James v. Social Security Administration, Commissioner
MEMORANDUM OPINION. Signed by Judge Abdul K Kallon on 7/30/2014. (PSM)
2014 Jul-30 AM 09:56
U.S. DISTRICT COURT
N.D. OF ALABAMA
IN THE UNITED STATES DISTRICT COURT
FOR THE NORTHERN DISTRICT OF ALABAMA
JIMMY DEAN JAMES,
CAROLYN W. COLVIN,
Acting Commissioner of Social Security, )
CIVIL ACTION NO.
Plaintiff Jimmy Dean James (“James”) brings this action pursuant to Section
205(g) of the Social Security Act (“the Act”), 42 U.S.C. § 405(g), seeking review of the
final adverse decision of the Commissioner of the Social Security Administration
(“SSA”). This court finds that the Administrative Law Judge’s (“ALJ”) decision - which
has become the decision of the Commissioner - is supported by substantial evidence.
Therefore, for the reasons elaborated herein, the court will affirm the decision denying
I. Procedural History
James, whose past relevant experience includes work as machine and forklift
operator, filed an application for Title II disability insurance benefits and Title XVI
Supplemental Security Income on March 24, 2009, alleging a disability onset date of July
23, 2009, due to depression, high blood pressure, and chest pains. (R. 27, 182). After
the SSA denied James’s claim, he requested a hearing before an ALJ. (R. 86). The ALJ
subsequently denied James’s claim, (R. 24-38), which became the final decision of the
Commissioner when the Appeals Council refused to grant review. (R. 1-6). James then
filed this action for judicial review pursuant to § 205(g) of the Act, 42 U.S.C. § 405(g).
II. Standard of Review
The only issues before this court are whether the record contains substantial
evidence to sustain the ALJ’s decision, See 42 U.S.C. § 405(g); Walden v. Schweiker,
672 F.2d 835, 838 (11th Cir. 1982), and whether the ALJ applied the correct legal
standards, see Lamb v. Bowen, 847 F.2d 698, 701 (11th Cir. 1988); Chester v. Bowen,
792 F.2d 129, 131 (11th Cir. 1986). Title 42 U.S.C. § 405(g) mandates that the
Commissioner’s “factual findings are conclusive if supported by ‘substantial evidence.’”
Martin v. Sullivan, 894 F.2d 1520, 1529 (11th Cir. 1990). The district court may not
reconsider the facts, reevaluate the evidence, or substitute its judgment for that of the
Commissioner; instead, it must review the final decision as a whole and determine if the
decision is “reasonable and supported by substantial evidence.” See id. (citing
Bloodsworth v. Heckler, 703 F.2d 1233, 1239 (11th Cir. 1983)). Substantial evidence
falls somewhere between a scintilla and a preponderance of evidence; “[i]t is such
relevant evidence as a reasonable person would accept as adequate to support a
conclusion.” Martin, 849 F.2d at 1529 (quoting Bloodsworth, 703 F.2d at 1239) (other
citations omitted). If supported by substantial evidence, the court must affirm the
Commissioner’s factual findings even if the preponderance of the evidence is against the
Commissioner’s findings. See Martin, 894 F.2d at 1529. While the court acknowledges
that judicial review of the ALJ’s findings is limited in scope, it notes that the review
“does not yield automatic affirmance.” Lamb, 847 F.2d at 701.
III. Statutory and Regulatory Framework
To qualify for disability benefits, a claimant must show “the inability to engage in
any substantial gainful activity by reason of any medically determinable physical or
mental impairments which can be expected to result in death or which has lasted or can
be expected to last for a continuous period of not less than twelve months.” 42 U.S.C.
§ 423(d)(1)(A); 42 U.S.C. § 416(i). A physical or mental impairment is “an impairment
that results from anatomical, physiological, or psychological abnormalities which are
demonstrated by medically acceptable clinical and laboratory diagnostic techniques.” 42
U.S.C. § 423(d)(3).
Determination of disability under the Act requires a five step analysis. 20 C.F.R.
§ 404.1520(a)-(f). Specifically, the Commissioner must determine in sequence:
whether the claimant is currently unemployed;
whether the claimant has a severe impairment;
whether the impairment meets or equals one listed by the Secretary;
whether the claimant is unable to perform his or her past work; and
whether the claimant is unable to perform any work in the national
McDaniel v. Bowen, 800 F.2d 1026, 1030 (11th Cir. 1986). “An affirmative answer to
any of the above questions leads either to the next question, or, on steps three and five, to
a finding of disability. A negative answer to any question, other than step three, leads to
a determination of ‘not disabled.’” Id. at 1030 (citing 20 C.F.R. § 416.920(a)-(f)). “Once
a finding is made that a claimant cannot return to prior work the burden shifts to the
Secretary to show other work the claimant can do.” Foote v. Chater, 67 F.3d 1553, 1559
(11th Cir. 1995) (citation omitted).
IV. The ALJ’s Decision
In performing the five step analysis, the ALJ found that James had not engaged in
substantial gainful activity since March 24, 2009, and, therefore, met Step One. (R. 29).
Next, the ALJ found that James satisfied Step Two because he suffered from the severe
impairments of “hypertension, peripheral edema and osteoarthritis.” Id. The ALJ then
proceeded to the next step and found that James failed to satisfy Step Three because he
“does not have an impairment or combination of impairments that meets or medically
equals one of the listed impairments.” (R. 31). Although the ALJ answered Step Three
in the negative, consistent with the law, see McDaniel, 800 F.2d at 1030, the ALJ
proceeded to Step Four where he determined that James has the residual functional
capacity (RFC) to
lift 20 pounds occasionally and 10 pounds frequently; stand and walk four
hours out of an 8-hour day; sit six hours out of an 8-hour day; frequently
climb ramps and stairs; occasionally climb ladders and scaffolds; can never
climb ropes; frequently balance, stoop, crouch and crawl; has no
manipulative, visual or communicative limitations; must avoid
concentrated exposure to extreme cold or heat and wetness; and he
experiences mild to moderate pain.
(R. 32). In light of his RFC, the ALJ held that James “is unable to perform any past
relevant work.” (R. 36). Lastly, in Step Five, the ALJ considered James’s age,
education, work experience,1 and RFC and determined “there are jobs that exist in
significant numbers in the national economy [James] can perform.” Id. Therefore, the
ALJ found that James “has not been under a disability, as defined in the Social Security
Act, from March 24, 2009, through the date of this decision.” (R. 37).
The court now turns to James’s contentions that the ALJ erred by (1) failing to
give proper weight to the opinion of his treating physician; (2) failing to recontact his
treating physician; and (3) giving controlling weight to the opinion of the State agency
reviewing psychiatrist. See doc. 7 at 7-10. The court addresses each contention in turn.
The ALJ properly considered Dr. Klaiss’s opinion
James contends the ALJ did not give proper weight to the opinion of Dr. Kitturah
Klaiss, one of his treating physicians. The record shows Dr. Klaiss treated James for
high blood pressure and back pain from September 2, 2009 through October 29, 2010.
(R. 270-77, 284-85). Dr. Klaiss also completed a physical capacities evaluation on
October 14, 2010, which limited James to a total of five hours sitting and two hours
As of the date of the ALJ’s decision, James was 50 years old, had a high school
education, and had past relevant medium semi-skilled work as a machine operator and
forklift operator. (R. 36).
standing/walking in an eight-hour workday, with additional postural limitations that
included no stooping. (R. 278). Dr. Klaiss also indicated on a Clinical Assessment of
Pain form that James’s pain was “distracting to adequate performance of daily activities
or work.” (R. 279). James argues the ALJ erred in giving Dr. Klaiss’s opinion little
weight. Doc. 7 at 7-9.
To determine how much weight to give Dr. Klaiss’s opinion, the ALJ had to
consider several factors, including whether Dr. Klaiss (1) had examined James; (2) had a
treating relationship with James; (3) presented medical evidence and explanation
supporting the opinion; (4) provided an opinion that is consistent with the record as a
whole; and (5) is a specialist. See 20 C.F.R. § 416.927(c). Because Dr. Klaiss is a
treating physician, the ALJ must give “controlling weight” to his opinion if it “is
well-supported by medically acceptable clinical and laboratory diagnostic techniques and
is not inconsistent with the other substantial evidence.” 20 C.F.R. § 416.927(c)(2).
Moreover, in this circuit “the testimony of a treating physician must be given substantial
or considerable weight unless ‘good cause’ is shown to the contrary.” Lewis v. Callahan,
125 F.3d 1436, 1440 (11th Cir. 1997). “Good cause” exists when the evidence does not
bolster the treating physician’s opinion; a contrary finding is supported by the evidence;
or the opinion is conclusory or inconsistent with the treating physician’s own medical
records. Id. Finally, if the ALJ rejects a treating physician’s opinion, “[t]he ALJ must
clearly articulate the reasons for giving less weight to the opinion . . . and the failure to
do so is reversible error.” Id.
Here, ALJ correctly applied the law and articulated multiple reasons for giving Dr.
Klaiss’s opinion “little weight.” (R. 35). Specifically, the ALJ found that Dr. Klaiss’s
own treatment notes undermine his opinions: “Dr. Klaiss’s opinion regarding the
physical limitations of the claimant are inconsistent with not only the claimant’s
testimony in this matter, but it is inconsistent with her treatment records.” Id. As the
ALJ observed, “Dr. Klaiss’s treatment records show that while the claimant reported pain
to her, [Dr. Klaiss] advised him on more than one occasion to perform stretching
exercises for his back and to exercise in order to get his cholesterol under control.” Id.
Based on this record, the ALJ reasonably found Dr. Klaiss’s “recommendation that the
claimant exercise is inconsistent with her opinion that the claimant would have pain
during physical activity to such an extent as to cause him to become distracted from or to
totally abandon, such activity.” Id.
Next, the ALJ found Dr. Klaiss’s opinions were inconsistent with James’s
testimony “that he was receiving worker’s compensation and that he had been seeking
employment.”2 Id. The ALJ also noted that James “did not testify that he stopped
working due to a physical inability to perform the work; rather, he testified that he
stopped working because the company closed down,” and that “had the company
remained in business, he would still try to work performing the duties of his previous
James testified that he had looked for work, “but there wasn’t nothing I
preferred, and jobs some of them wouldn’t hire no way.” (R. 59).
work.” Id. The ALJ reasonably found this testimony was inconsistent with Dr. Klaiss’s
Finally, the ALJ found that a review of the record as a whole supported giving Dr.
Klaiss’s opinions little weight. Id. For example, as the ALJ noted, the consultative
physical examination by Dr. John Waits was essentially normal:
Other than some mild tenderness to his bilateral medial knees, the
claimant’s physical examination was normal. He had a full range of motion
in all of his joints and back, no spasms or deformity in his back, and
negative straight leg raises. Dr. Waits indicated that the claimant had no
motor weakness, a negative Romberg’s, intact fine and gross manipulation,
intact dexterity, and 5/5 grip strength. His assessment was leg and foot
pain, depression, and hypertension.
(R. 33) (citations to the record omitted). Moreover, the ALJ observed that “Dr. Waits
stated that based on his medical findings, the claimant has the ability to do work-related
activities such as sitting, standing, walking, lifting, carrying handling objects, hearing,
speaking and traveling.” Id.
Put simply, the ALJ considered the factors set forth in the regulations and,
consistent with the law of this circuit, articulated good cause for giving Dr. Klaiss’s
opinions limited weight: i.e., that Dr. Klaiss’s opinions were inconsistent with her own
treatment notes, James’s testimony, and the medical evidence from other physicians. The
record supports the ALJ’s findings. Therefore, the ALJ had good cause for rejecting Dr.
Klaiss’s opinions, and committed no reversible error. See Lewis, 125 F.3d at 1440 (“good
cause” exists when physician’s opinion is inconsistent with own records, a contrary
finding is supported by the evidence, and the evidence does not bolster physician’s
opinion); 20 C.F.R. § 416.927(c)(2) (opinion must be “well-supported by medically
acceptable clinical and laboratory diagnostic techniques” to receive controlling weight).
The ALJ was not required to recontact Dr. Klaiss.
The court is not persuaded by James’s second contention that the ALJ should have
contacted Dr. Klaiss for clarification. Doc. 8 at 12-13. Under the relevant regulation in
effect at the time,3 the ALJ only had a duty to contact Dr. Klaiss if there was insufficient
medical evidence to allow the ALJ to determine whether James was disabled:
When the evidence we receive from your treating physician or psychologist
or other medical source is inadequate for us to determine whether you are
disabled, we will need additional information to reach a determination or a
decision. To obtain the information, we will take the following actions.
(1) We will first recontact your treating physician or psychologist or
other medical source to determine whether the additional information
we need is readily available.
20 C.F.R. § 404.912(e)(2010) (emphasis added). Unfortunately for James, the medical
evidence included numerous treatment notes and a consultative examination that showed
the extent of his impairments. Consequently, the ALJ had no obligation to recontact Dr.
Klaiss because the record contained sufficient medical evidence to allow the ALJ to make
an informed disability determination.
New regulations regarding recontacting of medical sources went into effect on
March 26, 2012. 77 Fed. Reg. 10651-01 (February 23, 2012). Under the new
regulations, recontacting a medical source is within the discretion of the ALJ. See 20
C.F.R. § 404.1520b(c)(1) (“We may recontact your treating physician . . . .”) (emphasis
Alternatively, James’s contention fails because he has not shown the requisite
prejudice. Before remanding for further development of the record, a reviewing court
must consider “whether the record reveals evidentiary gaps which result in unfairness or
‘clear prejudice.’” Smith v. Schweiker, 677 F.2d 826, 830 (11th Cir.1982) (quoting Ware
v. Schweiker, 651 F.2d 408, 413 (5th Cir. Unit A July 1981). James has not established
the requisite prejudice because there are no evidentiary gaps in the record that prevented
the ALJ from making a conclusive determination regarding his disability. Therefore,
remand for development of the record is not required.
The ALJ did not err in giving significant weight to the report of the State
agency reviewing psychiatrist.
Finally, James contends that the ALJ improperly gave “controlling weight” to Dr.
Robert Estock, the State agency reviewing psychiatrist. Doc. 7 at 10-11. The record
does not support James’s contention. The court notes that an ALJ must consider the
findings of a State agency medical consultant, who is considered an expert, and must
explain the weight given to such findings in the same way as with other medical sources.
See 20 C.F.R. § 416.927(e)(2). Consistent with the regulations, the ALJ gave Dr.
Estock’s opinion “significant weight” and explained his reasons:
Although Dr. Estock did not examine the claimant, he provided specific
reasons for his opinion that the claimant does not have a severe mental
impairment, indicating that it was based on the evidence of record,
including careful consideration of the objective medical evidence and the
claimant’s allegations regarding symptoms and limitations. Dr. Estock’s
opinion is internally consistent and consistent with the evidence as a whole.
As it is well supported, it has been given significant weight.
(R. 36). Contrary to James’s contention, the ALJ committed no error because although
“the report of a non-examining doctor is accorded little weight if it contradicts an
examining doctor’s report,” an ALJ may rely on the report when it does not contradict
the findings of examining doctors. Edwards v. Sullivan, 937 F.2d 580, 584 (11th Cir.
1991). There is no such contradiction here because James has not received any mental
health treatment and the only report from an examining mental healthcare source is the
consultative report of Dr. John Goff, Ph.D., who opined James’s “depression in and of
itself would seem to . . . represent a mild to moderate impairment that might improve if he
were to obtain treatment.” (R. 221). In fact, the ALJ gave significant weight to Dr.
Goff’s report, and relied on it to find James’s depression was not a “severe” impairment.
(R. 28, 35). In other words, Dr. Goff’s report does not contradict Dr. Estock’s findings of
mild limitations in activities of daily living, maintaining social functioning, and
maintaining concentration, persistence and pace. (R. 232). Significantly, only Dr. Estock
specifically assessed how James’s mental impairment affected his functioning in these
areas, which are relevant to a determination of whether James met a listing. As the
Eleventh Circuit found under similar circumstances:
Most importantly, [the nonexamining doctor] provided an interpretation of
[the claimant’s] condition vis-a-vis the limitations those conditions placed
on [the claimant’s] abilities. Because this information was not contained in
either [of the two examining doctor’s] reports, we cannot say that [the
nonexamining doctor] contradicted their findings. Consequently, the ALJ
did not err in relying on [the nonexamining doctor’s] report.
937 F.2d at 585. Similarly, here, because Dr. Estock’s report was not contradicted by the
report of Dr. Goff, the ALJ did not err in giving it significant weight.
Based on the foregoing, the court concludes that the ALJ’s determination that
James is not disabled is supported by substantial evidence, and that the ALJ applied
proper legal standards in reaching this determination. Therefore, the Commissioner’s
final decision is AFFIRMED. A separate order in accordance with the memorandum of
decision will be entered.
Done this 30th day of July, 2014.
ABDUL K. KALLON
UNITED STATES DISTRICT JUDGE
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