Lane v. Commissioner of Social Security

Filing 21

FINAL JUDGMENT and ORDER Regarding Plaintiff's Social Security Complaint signed by Magistrate Judge Erica P. Grosjean on 11/16/2017. CASE CLOSED. (Sant Agata, S)

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UNITED STATES DISTRICT COURT

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EASTERN DISTRICT OF CALIFORNIA

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Plaintiff,

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Case No. 1:16-cv-01386-EPG

KAREN LANE,

v.

FINAL JUDGMENT AND ORDER
REGARDING PLAINTIFF’S SOCIAL
SECURITY COMPLAINT

COMMISSIONER OF SOCIAL
SECURITY,

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Defendant.
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This matter is before the Court on Plaintiff’s complaint for judicial review of an

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unfavorable decision of the Commissioner of the Social Security Administration regarding his

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applications for supplemental security income and disability insurance benefits. The parties have

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consented to entry of final judgment by the United States Magistrate Judge under the provisions

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of 28 U.S.C. § 636(c) with any appeal to the Court of Appeals for the Ninth Circuit.

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At the hearing on November 16, 2017, the Court heard from the parties and, having

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reviewed the record, administrative transcript, the briefs of the parties, and the applicable law,

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finds as follows:

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For the reasons announced by the Court on the record at the conclusion of the parties’ oral

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argument on November 16, 2017, the Court finds that the decision of the Commissioner of Social

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Security should be reversed and the case should be remanded for further proceedings.

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On September 12, 2013, Licensed Marriage and Family Therapist (LMFT) Sahai-Bains

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diagnosed Ms. Lane with Bipolar Disorder I, with the most recent episode of mania, moderate,

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and referred Ms. Lane for group services and to Dr. Obata for psychiatric follow-up. (AR 505)

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On October 25, 2013, Psychiatrist Christine Obata, M.D. evaluated Ms. Lane. (AR 490-

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491) Dr. Obata assessed Ms. Lane as “Likely Bipolar Disorder Type I,” and “[c]urrently appears

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to be in a hypomanic episode.” (AR 491) Dr. Obata also assessed that Ms. Lane “requires more

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intensive mental health services than can be provided through primary care” and recommended

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that Plaintiff continue the psychotherapy at Fresno County Mental Health and to establish care
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with a psychiatrist for psychotropic medication management visits.
On December 20, 2013, Ms. Lane was again treated by psychiatrist Dr. Obata, who

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assessed “Depression NOS [more likely]; rule out Bipolar Disorder.” (AR 485) Dr. Obata noted

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that Ms. Lane was “uncontrollably tearful during most of interview,” prescribed an antidepressant

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and recommended continuing psychotherapy at Fresno County Mental Health.

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On May 29, 2014, psychiatrist Shawn Hersevoort, M.D. evaluated Ms. Lane at the request

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of Dr. Sheh, M.D. to assist with treatment planning. (AR 467) Dr. Hersevoort observed that Ms.

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Lane suffers from major depression, generalized anxiety disorder, and partially-resolved Post-

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Traumatic Stress Disorder (PTSD). Dr. Hersevoort further observed that Ms. Lane “by strict

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criteria likely fits into the Bipolar NOS category,” but has never been hospitalized for her

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symptoms and “scored a 7 on the [Mood Disorder Questionnaire], which is the minimum score

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for considering bipolar.” Dr. Hersevoort noted to “consider an adjunctive mood stabilizer at a

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later date to help with bipolar NOS.” (AR 473)

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On November 20, 2014, there was a subsequent psychiatric visit with Dr. Hersevoort,

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where he observed and opined that Ms. Lane is “suffering from a combination of cluster B

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personality disorder (most likely borderline) as well as a bipolar 2 illness.” (AR 448) Ms. Lane

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was treated by Dr. Hersevoort again on December 4, 2014, who observed that Ms. Lane was

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experiencing severe mood, anxiety and somatic symptoms. (AR 443) Dr. Hersevoort noted that

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Ms. Lane had a “complex history and presentation with likely borderline personality disorder,

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possible bipolar (1 vs 2), ADHD, PTSD.” In the diagnosis (Patient Active Problem List) section

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of the medical record, Dr. Hersevoort recorded the following mental conditions:

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Cluster B personality disorder (likely)
ADHD (attention deficit hyperactivity disorder)
PTSD
Bipolar disorder, unspecified
Intellectual disability

11/20/2014
6/20/2014
6/20/2014
5/29/2014
1/31/2014

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At step two of the five-step sequential disability analysis, the ALJ found Ms. Lane had

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severe impairments of “brittle diabetes mellitus with peripheral neuropathy, depressive disorder,

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borderline intellectual functioning, and ADHD. (AR 13). Although Ms. Lane had claimed she
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also suffered from bipolar disorder, the ALJ failed to discuss this disorder in any way in step 2

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and did not refer to the above mentioned doctor’s diagnoses at this step. Moreover, when the ALJ

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formulated Ms. Lane’s residual functioning capacity (“RFC”) assessment, the ALJ failed to

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address the opinions of treating doctors Obata and Hersevoort. This was legal error. See Lester

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v. Chater, 81 F.3d 821, 830–31 (9th Cir. 1995), as amended (Apr. 9, 1996) (providing that the

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ALJ must give “clear and convincing” reasons for rejecting the uncontradicted opinion of an

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examining physician, Pitzer v. Sullivan, 908 F.2d 502, 506 (9th Cir.1990), and “specific and

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legitimate” reasons that are supported by substantial evidence in the record for rejecting a

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contradicted opinion, Andrews v. Shalala, 53 F.3d 1035, 1043 (9th Cir. 1995)).

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The ALJ only mentioned bipolar disorder in the context of discrediting Ms. Lane’s

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credibility. The ALJ noted that Ms. Lane was seen in September 2013 by LMFT Sahai-Bains,

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who diagnosed bipolar disorder. (AR 18) In the same paragraph, the ALJ went on to express an

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opinion that Ms. Lane was exaggerating her symptoms in order to receive disability benefits.

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While this discussion includes references to medical records by Drs. Obata and Hersevoort, they

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are not mentioned by name or their diagnoses, and the ALJ does not provide specific reasons for

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discounting their opinions. Although the Commissioner argues that these page references are

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sufficient to satisfy the ALJ’s burden, the Court disagrees.

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The ALJ’s decision does cite to “Exhibit 6F,” which consists of 69 pages of medical

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records from Community Medical Centers, a medical group consisting of several doctors

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(including Obata and Hersevoort) that provided to treatment to Ms. Lane. (AR 432-499) The

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Court reviewed the all of instances where the ALJ cited to a specific page of Exhibit 6F, and none

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the citations were to the records of doctors Obata and Hersevoort.1

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The Court thus remands the case for additional development regarding the medical

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opinions of doctors Obata and Hersevoort and possible work-related limitations resulting from the

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conditions. On remand, the ALJ shall consider their opinions and either accept them or provide

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specific and legitimate reasons supported by substantial evidence for failing to do so.

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The ALJ also made a general citation to Exhibit 6F without a page number, but this appears to be a citation
to the records of Dr. Sheh.

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Accordingly, the Court GRANTS Plaintiff’s appeal from the administrative decision of

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the Commissioner of Social Security and the case is remanded to the Social Security

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Administration. The Clerk of the Court is DIRECTED to enter judgment in favor of Plaintiff and

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against Defendant Nancy A. Berryhill, Acting Commissioner of Social Security.

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IT IS SO ORDERED.
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Dated:

November 16, 2017

/s/
UNITED STATES MAGISTRATE JUDGE

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