Reneau v. Colvin

Filing 22

MEMORANDUM OPINION AND ORDER that the decision of the Commissioner be AFFIRMED and this action be DISMISSED. Signed by Magistrate Judge Katherine P. Nelson on 11/4/2016. (srr)

IN THE UNITED STATES DISTRICT COURT
FOR THE SOUTHERN DISTRICT OF ALABAMA
SOUTHERN DIVISION
PATRICIA L. RENEAU
Plaintiff,
v.
CAROLYN W. COLVIN,
Social Security Commissioner
Defendant.

)
)
)
)
) CIVIL ACTION NO. 15-613-N
)
)
)
)
)

MEMORANDUM OPINION AND ORDER
In this action under 42 U.S.C. §§ 405(g) Plaintiff, Patricia Reneau (“Reneau”
or “Plaintiff”) seeks judicial review of an adverse social security ruling denying
claims for disability insurance benefits and Supplemental Security Income (SSI)
(Docs. 1, 13).

With the consent of the parties, the Court has designated the

undersigned Magistrate Judge to conduct all proceedings and order the entry of
judgment in this civil action, in accordance with 28 U.S.C. § 636(c), Federal Rule of
Civil Procedure 73, and S.D. Ala. GenLR 73. (See Docs. 19, 21). Oral argument was
waived in this action (Doc. 20). After considering the administrative record and the
memoranda of the parties, it is ORDERED that the decision of the Commissioner
be AFFIRMED and that this action be DISMISSED.
PROCEDURAL BACKGROUND
Plaintiff protectively applied for disability insurance benefits and SSI on
November 17, 2012, and December 19, 2012, respectively, asserting a disability
onset date of September 18, 2012. (Tr. 151-164). At the time of the administrative

1

hearing, Plaintiff was forty-nine years old, had completed the tenth grade and had
previous work experience as a cashier checker. (Doc. 13; Fact Sheet). Plaintiff
alleges disability due to bipolar disorder, chronic lower back pain, and posttraumatic stress disorder.

(Id).

An Administrative Law Judge (“ALJ”) denied

benefits after determining that Reneau did not meet disability listing requirements;
the ALJ further found that Plaintiff was capable of performing the full range of
light unskilled work. (Tr. 22-28). Plaintiff requested review of the hearing decision
but the request was denied by the Appeals Council. (Tr. 1-6).
Plaintiff claims that the ALJ (1) committed reversible error in violation of
Social Security Regulations 20 CFR 416.927(d) and Social Security Ruling 96-2 by
failing to assign controlling weight to the opinions of Plaintiff’s treating physician,
Dr. Wilsania Rodriguez, M.D., and instead adopting his own medical opinion in
violation of Social Security Ruling 96-6p and Marbury v. Sullivan, and (2)
committed reversible error in violation of Social Security Regulation 20 C.F.R.
404.1529(b) in failing to fulfill his duty to develop the record by ordering a
consultative psychological examination. (Doc. 13 at 1-2). Defendant has responded
to—and denies—these claims (Doc. 16).
STANDARD OF REVIEW
“In Social Security appeals, [the Court] must determine whether the
Commissioner’s decision is ‘ “supported by substantial evidence and based on proper
legal standards. Substantial evidence is more than a scintilla and is such relevant
evidence as a reasonable person would accept as adequate to support a conclusion.” ’

2

” Winschel v. Comm'r of Soc. Sec., 631 F.3d 1176, 1178 (11th Cir. 2011) (quoting
Crawford v. Comm'r of Soc. Sec., 363 F.3d 1155, 1158 (11th Cir. 2004) (per curiam)
(internal citation omitted) (quoting Lewis v. Callahan, 125 F.3d 1436, 1439 (11th
Cir. 1997))). However, the Court “ ‘may not decide the facts anew, reweigh the
evidence, or substitute our judgment for that of the [Commissioner].’ ” Winschel,
631 F.3d at 1178 (quoting Phillips v. Barnhart, 357 F.3d 1232, 1240 n.8 (11th Cir.
2004) (alteration in original) (quoting Bloodsworth v. Heckler, 703 F.2d 1233, 1239
(11th Cir. 1983))).

“ ‘Even if the evidence preponderates against the

[Commissioner]’s factual findings, we must affirm if the decision reached is
supported by substantial evidence.’ ” Ingram, 496 F.3d at 1260 (quoting Martin v.
Sullivan, 894 F.2d 1520, 1529 (11th Cir. 1990)).
“Yet, within this narrowly circumscribed role, [courts] do not act as
automatons. [The court] must scrutinize the record as a whole to determine if the
decision reached is reasonable and supported by substantial evidence[.]”
Bloodsworth, 703 F.2d at 1239 (citations and quotation omitted). See also Owens v.
Heckler, 748 F.2d 1511, 1516 (11th Cir. 1984) (per curiam) (“We are neither to
conduct a de novo proceeding, nor to rubber stamp the administrative decisions that
come before us. Rather, our function is to ensure that the decision was based on a
reasonable and consistently applied standard, and was carefully considered in light
of all the relevant facts.”). “In determining whether substantial evidence exists, [a
court] must…tak[e] into account evidence favorable as well as unfavorable to the
[Commissioner’s] decision.” Chester v. Bowen, 792 F.2d 129, 131 (11th Cir. 1986).

3

Although the “claimant bears the burden of demonstrating the inability to
return to [his or] her past relevant work, the Commissioner of Social Security has
an obligation to develop a full and fair record.” Shnorr v. Bowen, 816 F.2d 578, 581
(11th Cir. 1987). See also Ellison v. Barnhart, 355 F.3d 1272, 1276 (11th Cir. 2003)
(per curiam) (“It is well-established that the ALJ has a basic duty to develop a full
and fair record. Nevertheless, the claimant bears the burden of proving that he is
disabled, and, consequently, he is responsible for producing evidence in support of
his claim.” (citations omitted)).

“This is an onerous task, as the ALJ must

scrupulously and conscientiously probe into, inquire of, and explore for all relevant
facts. In determining whether a claimant is disabled, the ALJ must consider the
evidence as a whole.” Henry v. Comm'r of Soc. Sec., 802 F.3d 1264, 1267 (11th Cir.
2015) (per curiam) (citation and quotation omitted).
Where, as here, the ALJ denied benefits and the Appeals Council denied
review of that decision, the Court “review[s] the ALJ’s decision as the
Commissioner’s final decision.” Doughty, 245 F.3d at 1278. “[W]hen the [Appeals
Council] has denied review, [the Court] will look only to the evidence actually
presented to the ALJ in determining whether the ALJ’s decision is supported by
substantial evidence.” Falge v. Apfel, 150 F.3d 1320, 1323 (11th Cir. 1998).
DISCUSSION
Reneau takes issue with the fact that the ALJ did not give controlling weight
to the opinion of Dr. Rodriguez, Reneau’s treating physician, that Reneau’s
psychological problems were disabling. (Id. at 5-6). Plaintiff additionally claims

4

that the ALJ failed to fully develop the record.

This Court will first address

whether the ALJ erred in not assigning Dr. Rodriguez’s opinion controlling weight.
At step four of the sequential evaluation process the ALJ found that Reneau
had the “residual functional capacity to perform the full range of light unskilled
work as defined in 20 C.F.R. 404.1567(b) and 416.967(b).” (Tr. 24).

More

specifically, the ALJ concluded that:
The limitation to light work accommodates the claimant's chronic lower back
pain, and any allegation of a ruptured disc. In addition, any complaint of
fatigue is accommodated by the limitation to light work. The limitation to
unskilled work accommodates the claimant's bipolar disorder and PTSD,
wherein she is unable to perform any work beyond unskilled work. Thus
limitation to unskilled work is supported by the generally within normal
limits findings at treatment examinations, her activities of daily living, her
general overall improvement in symptomology and her improved GAF score
over time.
(Tr. 26). As a result, the ALJ concluded that Plaintiff could perform her past relevant
work as a cashier and that she was not disabled. (Tr. 28-29). The ALJ summarized
Plaintiff’s medical records as follows:
Her medical records show that in 2013 she complained of back pain and was
assessed with chronic lower back pain (see Exhibit 15F). She was prescribed
medication and given a Toradol injection. In addition, the claimant
complained of hip pain with a burning sensation near her right thigh. In
terms of the claimant's alleged bipolar disorder and PTSD, the claimant's
symptoms have improved overtime with medication, treatment, and
counseling, and upon examination, generally the claimant's mental health
findings were within normal limits despite her reported suicidal ideation in
September 2012 that were agitated by family stressors, and one additional
time in January 2014.
The claimant's treatment records from Mobile Infirmary in September 2012
show that the claimant generally had all mental findings within normal
limits despite being agitated and in a dysphoric mood, particularly in light of
circumstances wherein the claimant's son lost custody of his children during
that time (Exhibit 3F). Her treatment notes from Altapointe in 2012 show

5

that the claimant was not doing well in September 2012, but her mood
improved thereafter (Exhibits 5F; 6F). While she had some suicidal ideation
in September 2012, upon examination, she was behaving normally,
cooperative, had an appropriate affect, and fair judgment, despite some
impairment in memory and concentration. She was assessed with a global
assessment of functioning (GAF) score of 50, which indicates serious
symptoms. Nevertheless, in November 2012, her mood was better, and she
appeared organized, calm, and was cooperative. Her affect was appropriate to
the situation, she had no suicidal ideation, her thoughts were logical, there
was no impairment in her memory and concentration, and her insight and
judgment was fair despite having mild anxiety.
When the claimant presented to the emergency room in October 2012 for a
physical non-severe issue, she was assessed as having a normal mood, affect,
and judgment (Exhibit 4F).
Treatment notes from Altapointe in 2013 show that despite reported
irritability and some depression symptoms by the claimant, upon
examination she was cooperative, her memory was unimpaired, and her
behavior was normal (Exhibits 11F; 14F). Moreover, as of October 2013, she
reported that she did not feel anxious anymore and her treatment notes set
forth that the claimant was doing better on her medication (Exhibit 14F).
Additional Altapointe records from 2014 show that the claimant continued to
be assessed with bipolar and anxiety, as well as a GAF score of 53, which
indicates moderate symptoms (Exhibit16F; 17F). Despite the claimant's
allegations of mood problems, hearing voices to tell her hurry up, suicidal
ideation, crying spells as set out in her treatment notes from January
2014,the examiner set forth that the claimant had not [had] any
hospitalizations in the past year (Exhibit 17F). Moreover, upon examination,
she was behaving normally, was cooperative, had no impairment in memory
or concentration, had logical thoughts, and had good insight and judgment. In
addition, her ability to care for herself was noted to be "good" and she had
interest in future recreation. In addition, the claimant reported that her
“friends tell [her] [sh]e do[es] too much for other people" (Exhibit 17F). She
reported that her present support system included her husband and a friend
that lives close to her. In addition, it was noted that her husband was
disabled and that she was applying for disability at that time.
(TR. 25). After summarizing the medical evidence, the ALJ stated that he gave only
some weight to Dr. Wilsania Rodriguez’s conclusion that Plaintiff’s psychological
problems were disabling.

(Id. at 26).

6

Plaintiff, however, contends that Dr.

Rodriguez’s opinion of November 18, 2013, wherein she opined “Im currently
treating her for HTN and DLP ... not any disabling condition ... I do feel her psych
problems are desabling [sic] though” should have been given controlling weight
because it was consistent with Plaintiff’s medical evidence of record. (TR. 527; Doc.
13 at 3).
“In assessing medical opinions, the ALJ must consider a number of factors in
determining how much weight to give to each medical opinion, including (1)
whether the physician has examined the claimant; (2) the length, nature, and
extent of a treating physician's relationship with the claimant; (3) the medical
evidence and explanation supporting the physician’s opinion; (4) how consistent the
physician’s opinion is with the record as a whole; and (5) the physician’s
specialization.

These factors apply to both examining and non-examining

physicians.” Eyre v. Comm'r, Soc. Sec. Admin., 586 F. App'x 521, 523 (11th Cir.
Sept. 30, 2014) (per curiam) (unpublished) (internal citations and quotation marks
omitted) (citing 20 C.F.R. §§ 404.1527(c) & (e), 416.927(c) & (e)). The Court notes
that "although the opinion of an examining physician is generally entitled to more
weight than the opinion of a non-examining physician, the ALJ is free to reject the
opinion of any physician when the evidence supports a contrary conclusion."
Oldham v. Schweiker, 660 F.2d 1078, 1084 (5th Cir. 1981);1 see also 20 C.F.R. §
404.1527. Regardless, the ALJ must state with particularity the weight given to

1The

Eleventh Circuit, in Bonner v. City of Prichard, 661 F.2d 1206, 1209 (11th Cir. 1981) (en banc), adopted
as precedent decisions of the former Fifth Circuit rendered prior to October 1, 1981.

7

different medical opinions and the reasons therefor. Sharfarz v. Bowen, 825 F.2d
278, 279 (11th Cir. 1987) (per curiam).
In the ALJ’s opinion, the weight given to Dr. Rodriguez’s opinion was
diminished because Dr. Rodriguez is not a mental health specialist and her opinions
were not consistent with Reneau’s medical history. (TR. 26). More specifically, with
regard to Dr. Rodriguez’s opinion that Reneau’s psychological problems are
disabling, the ALJ stated that her opinion:
[I]s an opinion not given by a mental health specialist, and is not consistent
with the claimant's improved symptoms with on-going and consistent mental
health treatment, counseling, and medication; the treatment examination
findings wherein the claimant generally was cooperative, behaved normally,
had fair judgment, and unimpaired memory and concentration; her improved
GAF score over time; and in light of her activities of daily living wherein she
is able to live with her husband, perform household chores, help take care of
the family pet, and go out in public to the grocery store and to doctor's
appointments.
(Id.). Despite, Plaintiff’s assertions to the contrary, this Court finds that there was
substantial evidence that contradicted Dr. Rodriguez’s opinion such that the ALJ
did not err by giving her opinion as to Plaintiff’s mental disability only some weight.
Further, the ALJ’s explanation specifically articulates the reasoning behind his
decision to diminish the weight attributed to Dr. Rodriguez’s opinion, i.e. a lack of
specialty in the field in which she opined and inconsistencies between her opinion
and Plaintiff’s medical record. As such, Plaintiff’s assertion that Dr. Rodrigeuz’s
opinion should have been given controlling weight is without merit.

8

Plaintiff has additionally asserted that the ALJ committed reversible error by
failing to fully develop the record by ordering a consultative psychological
examination. (Doc. 13 at 5).
It is well-established that the ALJ has a basic duty to develop a full and fair
record. 20 C.F.R. § 416.912(d). “Nevertheless, the claimant bears the burden of
proving that he is disabled, and, consequently, he is responsible for producing
evidence in support of his claim.” Ellison v. Barnhart, 355 F.3d 1272, 1276 (11th
Cir. 2003); See 20 C.F.R. § 416.912(a) (stating that “[claimant] must furnish medical
and other evidence that we can use to reach conclusions about your medical
impairment(s)”); 20 C.F.R. § 416.912(c) (stating “[y]our responsibility. You must
provide medical evidence showing that you have an impairment(s) and how severe
it is during the time you say you are disabled”). “In fulfilling the duty to conduct a
full and fair inquiry, the ALJ is not required to order a consultative examination
unless the record establishes that such is necessary to enable the ALJ to render a
decision.” River v. Astrue, 901 F.Supp.2d 1317, 1327 (S.D.Ala. 2012); See Ingram v.
Commissioner of Soc. Sec. Admin., 496 F.3d 1253, 1269 (11th Cir.2007). (“The
administrative law judge has a duty to develop the record where appropriate but is
not required to order a consultative examination as long as the record contains
sufficient evidence for the administrative law judge to make an informed decision.”).
In support of her argument that a consultative psychological exam should
have been ordered, Plaintiff does not state that there was a lack of medical
evidence.

Rather, Plaintiff argues that “in failing to order a consultative

9

psychological examination and in failing to take into account the Plaintiff’s
treatment records and opinion of Plaintiff’s treating physician, the Administrative
Law Judge’s adopted residual functional capacity does not truly encompass
Plaintiff’s severe mental impairments.” (Doc. 13 at 6). Such an assertion gives no
merit to Plaintiff’s position that there was insufficient medical evidence for the ALJ
to consider in making an informed decision. Further, as indicated by the ALJ’s
opinion, he had access to and did, in fact, review all of the medical records
referencing Plaintiff’s mental conditions and treatment before making his
determination. There is no indication that the ALJ did not have sufficient evidence
on which to make a determination such that a consultative exam was necessary. As
a result, the ALJ’s failure to order a consultative exam was not reversible error.
CONCLUSION
Plaintiff has raised two claims in bringing this action; both are without merit.
Upon consideration of the entire record, the Court finds "such relevant evidence as a
reasonable mind might accept as adequate to support a conclusion." Richardson v.
Perales, 402 U.S. 389, 401 (1971). Therefore, it is ORDERED that the Secretary's
decision be AFFIRMED, see Fortenberry v. Harris, 612 F.2d 947, 950 (5th Cir.
1980), and that this action be DISMMISSED.

Judgment will be entered by

separate Order.
DONE this 4th day of November, 2016.

/s/ Katherine P. Nelson
KATHERINE P. NELSON
UNITED STATES MAGISTRATE JUDGE

10