation as to why the ALJ properly assessed the mental RFC cannot serve as a substitute for the ALJ's findings. See Snell v. Apfel,
*394Michels v. Berryhill, No. 1:15-CV-00688 (MAT),
In sum, the ALJ erroneously assessed Plaintiff's mental limitations in the absence of a competent medical opinion. The ALJ should have, at a minimum, secured a consulting physician to examine Plaintiff and render an opinion as to his functional limitations. See Falcon v. Apfel,
B. Plaintiff's Remaining Arguments
As set forth above, Plaintiff has identified additional reasons why he 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. 8) 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.
Although Plaintiff's disability applications do not list mental impairments affecting his ability to work, as discussed above, Plaintiff clearly identified his mental conditions as affecting his ability to work at his administrative hearing. Plaintiff's failure to list his mental impairments on his disability application does not relieve the ALJ of her duty to obtain opinion evidence relating to these limitations. See Guzman v. Berryhill, No. 15 CV 3920 (VB)(LMS),
Reference
- Full Case Name
- Adam Franklin DYE v. COMMISSIONER OF SOCIAL SECURITY
- Cited By
- 28 cases
- Status
- Published