Sanders v. Social Security Administration, Commissioner
MEMORANDUM OPINION Signed by Magistrate Judge T Michael Putnam on 3/19/15. (MRR )
2015 Mar-19 PM 02:52
U.S. DISTRICT COURT
N.D. OF ALABAMA
IN THE UNITED STATES DISTRICT COURT
FOR THE NORTHERN DISTRICT OF ALABAMA
ALISON MICHELE SANDERS,
CAROLYN W. COLVIN,
Commissioner of Social Security,
Case No. 2:13-cv-2090-TMP
The plaintiff, Alison Michele Sanders, appeals from the decision of the
Commissioner of the Social Security Administration (ACommissioner@) denying her
application for Supplemental Security Income (ASSI@) and Disability Insurance
Benefits (ADIB@). Ms. Sanders timely pursued and exhausted her administrative
remedies, and the decision of the Commissioner is ripe for review pursuant to 42
U.S.C. '' 405(g), 1383(c)(3). The parties have consented to the jurisdiction of the
undersigned magistrate judge pursuant to 28 U.S.C. ' 626(c).
Ms. Sanders was 41 years old at the time of the Administrative Law Judge=s
(AALJ=s@) decision, and she has a high school education. (Tr. at 40). Her past work
experiences include employment as a secretary, pharmacy technician, dispute
specialist with a credit union, accounts payable clerk, and a manager of a movie
rental store. (Tr. at 75-79). Ms. Sanders claims that she became disabled on
October 5, 2009, due to bipolar disorder, low back pain, migraines, kidney problems,
and a stroke that impaired her memory. 1 (Tr. at 190).
When evaluating the disability of individuals over the age of eighteen, the
regulations prescribe a five-step sequential evaluation process. See 20 C.F.R.
'' 404.1520, 416.920; see also Doughty v. Apfel, 245 F.3d 1274, 1278 (11th Cir.
2001). The first step requires a determination of whether the claimant is Adoing
substantial gainful activity.@ 20 C.F.R. '' 404.1520(a)(4)(i), 416.920(a)(4)(i). If
he or she is, the claimant is not disabled and the evaluation stops. Id. If he or she is
not, the Commissioner next considers the effect of all of the physical and mental
impairments combined. 20 C.F.R. '' 404.1520(a)(4)(ii), 416.920(a)(4)(ii). These
impairments must be severe and must meet the durational requirements before a
claimant will be found to be disabled. Id. The decision depends upon the medical
evidence in the record. See Hart v. Finch, 440 F.2d 1340, 1341 (5th Cir. 1971). If
the claimant=s impairments are not severe, the analysis stops.
The Plaintiff also has listed Amanic depression@ as a disorder, but it appears to be
treated synonymously with bipolar disorder in her medical records.
'' 404.1520(a)(4)(ii), 416.920(a)(4)(ii). Otherwise, the analysis continues to step
three, which is a determination of whether the claimant=s impairments meet or equal
the severity of an impairment listed in 20 C.F.R. pt. 404, Subpart P, Appendix 1. 20
C.F.R. '' 404.1520(a)(4)(iii), 416.920(a)(4)(iii). If the claimant=s impairments fall
within this category, she will be found disabled without further consideration. Id.
If she does not, a determination of the claimant=s residual functional capacity
(ARFC@) will be made and the analysis proceeds to the fourth step. 20 C.F.R.
'' 404.1520(e), 416.920(e). Residual functional capacity is an assessment based
on all relevant evidence of a claimant=s remaining ability to do work despite her
impairments. 20 C.F.R. ' 404.1545(a).
The fourth step requires a determination of whether the claimant=s
impairments prevent her from returning to past relevant work.
'' 404.1520(a)(4)(iv), 416.920(a)(4)(iv). If the claimant can still do his or her past
relevant work, the claimant is not disabled and the evaluation stops. Id. If the
claimant cannot do past relevant work, then the analysis proceeds to the fifth step.
Id. Step five requires the court to consider the claimant=s RFC, as well as the
claimant=s age, education, and past work experience, in order to determine if he or
she can do other work. 20 C.F.R. '' 404.1520(a)(4)(v), 416.920(a)(4)(v). If the
claimant can do other work, the claimant is not disabled. Id. The burden of
demonstrating that other jobs exist which the claimant can perform is on the
Commissioner; and, once that burden is met, the claimant must prove her inability to
perform those jobs in order to be found to be disabled. Jones v. Apfel, 190 F.3d
1224, 1228 (11th Cir. 1999).
Applying the sequential evaluation process, the ALJ found that Ms. Sanders
has not been under a disability within the meaning of the Social Security Act from
the date of onset through the date of her decision. (Tr. at 42). He determined that
Ms. Sanders has not engaged in substantial gainful activity since the alleged onset of
her disability. (Tr. at 24). According to the ALJ, Plaintiff=s history of kidney
stones, history of occipital neuralgia, migraines, degenerative disc disease,2 bipolar
disorder, generalized anxiety disorder, and panic disorder are considered Asevere@
based on the requirements set forth in the regulations. (Id.) He further determined
that these impairments neither meet nor medically equal any of the listed
impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1. (Tr. at 30-33).
ALJ further determined that Ms. Sanders has the Anon-severe@ impairments of
hypertension and an old lacunar infarct. The ALJ did not find Ms. Sanders=
The ALJ specifically described her spinal disc problems as Amultilevel cervical
degenerative disc disease, severe L5-S1 degenerative disc disease, associated severe left L5-S1
neuroforaminal and lateral recess stenosis probably causing left S1 radiculopathy, multilevel
lumbar degenerative disc disease, lumbar spondylosis and facet arthrosis.@ (Tr. at 24).
allegations to be totally credible (Tr. at 35), and he determined that the plaintiff has
the residual functional capacity to perform light work with only occasional bending
and stooping, no climbing, no work at unrestricted heights, and only simple
repetitive, non-complex tasks. (Tr. at 33).
According to the ALJ, Ms. Sanders is unable to perform any of her past
relevant work, she was a Ayounger individual@ at the date of alleged onset, she has a
high school education, and she is able to communicate in English, as those terms are
defined by the regulations. (Tr. at 40). He determined that A[t]ransferability of job
skills is not material to the determination of disability@ in this case.
ALJ found that Ms. Sanders has the residual functional capacity to perform a
significant range of light work, and that, even though Plaintiff cannot perform the
full range of light work, there are a significant number of jobs in the national
economy that she is capable of performing, such as blood donor unit assistant,
information clerk, and fund raiser II.
(Tr. at 41). The ALJ concluded his findings
by stating that Plaintiff is Anot disabled@ under the Social Security Act. (Tr. at 42).
Standard of Review
This Court=s role in reviewing claims brought under the Social Security Act is
a narrow one. The scope of its review is limited to determining (1) whether there is
substantial evidence in the record as a whole to support the findings of the
Commissioner, and (2) whether the correct legal standards were applied. See
Richardson v. Perales, 402 U.S. 389, 390, 401 (1971); Wilson v. Barnhart, 284 F.3d
1219, 1221 (11th Cir. 2002). The Court approaches the factual findings of the
Commissioner with deference, but applies close scrutiny to the legal conclusions.
See Miles v. Chater, 84 F.3d 1397, 1400 (11th Cir. 1996). The Court may not decide
facts, weigh evidence, or substitute its judgment for that of the Commissioner. Id.
AThe substantial evidence standard permits administrative decision makers to act
with considerable latitude, and >the possibility of drawing two inconsistent
conclusions from the evidence does not prevent an administrative agency=s finding
from being supported by substantial evidence.=@ Parker v. Bowen, 793 F.2d 1177,
1181 (11th Cir. 1986) (Gibson, J., dissenting) (quoting Consolo v. Fed. Mar.
Comm=n, 383 U.S. 607, 620 (1966)). Indeed, even if this Court finds that the
evidence preponderates against the Commissioner=s decision, the Court must affirm
if the decision is supported by substantial evidence. Miles, 84 F.3d at 1400. No
decision is automatic, however, for Adespite this deferential standard [for review of
claims] it is imperative that the Court scrutinize the record in its entirety to
determine the reasonableness of the decision reached.@ Bridges v. Bowen, 815 F.2d
622, 624 (11th Cir. 1987). Moreover, failure to apply the correct legal standards is
grounds for reversal. See Bowen v. Heckler, 748 F.2d 629, 635 (11th Cir. 1984).
Ms. Sanders alleges as the only basis for reversal of the ALJ’s decision that
the ALJ=s mental RFC was not based on substantial evidence.
Specifically, the plaintiff argues that the ALJ failed to give proper weight to the
consultative psychologist=s opinion. (Doc. 13, pp. 6-10). The plaintiff further
asserts that the ALJ had a duty to more fully develop the record by calling for
additional review by a medical expert. (Doc. 13, p. 10). Finally, the plaintiff urges
that the ALJ=s determination is inconsistent with his own assessment of the
plaintiff=s impairments. (Doc. 13, p. 11). Plaintiff does not challenge the ALJ’s
assessment of her physical RFC.
A. Consultative Examiner=s Assessment
The plaintiff asserts that the ALJ failed to give proper weight to the opinion of
the consultative psychologist, Dr. Heath Patterson. Dr. Patterson evaluated Ms.
Sanders on January 26, 2011.
Dr. Patterson noted that Ms. Sanders had an
Aextensive history of full-time employment in a number of arenas,@ and that her
employment as an office worker for a security company ended in 2008 Awhen
psychiatric decompensation interfered with her ability to complete routine work
duties.@ (Tr. at 756). Dr. Patterson further noted that Ms. Sanders had a history of
depression, and had received mental health treatment since she was in her 20s. (Tr.
at 756-57). He stated that she reported that she had taken psychoactive medications
for many years and found them Ahelpful.@ (Id.) Dr. Patterson found Ms. Sanders to
be Afully oriented to all spheres@ with Aintact@ attention and concentration, but with
Amarked slowing.@ He further found her abstract reasoning skills to be Awithin
expected limits,@ and her judgment to be Afair.@
(Tr. at 757).
Her fund of
information was within Aexpected parameters;@ her long-term memory Afair@ and her
short term memory better; her thought process was Alogical, coherent, and
(Tr. at 758).
He next reported that Ms. Sanders reported
experiencing Ahallucinations/perceptual distortions,@ including Aunknown voices
making derogatory comments about her and instructing her to harm herself,@ but that
she did not act on those thoughts. (Tr. at 758). Dr. Patterson summarized Ms.
Sanders= condition as having Aadequate judgment to make acceptable work
decisions@ in relatively simple, unskilled jobs. (Id.) He opined that Plaintiff had
no Acognitive limitations that would preclude obtaining steady employment,@ but he
also noted that her Apsychotic disturbances,@ such as hallucinations, depression, and
anxiety, cause Amarked impairment in daily functioning@ and Acould preclude ...
gainful employment.@ (Tr. at 759).
In determining the weight to be given to a medical opinion, and ALJ must
consider factors that include the examining relationship, the treatment relationship,
the evidence that supports the opinion, and the degree to which the opinion is
consistent with other evidence. 20 C.F.R. ' 404.1527(c). Different types of
medical sources are entitled to differing weights.
The opinion of a treating
physician, who has an ongoing relationship with the patient, is entitled to the
greatest weight. A non-treating physician or psychologist, who has examined the
patient but does not treat the patient, is entitled to less weight. The least weight is
given to a non-examining medical source, who may provide an opinion based on the
record but who has not examined the patient. 20 C.F.R. ' 404.1502. Even so, any
medical source=s opinion can be rejected where the evidence supports a contrary
conclusion. See, e.g., McCloud v. Barnhart, 166 Fed. App=x 410, 418-19 (11th Cir.
2008). Even the opinion of a treating physician can be disregarded where Agood
cause@ is shown. Crawford v. Commissioner of Social Security, 363 F.3d 1155, 1159
(11th Cir. 1997). The weight to be afforded a medical opinion regarding the nature
and severity of a claimant=s impairments depends, among other things, upon the
examining and treating relationship the medical source had with the claimant, the
evidence the medical source presents to support the opinion, how consistent the
opinion is with the record as a whole, and the specialty of the medical source. See
20 C.F.R. '' 404.1527(d), 416.927(d). AGood cause@ exists for an ALJ not to give a
treating physician=s opinion substantial weight when the A(1) treating physician=s
opinion was not bolstered by the evidence; (2) evidence supported a contrary
finding; or (3) ... was conclusory or inconsistent with the doctor=s own medical
records.@ Phillips v. Barnhart, 357 F.3d 1232, 1241 (11th Cir. 2004) citing Lewis,
125 F.3d at 1440; see also Edwards v. Sullivan, 937 F.2d 580, 583-84 (11th Cir.
1991) (holding that Agood cause@ exists where the opinion was contradicted by other
notations in the physician=s own record).
At issue in this case is the opinion of a consultative psychologist, who
examined the plaintiff on one occasion, but had no ongoing relationship with her and
who did not treat her. He based many of his conclusions on plaintiff’s own
descriptions of her condition. His opinion is entitled to weight only to the extent
that it is bolstered by the evidence, is not contrary to other medical evidence, does
not contradict the opinions of treating physicians, and to the extent that it is not
conclusory or inconsistent with his own findings.
In this case, Dr. Patterson reached a conclusion B that her hallucinations
Acould preclude@ her from working B that is both inconsistent with the opinions of all
of her treating physicians, and inconsistent with his more specific observations and
diagnoses of her conditions. The ALJ noted that Dr. Patterson=s opinion regarding
the severity of Ms. Sander=s depression was not Aconsistent with the remainder of his
report, or with the remainder of the medical records.@ (Tr. at 38). None of Ms.
Sanders treating physicians has opined that Ms. Sanders= mental conditions are
disabling, despite the fact that she has been treated for depression, anxiety, and
bipolar disease for many years. To the contrary, Ms. Sanders responded well to the
medications prescribed to her through 2007 by Dr. Siddiqui. She stopped seeing a
psychiatrist after 2007, even though she was given a referral to a psychiatrist by Dr.
Lott in 2011.
In May of 2011, Ms. Sanders reported that her anxiety was
Amoderate,@ Aintermittent,@ and Arelieved by medication.@ She denied suicidal or
homicidal ideations. (Tr. at 905). She also described her depression as moderate
and intermittent, and said it also was relieved by medication. (Tr. at 906). Her
bipolar disorder was assessed at that time as Astable.@ (Id.) At a doctor=s visit in
August of 2011, two years after the alleged onset date, Dr. Khatri recorded that Ms.
Sanders= memory was intact, and her psychiatric assessment was normal, in spite of
(Tr. at 903). Dr. Marshall, a treating physician, did note in October 2011
that Ms. Sanders= bipolar disease was poorly controlled, but treated her condition by
increasing her dosage of Depakote. (Tr. at 897). In January of 2012, Dr. Marshall
reported that Ms. Sanders complained of being Avery depressed@ with suicidal
ideations. (Tr. at 890). She also noted, however, that while Ms. Sanders presented
with a cane, she left without it and was walking Awith a normal gait@ until she was
reminded that she left her cane behind and her Agait changed and she began walking
slightly hunched forward and with a mild limp.@ (Tr. at 890).
None of the records
of her treating physicians during the time since her onset date mentions
hallucinations or hearing voices.
Ms. Sanders= own descriptions of her daily activities, while limited, also do
not support the conclusion that she would be unable to work because of mental
disabilities. She reports that she is able to do laundry, help her children, and do
some cooking and shopping. Although she has suffered from depression, anxiety,
and bipolar disease for well over a decade, she did not stop working until October of
2009. She testified at the hearing that she stopped because A[t]he company closed.@
(Tr. at 75).
The ALJ relied heavily upon the assessment of Dr. Lott, a treating
physician, who found that Ms. Sanders= depression and anxiety were only
Amoderate,@ when he saw her after Dr. Patterson=s evaluation. (Tr. at 39).
Opinions such as whether a claimant is disabled, the claimant=s residual
functional capacity, and the application of vocational factors Aare not medical
opinions, ... but are, instead, opinions on issues reserved to the Commissioner;@ thus
the court Amay not decide facts anew, reweigh the evidence, or substitute [its]
judgment for that of the Commissioner.@ Dyer v. Barnhart, 395 F.3d 1206, 1210
(11th Cir. 2005).
The court instead looks to the doctors= evaluations of the
claimant=s condition and the medical consequences thereof, not their opinions of the
legal consequences of his [or her] condition.@ Lewis, 125 F.3d at 1440.
statements by a physician are relevant to the ALJ=s findings, but they are not
determinative, because it is the ALJ who bears the responsibility of assessing a
claimant=s residual functional capacity. See, e.g., 20 C.F.R. ' 404.1546(c). In this
case, the ALJ carefully reviewed the treating physician=s records, and heeded the
medical opinions therein. The ALJ clearly articulated Agood cause@ for the limited
weight he gave to Dr. Patterson=s assessment as a consultative examiner; therefore,
the ALJ did not commit reversible error.
B. Duty to More Fully Develop the Record
While plaintiff suggests that the ALJ had a duty to re-contact Dr. Patterson for
Aclarification,@ such a duty arises only where the evidence is insufficient to make a
disability decision. Shaw v. Astrue, 392 Fed. App=x 684, 688-89 (11th Cir. 2008).
The regulations pertaining to consultative examinations require the ALJ to
re-contact a consultative examiner only if the examiner's report is Ainadequate@ or
Aincomplete.@ See 20 C.F.R. ' 404.1519p(b).
It is clear that Dr. Patterson=s
evaluation was neither Ainadequate@ nor Aincomplete,@ and therefore clarification
was not needed. Instead, the ALJ found that the internal inconsistencies in the
report, and the inconsistencies with virtually all of the treating physician=s records,
rendered some of Dr. Patterson=s conclusions to be entitled to little or no weight.
The ALJ=s duty is simply to develop a full and fair record. Couch v. Astrue, 267
Fed. App=x 853 (11th Cir. 2008). An ALJ is not required to obtain additional
evidence or seek clarification where the record is sufficient to support a decision
regarding disability. See Jones v. Astrue, 691 F.3d 730, 733 (5th Cir. 2012). The
ALJ did develop a complete medical record for the 12 months preceding the filing of
Ms. Sanders= application, and then assessed and properly weighed the evidence from
both treating physicians, the consultative examiner, and all other sources.
viewed Ms. Sanders= medical condition as a whole, and articulated specific reasons
for giving no weight to the Dr. Patterson=s conclusory statement that Ms. Sanders=
mental illnesses Acould preclude@ employment.
The ALJ=s determination is supported by substantial evidence and was both
comprehensive and consistent with the applicable SSA rulings. The objective
medical and other evidence supports the ALJ’s conclusion that Ms. Sanders’
conditions did not cause disabling limitations and instead shows that she could
perform some work.
Upon review of the administrative record, and considering all of Ms. Sanders=
arguments, the Commissioner=s decision is due to be and hereby is AFFIRMED and
the action is DISMISSED WITH PREJUDICE.
DATED the 19th day of March, 2015.
T. MICHAEL PUTNAM
UNITED STATES MAGISTRATE JUDGE
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