McClellan v. Commissioner of Social Security
Filing
15
MEMORANDUM OPINION AND ORDER. Signed by Magistrate Judge Monte C. Richardson on 7/25/2013. (MOH)
UNITED STATES DISTRICT COURT
MIDDLE DISTRICT OF FLORIDA
JACKSONVILLE DIVISION
IAN MCCLELLAN,
Plaintiff,
vs.
Case No. 3:12-cv-837-J-MCR
COMMISSIONER OF THE
SOCIAL SECURITY ADMINISTRATION,
Defendant.
_____________________________________/
MEMORANDUM OPINION AND ORDER1
This cause is before the Court on Plaintiff’s appeal of an administrative decision
denying his application for Social Security benefits. The Court has reviewed the record,
the briefs, and the applicable law. For the reasons set forth herein, the Commissioner’s
decision is AFFIRMED.
I.
PROCEDURAL HISTORY
Plaintiff filed an application for a period of disability and Disability Insurance
Benefits (“DIB”) on June 13, 2008 alleging June 13, 2008 as the onset date. (Tr. 9197). Plaintiff’s claims were denied initially on November 5, 2008 and upon
reconsideration on February 18, 2009. (Tr. 46-50). Thereafter, Plaintiff requested a
hearing before an Administrative Law Judge (“ALJ”), which was conducted on August
25, 2010. (Tr. 29-42). The ALJ ultimately found Plaintiff was not disabled in a decision
dated October 5, 2010. (Tr. 16-23). Plaintiff requested review of the ALJ’s decision and
the Appeals Council denied the request on May 22, 2012. (Tr. 1-3). Plaintiff timely filed
1
The parties consented to the exercise of jurisdiction by a United States Magistrate
Judge. (Doc. 6).
his complaint in this Court seeking judicial review of the Commissioner’s decision finding
him disabled. (Doc. 1).
II.
NATURE OF DISABILITY CLAIM
A.
Basis of Claimed Disability
Plaintiff claimed to be disabled since June 13, 2008 due to mental and physical
impairments. (Doc. 13, p. 3).
B.
Summary of Evidence Before the ALJ
Plaintiff was thirty-nine years old on the date of his hearing before the ALJ on
July 30, 2008. (Doc. 13, p. 3). Plaintiff has a high school education and past relevant
work as a meat cutter. Id.
As Plaintiff’s appeal deals exclusively with his alleged mental impairments, the
Court will focus its summary of the medical records on evidence addressing those
impairments. In September 2009, Plaintiff had surgery to remove his gallbladder. (Doc.
13, p. 3). Plaintiff reported to his physicians that he was awake and remembered three
incisions made during the surgery. Id. Plaintiff was referred for a psychiatric evaluation.
Id. Michael Speisman, ARNP, performed a psychiatric evaluation on November 24,
2009. (Tr. 299-302). Mr. Speisman noted at the time of the examination Plaintiff was
“tearful, crie[d] easily, ha[d] nightmares, and [was] emotionally labile.” (Tr. 299). Mr.
Speisman listed Plaintiff’s abilities as being able to help out with household chores, help
with the care of his children, and make decisions regarding his health care. (Tr. 301).
Plaintiff was diagnosed with Depressive Disorder, NOS and assigned a GAF score of
2
55.2 (Tr. 302). His prognosis was fair. Id.
Plaintiff’s next visit with Mr. Speisman was December 14, 2009 and Plaintiff
reported difficulty sleeping and feeling stressed due to family issues. (Tr. 297). Plaintiff
returned on January 11, 2010 and reported feeling less depressed but Plaintiff’s wife
reported Plaintiff had a quick temper. (Tr. 295). On January 19, 2010, Plaintiff reported
to his physician, Dr. Mhatre, that his mood was improving, but that he was not sleeping.
(Tr. 294). Plaintiff was placed on Sinequan and instructed to use his C-Pap machine
when he slept. Id.
On January 25, 2010, Plaintiff reported feeling overwhelmed by family issues.
(Tr. 292). Mr. Speisman noted Plaintiff’s mood had improved and Plaintiff’s GAF was
60. Id. During Plaintiff’s next visit on March 8, 2010, Plaintiff was tearful and stated he
felt overwhelmed by responsibility. (Tr. 290). On April 29, 2010, Plaintiff reported he
worried excessively and still felt depressed. (Tr. 288). On May 20, 2010, Mr. Speisman
completed a treatment plan review where he noted Plaintiff needed to attend more
scheduled appointments consistently. (Tr. 285). Mr. Speisman also opined Plaintiff had
made significant progress coping with trauma and stress and had improved his
functioning as a parent/spouse. (Tr. 286). Mr. Speisman believed Plaintiff had a more
positive/optimistic outlook for the future and estimated Plaintiff’s GAF was a 65.3 (Tr.
2
The Global Assessment of Functioning (“GAF”) Scale describes an individual’s overall
psychological, social, and occupational functioning as a result of mental illness, without
including any impaired functioning due to physical or environmental limitations. Diagnostic and
Statistical Manual of Mental Disorders (DSM-IV) at 32 (4th ed. 1994). A GAF score of 51-60
indicates moderate symptoms, or moderate difficulty in social or occupational functioning (e. g.
few friends, conflicts with peers or co-workers). Id.
3
A GAF score of 61-70 indicates some mild symptoms (e.g. depressed mood and mild
insomnia) or some difficulty in social, occupational, or school functioning, but generally
functioning pretty well.
3
286-87). The last treatment record for Plaintiff was dated June 7, 2010, at which time
he reported difficulty sleeping, nightmares, and scratching his skin to the point of
bleeding. (Tr. 282). Mr. Speisman listed Plaintiff’s GAF as a 60.
C.
Summary of the ALJ’s Decision
A plaintiff is entitled to disability benefits when he is unable to engage in
substantial gainful activity by reason of any medically determinable physical or mental
impairment which can be expected to either result in death or last for a continuous
period of not less than 12 months. 42 U.S.C. §§ 416(i), 423(d)(1)(A); 20 C.F.R. §
404.1505. The ALJ must follow five steps in evaluating a claim of disability. See 20
C.F.R. §§ 404.1520. First, if a claimant is working at a substantial gainful activity, he is
not disabled. 29 C.F.R. § 404.1520(b). Second, if a claimant does not have any
impairment or combination of impairments which significantly limit his physical or mental
ability to do basic work activities, then he does not have a severe impairment and is not
disabled. 20 C.F.R. § 404.1520(c). Third, if a claimant’s impairments meet or equal an
impairment listed in 20 C.F.R. Part 404, Subpart P, Appendix 1, he is disabled. 20
C.F.R. § 404.1520(d). Fourth, if a claimant’s impairments do not prevent him from
doing past relevant work, he is not disabled. 20 C.F.R. § 404.1520(e). Fifth, if a
claimant’s impairments (considering his residual functional capacity, age, education,
and past work) prevent him from doing other work that exists in the national economy,
then he is disabled. 20 C.F.R. § 404.1520(f). Plaintiff bears the burden of persuasion
through step four, while at step five, the burden shifts to the Commissioner. Bowen v.
Yuckert, 482 U.S. 137, 146, 107 S.Ct. 2287 n.5 (1987).
4
In the instant case, the ALJ determined Plaintiff met the insured status
requirements of the Social Security Act through December 31, 2012. (Tr. 18). At step
one, the ALJ determined Plaintiff had not engaged in substantial gainful activity since
his alleged onset date of June 13, 2008. Id. At step two, the ALJ found Plaintiff’s
severe impairments included hernia and obesity. Id. The ALJ noted Plaintiff’s “left knee
strain and depression [were] found to be non-severe impairments, as these impose no
more than a minimal impact on [Plaintiff’s] ability to perform work-related activity.” (Tr.
19).
At step three, the ALJ determined Plaintiff did not have an impairment or
combination of impairments that met or medically equaled one of the listed impairments
in 20 C.F.R. Part 404, Subpart P, Appendix 1. Id. The ALJ next found Plaintiff had the
residual functional capacity (“RFC”) to perform the full range of light work. (Tr. 20). In
making this conclusion, the ALJ determined Plaintiff’s “medically determinable
impairments could reasonably be expected to cause the alleged symptoms; however,
[Plaintiff’s] statements concerning the intensity, persistence and limiting effects of these
symptoms [were] not credible to the extent they [were] inconsistent with the above
residual functional capacity.” (Tr. 21).
Based on the RFC, the ALJ found that at step four, Plaintiff was not able to
perform any of his past relevant work. (Tr. 22). Therefore, the ALJ proceeded to step
five where he considered Plaintiff’s age, education, and work experience and
determined a finding of not disabled was directed by Medical-Vocational Rule 202.21.
(Tr. 23).
5
III.
ANALYSIS
A.
The Standard of Review
The scope of this Court’s review is limited to determining whether the ALJ
applied the correct legal standards, McRoberts v. Bowen, 841 F.2d 1077, 1080 (11th
Cir. 1988), and whether the findings are supported by substantial evidence. Richardson
v. Perales, 402 U.S. 389, 390, 91 S.Ct. 1420 (1971). The Commissioner’s findings of
fact are conclusive if supported by substantial evidence. 42 U.S.C. § 405(g).
Substantial evidence is more than a scintilla – i.e., the evidence must do more than
merely create a suspicion of the existence of a fact, and must include such relevant
evidence as a reasonable person would accept as adequate to support the conclusion.
Foote v. Chater, 67 F.3d 1553, 1560 (11th Cir. 1995) (citing Walden v. Schweiker, 672
F.2d 835, 838 (11th Cir. 1982) and Richardson, 402 U.S. at 401).
Where the Commissioner’s decision is supported by substantial evidence, the
district court will affirm, even if the reviewer would have reached a contrary result as
finder of fact, and even if the reviewer finds that the evidence preponderates against the
Commissioner’s decision. Edwards v. Sullivan, 937 F.2d 580, 584 n.3 (11th Cir. 1991);
Barnes v. Sullivan, 932 F.2d 1356, 1358 (11th Cir. 1991). The district court must view
the evidence as a whole, taking into account evidence favorable as well as unfavorable
to the decision. Foote, 67 F.3d at 1560; accord Lowery v. Sullivan, 979 F.2d 835, 837
(11th Cir. 1992) (court must scrutinize the entire record to determine reasonableness of
factual findings).
6
B.
Issue on Appeal
Plaintiff argues one issue in this appeal, that the ALJ erred by failing to find
Plaintiff suffered from severe mental impairments that impacted his RFC. (Doc. 13, p.
6). Plaintiff argues the ALJ’s reasons for finding Plaintiff’s mental impairments not
severe are either directly contradicted by the evidence of record or are inconsistent with
the Commissioner’s rulings and regulations. Id. The Commissioner responds that
substantial evidence supports the ALJ’s finding that Plaintiff’s depression was a nonsevere impairment. (Doc. 14, p.3).
Plaintiff argues the ALJ listed three reasons for finding Plaintiff’s depression was
not severe. According to Plaintiff, the ALJ’s reasons were: (1) despite alleging an onset
of disability as of June 2008, Plaintiff did not seek treatment for his depression until
November 2009; (2) the record did not show Plaintiff took any medications for
depression or did not take the medications as prescribed; and (3) the depression did not
meet the durational requirements of 20 C.F.R. §404.1505. (Doc. 13, pp. 8-9). With
respect to the first two reasons, Plaintiff argues the mere fact that Plaintiff experienced
an additional severe impairment after the onset date is not a sufficient reason to find the
impairment not severe and Plaintiff notes that the record clearly indicates Plaintiff was
prescribed numerous medications for his depression and there is nothing in the record
to support a claim that Plaintiff was not taking medications as prescribed. Plaintiff is
correct that neither of these reasons is sufficient to find Plaintiff’s mental impairment to
be non-severe. First, as Plaintiff points out, there is nothing wrong or even unusual
about a claimant experiencing an additional severe impairment after the onset date.
Further, Plaintiff is correct and the Commissioner concedes that the medical records
7
indicate Plaintiff was prescribed medications for his depression and there are no
records showing he failed to take the medications as prescribed. Had the ALJ simply
relied on these reasons for finding Plaintiff’s depression to be non-severe, the
undersigned would be compelled to reverse and remand. However, the ALJ provided
additional reasons for finding Plaintiff’s depression to be non-severe and the
undersigned believes these reasons are supported by substantial evidence.
As noted by Plaintiff, the ALJ also indicated that Plaintiff’s mental impairment did
not satisfy the durational requirements of 20 C.F.R. §404.1505, which provides:
The law defines disability as the inability to do any substantial
gainful activity by reason of any medically determinable
physical or mental impairment 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 12 months.
Plaintiff believes the ALJ focused simply on whether Plaintiff’s depression lasted for a
continuous period of twelve months and ignored the second part of the regulation
regarding whether the depression could be expected to last for a continuous period of
twelve months. (Doc. 13, pp. 9-10). However, Plaintiff has failed to point to any
evidence supporting a finding that Plaintiff’s depression was expected to last for twelve
months. As pointed out by the Commissioner, the medical records indicate Plaintiff’s
depression responded well to medication and Plaintiff’s mood had improved. (Doc. 14,
p.6). In May 2010, Mr. Speisman noted Plaintiff “made significant progress coping with
trauma and stress, had improved functioning, and had a more positive/optimistic outlook
for the future.” (Tr. 286).
In any event, even assuming Plaintiff’s depression could be expected to last for a
continuous period of not less than twelve months, the Court still believes the ALJ
8
correctly found it to be non-severe. The Court is most compelled by the reason
provided by the ALJ and not mentioned by Plaintiff: that Plaintiff’s mental impairment did
not cause more than minimal limitations on Plaintiff’s ability to perform work activities.
(Tr. 19).
At step two, the claimant bears the burden of proving the existence of a severe
impairment. See Yuckert, 482 U.S. at 146. The “‘severity’ of an ascertained disability
must be measured in terms of its effect upon ability to work, and not simply in terms of
deviation from purely medical standards of bodily perfection or normality.” McCruter v.
Bowen, 791 F.2d 1544, 1547 (11th Cir. 1988); see also 20 C.F.R. § 404.1520(c) (“If you
do not have any impairment or combination of impairments which significantly limits
your physical or mental ability to do basic work activities, we will find that you do not
have a severe impairment . . .”); and Social Security Ruling (“SSR”) 96-3p (in
considering an alleged impairment, the ALJ must evaluate evidence about its
“functionally limiting effects” to determine how it affects the claimant’s ability to do basic
work activities). In the instant case, the ALJ specifically noted that Plaintiff’s depression
did not “cause more than minimal limitation in [Plaintiff’s] ability to perform basic mental
work activities and is therefore, non-severe.” (Tr. 19). The ALJ went on to consider the
four broad functional areas from 20 C.F.R. § 404.1520a with respect to Plaintiff’s
depression. Id. In the first functional area, activities of daily living, the ALJ determined
Plaintiff had a mild limitation. Id. The ALJ observed that Plaintiff cared for four children
while his wife was at work, was able to prepare meals and feed himself, and also helped
with household chores. Id. The ALJ then considered the second functional area, social
functioning, and determined Plaintiff had no limitation as Plaintiff alleged no difficulty
9
with social functioning and the record contained no reports of Plaintiff being
uncooperative with any physicians. Id. Next, with respect to the functional area of
concentration, persistence, or pace, the ALJ found Plaintiff had a mild limitation. Id.
The ALJ noted Plaintiff spent seventeen to eighteen hours each day in bed, but was still
able to take care of his four children while his wife was at work. Id. Lastly, the ALJ
found Plaintiff had not experienced any episodes of decompensation, which have been
of extended duration. (Tr. 20).
These findings support the ALJ’s decision that Plaintiff’s depression was not
severe and Plaintiff failed to point to any evidence showing the depression caused any
limitations on Plaintiff’s ability to perform work activities. As such, the Court finds no
error in the ALJ’s determination that Plaintiff’s depression was not severe.
IV.
CONCLUSION
For the foregoing reasons, the Commissioner’s decision is hereby AFFIRMED.
The Clerk of the Court is directed to enter judgment consistent with this opinion and,
thereafter, to close the file.
DONE AND ORDERED at Jacksonville, Florida, this
Copies to:
Counsel of Record
10
25th
day of July, 2013.
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?