Gray v. Social Security Administration, Commissioner
Filing
13
MEMORANDUM OPINION. Signed by Judge L Scott Coogler on 8/5/2014. (KAM, )
FILED
2014 Aug-05 AM 11:17
U.S. DISTRICT COURT
N.D. OF ALABAMA
IN THE UNITED STATES DISTRICT COURT
FOR THE NORTHERN DISTRICT OF ALABAMA
WESTERN DIVISION
Misty Dawn Gray,
Plaintiff,
vs.
CAROLYN W. COLVIN,
Commissioner of Social Security,
Defendant.
)
)
)
)
)
)
)
)
)
)
7:13-CV-01361-LSC
MEMORANDUM OF OPINION
I.
Introduction
The plaintiff, Misty Dawn Gray, appeals from the decision of the Commissioner
of the Social Security Administration (“Commissioner”) denying her applications for
a period of disability, Disability Insurance Benefits (“DIB”), and Supplemental
Security Income (“SSI”). Ms. Gray 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).
Ms. Gray was thirty-five years old at the time of the Administrative Law Judge’s
(“ALJ’s”) decision, and she has a tenth grade education, as well as a General
Page 1 of 15
Equivalency Diploma. (Tr. at 31.) Her past work experiences include employment as
a retail cashier and shift supervisor/assistant manager. (Tr. at 18.) Ms. Gray claims
that she became disabled on July 11, 2007, due to lower back pain, bilateral hip pain,
knee and ankle pain and swelling, and that her disabilities were further exacerbated by
events stemming from the April 27, 2011, tornado in Tuscaloosa, Alabama. (Tr. at 1517.)
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 “doing 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 on 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. 20 C.F.R. §§ 404.1520(a)(4)(ii), 416.920(a)(4)(ii).
Page 2 of 15
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, he or she
will be found disabled without further consideration. Id. If they do not, a
determination of the claimant’s residual functional capacity (“RFC”) will be made
and the analysis proceeds to the fourth step. 20 C.F.R. §§ 404.1520(e), 416.920(e).
The fourth step requires a determination of whether the claimant’s
impairments prevent him or her from returning to past relevant work. 20 C.F.R. §§
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.
Applying the sequential evaluation process, the ALJ found that Ms. Gray meets
the non-disability requirements for a period of disability and DIB and was insured
Page 3 of 15
through the date of his decision. (Tr. at 10.) He further determined that Ms. Gray has
not engaged in substantial gainful activity since the alleged onset of her disability. Id.
According to the ALJ, Plaintiff’s obesity, asthma, mild degenerative disc disease
(DDD) of the lumbar spine, osteoarthritis (OA), depression, and posttraumatic stress
disorder (PTSD) are considered “severe” based on the requirements set forth in the
regulations. Id. However, he found 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 12.) The Commissioner did not find Ms. Gray’s allegations to be totally credible,
and he determined that she has the following residual functional capacity: simple,
unskilled work; she can tolerate infrequent changes to her workplace that are gradual
in nature and well explained; she can tolerate only occasional interaction with the
public, coworkers, and supervisors; she should avoid tandem tasks with coworkers;
and she is able to climb ramps/stairs, balance, stoop, kneel, and crouch frequently and
crawl occasionally. Id.
According to the ALJ, Ms. Gray is unable to perform any of her past relevant
work. (Tr. at 18.) He determined that Plaintiff is a “younger individual” and has “no
transferable skills from any past relevant work and/or transferability of skills is not an
issue in this case.” Id. The ALJ found that Ms. Gray has the residual functional
Page 4 of 15
capacity to perform light, simple, unskilled work. (Tr. at 14.) The ALJ used MedicalVocational Rule 202.21 as a guideline for finding that there are a significant number
of jobs in the national economy that she is capable of performing, such as parking lot
attendant and cashier. (Tr. at 19.) The ALJ concluded his findings by stating that
Plaintiff “was not under a ‘disability,’ as defined in the Social Security Act, at any
time through the date of this decision.” Id.
II.
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. “The
substantial evidence standard permits administrative decision makers to act with
considerable latitude, and ‘the possibility of drawing two inconsistent conclusions
Page 5 of 15
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. “Substantial evidence is more than a
mere scintilla. It means such relevant evidence as a reasonable mind might accept as
adequate to support a conclusion.” Richardson, 402 U.S. at 401. No decision is
automatic, however, for “despite 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).
III.
Discussion
Ms. Gray alleges that the Commissioner’s decision should be reversed and
remanded because, in assessing Ms. Gray’s mental health, the ALJ gave too little
weight to the opinion of Dr. Goff, a one-time examining neuropsychologist, while
giving too much weight to the opinions of two non-examining state-agency physicians,
Page 6 of 15
Drs. Estock and Heilpern. (Doc. 11 at 9.)
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). Within the classification of acceptable medical sources are
the following different types of sources which are entitled to different weights of
opinion: 1) a treating source, which is defined in the regulations as “your physician,
psychologist, or other acceptable medical source who provides you, or has provided
you, with medical treatment or evaluation and who has, or has had, an ongoing
treatment relationship with you;” 2) a non-treating source, which is defined as “a
physician, psychologist, or other acceptable medical source who has examined you but
does not have, or did not have, an ongoing treatment relationship with you;” and 3)
a non-examining source, which is a “a physician, psychologist, or other acceptable
medical source who has not examined you but provides a medical or other opinion in
your case . . . includ[ing] State agency medical and psychological consultants . . . .”
20 C.F.R. § 404.1502. The regulations and case law set forth a general preference for
Page 7 of 15
treating sources’ opinions over those of non-treating sources, and non-treating
sources over non-examining sources. See 20 C.F.R. § 404.1527(d)(2); Ryan v. Heckler,
762 F.2d 939, 942 (11th Cir. 1985). However, an ALJ “may reject the opinion of any
physician when the evidence supports a contrary conclusion.” McCloud v. Barnhart,
166 F. App’x 410, 418–19 (11th Cir. 2006) (citing Bloodsworth v. Heckler, 703 F.2d
1233, 1240 (11th Cir. 1983)).
After thorough review, this Court is of the opinion that substantial evidence
supports the ALJ’s decision to give Dr. Goff’s opinion little weight. Dr. Goff
examined Plaintiff on May 15, 2012, for a psychological evaluation. (Tr. at 459.)
During the examination Plaintiff alleged injuries following the tornado in April of 2011
in Tuscaloosa, Alabama, she but admitted she had not returned for mental health
treatment since then. (Tr. at 456.) Plaintiff obtained a full scale IQ of 88 and a verbal
IQ of 87, placing her in the low average range of intelligence. (Tr. at 457.) Dr. Goff
ultimately diagnosed Ms. Gray with depression and PTSD. (Tr. at 458.) He
concluded that Plaintiff’s “medical problems” would interfere with her ability to deal
with the stresses and pressures of the workplace. Id. On a functional capacity form,
Dr. Goff indicated that Plaintiff would have “marked” and “extreme” mental
limitations. (Tr. 460-62.)
Page 8 of 15
As an initial matter, the severity of limitations noted by Dr. Goff is inconsistent
with his own narrative report from the examination. Dr. Goff noted that Plaintiff “was
able to understand, follow, and carry out simple instructions,” but was “somewhat
confused by complex sorts of instructions and would have difficulty responding to
instructions requiring a substantial physical response.” Id. However, in his report he
opined that she had only a mild impairment in her ability to understand and carry out
complex instructions. Id. He also noted in his narrative that Plaintiff had reported
problems with anger management, but then opined that she has only a mild
impairment in her ability to interact appropriately with the general public and a
moderate impairment in her ability to get along with co-workers and peers. Id.
Despite Plaintiff’s reported anger management problems, Dr. Goff noted that a
rapport with her was “easily established and well maintained.” (Tr. at 456, 458.)
Additionally, Dr. Goff’s findings of “marked” and “extreme” mental
limitations are contradicted by the fact that Plaintiff underwent very little medical
treatment, let alone mental health treatment, during the relevant periods for
DIB—July 11, 2007 through December 31, 2008—and SSI—September 3, 2010
through the date of the SSI application.
On September 27, 2007, an MRI of the lumbar spine revealed only mild facet
Page 9 of 15
arthropathy with no disc herniation. (Tr. at 243.) On October 15, 2007, Plaintiff was
treated with medication for depressive disorder at Indian Rivers Mental Health Center
(“Indian Rivers”). (Tr. at 260.) At this visit she reported that she was not working
because she was trying to get on disability. (Id.) At a subsequent visit on December
27, 2007, Plaintiff’s medications were changed. (Tr. at 389.) On April 24, 2008,
Plaintiff returned to Indian Rivers and reported improvement in her depression with
medication. (Tr. at 262-64.) This was her last documented visit at Indian Rivers. On
June 5, 2008, she was treated at DCH Hospital for bronchitis and otisis. (Tr. at 298302.) On December 11, 2008, Plaintiff was treated at Whatley Health Services, and
non-compliance with medication for depression and hypertension was noted. (Tr. at
448.) There is no additional treatment prior to December 31, 2008.
Beginning on September 3, 2010 through the date of the SSI application, the
record reveals no mental health treatment and few medical visits. On September 2
and 3, 2010, Plaintiff was treated at DCH Hospital for complaints of a headache. (Tr.
at 269-89.) Testing was normal. (Tr. at 273-74, 277, 280, 289.) On March 28, 2010,
Plaintiff was treated at DCH for conjunctivitis. (Tr. at 291-95.) On March 8, 2011,
Plaintiff returned to Whatley Health Services with complaints of migraines and leg
pain. (Tr. at 438.) It was noted that Plaintiff had a full range of motion and was
Page 10 of 15
negative for radiculopathy. (Tr. at 438.) Plaintiff was counseled to lose weight. (Tr.
at 438.) On the day of the tornado, April 27, 2011, Plaintiff was treated at Cooper
Green Hospital for fractures of the left hip, and left fifth metacarpal. (Tr. at 463-81.)
Fractures were also noted in the lumbar spine. (Tr. at 473.) Plaintiff was advised to
undergo physical therapy. (Tr. at 481.) On August 22, 2011, Plaintiff was seen at
Whatley Health Services for complaints of hip pain and medication refills. (Tr. at
437.) On January 18, 2012, she had a normal physical examination except for
tenderness in her left hip, and she was prescribed Diclofen, Prozac, Buspar, and
Norvasc. (Tr. at 250-55.) On February 2, 2012, Plaintiff was treated at DCH for
colitis. (Tr. at 399-402, 418-23.) On March 22, 2012, Plaintiff was treated at Whatley
Health Services for colitis, pharyngitis, and hypertension. This record does not
support Dr. Goff’s finding of “marked” and “extreme” mental limitations.
Moreover, Plaintiff’s complaints to Dr. Goff, on which he presumably relied in
finding her to have “marked” and “extreme” difficulties, are not supported by the
mental health records that are in the record, including Plaintiff’s own testimony.
Plaintiff claimed ongoing symptoms of depression and PTSD that she blamed on her
abusive childhood and on the April 27, 2011, Tuscaloosa tornado. (Tr. at 33, 455-56.)
While Plaintiff reported that she had seen significant benefit from psychotropic
Page 11 of 15
medication in the past, she sought assistance at the Mental Health Center only
infrequently between April 2008 and May 2012. At these infrequent visits, Plaintiff
did not always complain of depression. Plaintiff stated that she was unable to seek
frequent treatment because she could not afford the $20.00 co-pay to be seen;
however, Plaintiff opines that she manages to support her daily tobacco habit and
dines out frequently with her family. (Tr. at 52-53.) “[R]efusal to follow prescribed
medical treatment without a good reason will preclude a finding of disability.”
Dawkins v. Bowen, 848 F.2d 1211, 1213 (11 th Cir. 1988). While “poverty excuses
noncompliance,” id., the Eleventh Circuit has upheld an ALJ’s ability to consider a
claimant’s failure to comply with a treatment regimen as a factor in assessing his or
her credibility. See e.g., Brown v. Astrue, 298 F. App’x 851, 852 (11th Cir. 2008)
(although the plaintiff stated that he could not afford the necessary treatment, he also
acknowledged that the Veteran’s Administration provided medications and the
medical records revealed that he received samples of medications); East v. Barnhart,
197 F. App’x 899, 905 (11th Cir. 2006) (substantial evidence supported the ALJ’s
determination that the claimant was not credible because although she alleged that she
could not afford her prescription medications, she “used her children’s child support
to buy up to 45 packs of cigarettes per month”). Plaintiff also reported that she has
Page 12 of 15
had difficulty dealing with authority figures and anger management throughout her
life, and claims that she lost all of her jobs because of these problems. (Tr. at 455-56.)
While Plaintiff’s work history does reflect multiple jobs of short duration and her
treatment records from Indian Rivers reflect a reported history of childhood physical
and emotional abuse, no observations of heightened anger or difficulty interacting
were recorded during these examinations. (Exhibits 4D, 4F.) Plaintiff further claims
that she is able to form and maintain long-term relationships, has a close relationship
with her family members, and frequently interacts with restaurant staff and store
clerks with no reports of difficulty interacting. (Tr. at 40-44.) In any event, the ALJ
accounted for these symptoms by finding that Plaintiff had severe impairments due
to depression and PTSD.
Finally, Dr. Goff’s opinion is also contradictory to the opinions of the two stateagency non-examining physicians. Dr. Estock, a state agency psychiatrist, reviewed
the medical evidence on October 28, 2010, and reported that Plaintiff demonstrated
only “mild” and “moderate” functional limitations. (Tr. at 365.) Dr. Estock opined
that Plaintiff could engage in personal care, shop, and drive a vehicle. (Tr. at 366.) He
noted that Plaintiff was alert, oriented, and exhibited a normal mood. (Tr. at 367.)
The ALJ gave Dr. Estock’s opinion partial weight. Dr. Heilpern, also a state agency
Page 13 of 15
physician, reviewed the medical evidence on October 29, 2010, and reported that
Plaintiff could occasionally crawl, could frequently climb ramps and stairs, stoop,
kneel, and crouch, and could frequently lift and carry up to 25 pounds and could sit
or stand and walk up to 6 hours in an 8 hour day. (Tr. at 370-71.) Dr. Heilpern opined
that Plaintiff could perform medium and light work. (Tr. at 369-76.) The ALJ gave
Dr. Heilpern’s opinion substantial weight. Social Security Ruling 96-6p allows for the
opinions of non-examining medical sources to be granted the same weight as the
opinions of treating medical sources if they are supported by an accurate and
comprehensive record. Here, the opinions of Drs. Estock and Heilpern are each
consistent not only with the other’s diagnosis, but also with the record as a whole.
Plaintiff complains that these opinions predate, and thus do not take into the account,
her PTSD following the April 27, 2011 tornado, but as mentioned, the ALJ accounted
for depression and PTSD in finding those ailments to be severe under the regulations.
The ALJ ultimately found that even with those impairments, Plaintiff could do light
work with additional restrictions, a finding that is consistent with substantial evidence
in the record. As noted, with regard to Plaintiff’s DIB application, she only sought
limited mental health treatment through April 2008. With regard to her SSI
application, she had only a brief period of left hip pain ending in January 2012, and
Page 14 of 15
aside from Dr. Goff’s report, no documented mental health issues.
For these reasons, the Court is of the opinion that the ALJ appropriately gave
little weight to Dr. Goff’s May 2012 assessment of Plaintiff’s condition.
IV.
Conclusion
Upon review of the administrative record, and considering all of Ms. Gray’s
arguments, the Court finds the Commissioner’s decision is supported by substantial
evidence and in accord with the applicable law. A separate order will be entered.
Done this 5th day of August 2014.
L. Scott Coogler
United States District Judge
[160704]
Page 15 of 15
Disclaimer: Justia Dockets & Filings provides public litigation records from the federal appellate and district courts. These filings and docket sheets should not be considered findings of fact or liability, nor do they necessarily reflect the view of Justia.
Why Is My Information Online?