West v. Commissioner of Social Security
Filing
19
OPINION AND ORDER: The Commissioner's decision is REVERSED and REMANDED pursuant to sentence four of 42 U.S.C. § 405(g) for further proceedings. The Clerk shall enter judgment accordingly and close the file. Signed by Magistrate Judge Monte C. Richardson on 9/14/2016. (ADM)
UNITED STATES DISTRICT COURT
MIDDLE DISTRICT OF FLORIDA
JACKSONVILLE DIVISION
MARGARET ELIZABETH WEST,
Plaintiff,
v.
CASE NO. 3:15-cv-758-J-MCR
CAROLYN W. COLVIN, 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 her application for a period of disability and disability insurance
benefits (“DIB”). Plaintiff alleges she became disabled on January 23, 2012. (Tr.
161.) The assigned Administrative Law Judge (“ALJ”) held a hearing on February
12, 2014, at which Plaintiff was represented by an attorney. (Tr. 57-78.) The ALJ
found Plaintiff not disabled from January 23, 2012 through May 30, 2014, the
date of the decision.2 (Tr. 41-50.)
In reaching the decision, the ALJ found that Plaintiff had severe
impairments, including a history of neurocardiogenic syncope and autonomic
dysfunction, disorders of the spine, fibromyalgia, and obesity. (Tr. 43.) The ALJ
1
The parties consented to the exercise of jurisdiction by a United States
Magistrate Judge. (Docs. 9, 12.)
2
Plaintiff had to establish disability on or before December 31, 2016, her date
last insured, in order to be entitled to a period of disability and DIB. (Tr. 41.)
also found that Plaintiff had the residual functional capacity (“RFC”) to perform a
reduced range of light work. (Tr. 44-45.)
Plaintiff is appealing the Commissioner’s decision that she was not
disabled from January 23, 2012 through May 30, 2014. Plaintiff has exhausted
her available administrative remedies and the case is properly before the Court.
The Court has reviewed the record, the briefs, and the applicable law. For the
reasons stated herein, the Commissioner’s decision is REVERSED and
REMANDED.
I.
Standard
The scope of this Court’s review is limited to determining whether the
Commissioner applied the correct legal standards, McRoberts v. Bowen, 841
F.2d 1077, 1080 (11th Cir. 1988), and whether the Commissioner’s findings are
supported by substantial evidence, Richardson v. Perales, 402 U.S. 389, 390
(1971). “Substantial evidence is more than a scintilla and is such relevant
evidence as a reasonable person would accept as adequate to support a
conclusion.” Crawford v. Comm’r of Soc. Sec., 363 F.3d 1155, 1158 (11th Cir.
2004). 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
2
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 v.
Chater, 67 F.3d 1553, 1560 (11th Cir. 1995); accord Lowery v. Sullivan, 979 F.2d
835, 837 (11th Cir. 1992) (stating the court must scrutinize the entire record to
determine the reasonableness of the Commissioner’s factual findings).
II.
Discussion
Plaintiff raises three issues on appeal. First, Plaintiff argues that the ALJ
failed to articulate good cause for not crediting the treating opinions of
Kaushalendra K. Singh, M.D., P.A.3 that Plaintiff was unable to work due to the
unpredictability of her syncopal episodes. Second, Plaintiff argues that the ALJ
failed to articulate good cause for not crediting the opinions of her treating
cardiologist Dr. David Bello. Finally, Plaintiff argues that the Appeals Council
erred in finding that the opinion of Randi Most, Ph.D., ABN, Board Certified
Neuropsychologist, pertained to a time after the ALJ denied Plaintiff’s claim and
in failing to remand her case. The Court agrees with Plaintiff that the ALJ’s failure
to address pertinent opinions warrants a remand.
The ALJ found that Plaintiff was capable of performing light work “with no
more than occasional climbing ramps/stairs, balancing, stooping, kneeling,
crouching, and crawling,” and that she should avoid climbing ladders, ropes, and
scaffolds, concentrated exposure to vibrations and even moderate exposure to
3
Dr. Singh is an internal medicine and pulmonary disease physician.
3
extreme heat, humidity, and hazards (machinery, heights, etc.). (Tr. 44-45.) In
making this finding, the ALJ discussed the medical opinions of record, including,
but not limited to, the opinions of Dr. Singh, Dr. Bello, Irena Assefa, M.D.
(Plaintiff’s family physician), and the State agency non-examining consultants.
(Tr. 46-48.) With respect to Dr. Singh’s opinions, the ALJ stated:
Kaushalendra Singh, M.D. completed a treating physician
questionnaire in which he noted that the claimant does not suffer
from a mental impairment that significantly interferes with her daily
functioning and that no medications were prescribed. (Exhibit 13F)
This opinion is given significant weight as it is consistent with the
objective evidence of record.
(Tr. 47.)
However, the ALJ did not discuss any of Dr. Singh’s remaining opinions,
including the opinion from April 9, 2012 that Plaintiff was off work until seen at
Mayo Clinic (Tr. 385), the opinion from May 24, 2012 that Plaintiff should stay off
work (Tr. 384), the opinion from June 1, 2012 that Plaintiff was still unable to work
(Tr. 383), and the opinion from June 21, 2012 that Plaintiff was unable to work
because of the chance of syncopal episodes and their unpredictability (Tr. 382).4
4
Drs. Bello and Assefa similarly opined that Plaintiff should be off work. (See Tr.
334 (“Autonomic dysfunction with severe neurocardiogenic syncope, failed Florinef. . . .
She needs to be off work, and she is to retry this new therapy.”), 568-73 (opining in a
Cardiac RFC Questionnaire that Plaintiff had marked limitation of physical activity,
should not operate machinery or stand for prolonged periods, was incapable of even
low stress jobs, had frequent episodes of passing out, and was likely to be absent from
work more than four days per month due to impairments or treatment), 579 (“She is
very upset about [sic] she continue [sic] to have dizziness, lightheadedness, and near
syncope events. . . . The patient continues to be extremely symptomatic and unable to
(continued...)
4
Dr. Singh’s note from June 21, 2012 also states that Plaintiff was “advised to be
off limits from dangerous places where the chances of having a syncopal episode
is [sic] alarming.” (Id.) It further states:
Patient has been seen at Mayo Clinic for the most difficult reason for
new cardiac syndrome . . . . A vague diagnosis of orthostatic
intolerance has been suggested by a Mayo Clinic physician. Patient
continues to have pain in the back and both legs. The pain is worse
on the right leg and unable to sleep well because of the same,
persistent headache and palpitations. Patient has passed out on
different occasions at work and at home.
(Id.)
Although the ALJ was not required to mention every piece of evidence in
the decision, pursuant to SSR 96-5P, the ALJ could not ignore Dr. Singh’s
opinions and was required to evaluate them. See Moon v. Comm’r of Soc. Sec.,
2014 WL 548110, *3 (M.D. Fla. Feb. 11, 2014) (citing SSR 96-5P); Spahiu v.
Colvin, 2013 WL 828460, *6 (M.D. Fla. Mar. 6, 2013) (“Even if a treating
physician’s opinion pertains to an issue reserved to the Commissioner (e.g. a
4
(...continued)
return to work at this time given the ongoing marked abnormalities of her present
symptoms.”), 598-603 (opining in a Physical RFC Questionnaire that Plaintiff was
incapable of even low stress jobs; could sit, stand, or walk for less than two hours total
in an eight-hour workday; would need unpredictable, unscheduled breaks; and w ould
be absent from work for more than four days per month due to impairments or
treatment), 643 (“Although her condition has improved, she continues to experience
episodes of passing out without much warning, therefore it would be detrimental to
operate or be around dangerous machinery for her safety and the safety of others
around her. It has been recommended for her not to return to her place of employment
due to the safety concerns.”).) These opinions are consistent with Plaintiff’s testimony
of continuing, unpredictable spells of passing out, which, according to the Vocational
Expert (“VE”), might be tolerated once but not over time. (Tr. 67, 73, 77.)
5
statement that the claimant is unable to work or is disabled), the ALJ must still
‘carefully consider’ and ‘never ignore’ these opinions.”). Pursuant to SSR 96-5P,
“[i]f the case record contains an opinion from a medical source on an issue
reserved to the Commissioner, the adjudicator must evaluate all the evidence in
the case record to determine the extent to which the opinion is supported by the
record.” SSR 96-5P. Further, with respect to opinions from treating sources, the
Commissioner is required to “make every reasonable effort to recontact such
sources for clarification when they provide opinions on issues reserved to the
Commissioner and the bases for such opinions are not clear” to the
Commissioner. Id. Although “treating source opinions on issues that are
reserved to the Commissioner are never entitled to controlling weight or special
significance . . . , opinions from any medical source on issues reserved to the
Commissioner must never be ignored.” Id.
In Moon, Judge Whittemore found that the ALJ’s failure to mention an
opinion from an examining physician that the claimant was disabled and to
discuss the weight afforded to that opinion, was an error requiring remand. 2014
WL 548110 at *3. He explained: “The gist of [SSR 96-5P] is that the ALJ must
weigh and evaluate any opinion from a medical source, even if it concerns an
ultimate issue reserved for the ALJ. The only restriction on the normal evaluative
process is that the ALJ is prohibited from affording such an opinion controlling or
significant weight.” Id.
6
As in Moon, the ALJ here failed to address any of Dr. Singh’s opinions that
Plaintiff was unable to work, as well as the notes accompanying such opinions.
Under these circumstances, the Court can only infer that the ALJ failed to
consider and evaluate these opinions. This error alone requires a remand. See
Moon, 2014 WL 548110 at *3-4. Therefore, the Court need not address Plaintiff’s
remaining arguments. See Jackson v. Bowen, 801 F.2d 1291, 1294 n.2 (11th
Cir. 1986) (per curiam); Freese v. Astrue, 2008 WL 1777722, at *3 (M.D. Fla. Apr.
18, 2008); see also Demenech v. Sec’y of the Dep’t of Health & Human Servs.,
913 F.2d 882, 884 (11th Cir. 1990) (per curiam).
However, the Court notes that the ALJ’s evaluation of Dr. Bello’s opinions
seems confusing. Although the ALJ gave Dr. Bello’s opinions “no significant
weight, as there is no rationale explaining why the claimant would be incapable of
performing low stress jobs or working in an environment where she would not be
exposed to hazards,” the ALJ indicated that both of these limitations have been
included in the RFC. (Tr. 48.) The ALJ then stated: “As discussed above, by
January 2013, the claimant was doing very well and no such extreme limitations
are ever documented in any of the treatment records.” (Id.) As Plaintiff points
out, it is unclear why the ALJ stated she incorporated limitations into the RFC,
which the ALJ ultimately found to be unsupported by the record. Moreover, the
ALJ did not actually incorporate a limitation to low stress jobs and included a
limitation to only moderate exposure (as opposed to no exposure) to hazards.
7
(See Tr. 45.) Accordingly, on remand, the ALJ must reconsider Dr. Bello’s and
Dr. Singh’s opinions, state the weight accorded to these opinions, and the
reasons therefor. The ALJ should also consider Dr. Most’s opinions, which were
originally submitted to the Appeals Council.
Accordingly, it is ORDERED:
1.
The Commissioner’s decision is REVERSED and REMANDED
pursuant to sentence four of 42 U.S.C. § 405(g), with instructions to the ALJ to:
(a) reconsider the medical opinions of record, as stated in this Order; (b)
reevaluate Plaintiff’s RFC assessment, if necessary; and (c) conduct any further
proceedings deemed appropriate.
2.
The Clerk of Court is directed to enter judgment accordingly,
terminate any pending motions, and close the file.
3.
In the event that benefits are awarded on remand, any § 406(b) or §
1383(d)(2) fee application shall be filed within the parameters set forth by the
Order entered in In re: Procedures for Applying for Attorney’s Fees Under 42
U.S.C. §§ 406(b) & 1383(d)(2), Case No.: 6:12-mc-124-Orl-22 (M.D. Fla. Nov. 13,
2012). This Order does not extend the time limits for filing a motion for attorney’s
fees under the Equal Access to Justice Act, 28 U.S.C. § 2412.
8
DONE AND ORDERED at Jacksonville, Florida, on September 14, 2016.
Copies to:
Counsel of Record
9
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?