Copeland v. Colvin

Filing 15

ORDER re 3 SOCIAL SECURITY COMPLAINT, filed by Regina Copeland Signed on 2/20/15 by District Judge M. Douglas Harpool. (View, Pat)

IN THE UNITED STATES DISTRICT COURT FOR THE
WESTERN DISTRICT OF MISSOURI
WESTERN DIVISION
REGINA COPELAND,
Plaintiff,
vs.
CAROLYN W. COLVIN,
Acting Commissioner of
Social Security,
Defendant.

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Case No. 14-03122-MDH

ORDER
Before the Court is Plaintiff’s appeal of the Commissioner’s denial of her application for
Social Security Disability Insurance benefits under Title II of the Social Security Act (“Act”), 42
U.S.C. §§ 401-434. Plaintiff has exhausted her administrative remedies and the matter is now
ripe for judicial review. This Court has carefully reviewed the record before it, and finds the
ALJ’s opinion is supported by substantial evidence on the record as a whole. The decision of the
Commission is affirmed.
BACKGROUND
Plaintiff filed her application for disability insurance benefits under Title II on August 30,
2011. Plaintiff was born in 1978 and claims she became disabled beginning on December 15,
2009. Plaintiff’s disability report states she has an alleged disability due to left knee
problems/pain, hip pain, back pain, leg pain, numbness in the left leg, inability to sit or stand for
“long periods,” and migraines.

The claim was initially denied on November 14, 2011. Plaintiff filed a request for an
Administrative Law Judge hearing, and a hearing was held on November 14, 2012. On March 1,
2013, the ALJ issued a decision finding the Plaintiff was not disabled as defined by the Act.
Plaintiff then filed a request for Review of the ALJ’s decision before the Appeals Council, which
was denied.
The ALJ found that Plaintiff had severe impairments that included degenerative joint
disease of the knee, migraines and recurrent bronchitis. However, the ALJ held that Plaintiff
does not have an impairment or combination of impairments listed in or medically equal to one
contained in 20 C.F.R. part 404, subpart P, appendix 1. The ALJ determined that Plaintiff
retained the RFC to perform light work as defined in 20 C.F.R. § 404.1567(b) except the
claimant must have a sit/stand option with the ability to change positions frequently, but not
more often than once every thirty minutes. The claimant can occasionally climb ramps and
stairs, and can occasionally kneel and crouch. The claimant can never climb ladders, ropes, or
scaffolds, and can never crawl. The claimant is limited to pushing and pulling with the left leg
frequently at a maximum of ten pounds. The claimant must avoid moderate exposure to noise,
and concentrated exposure to extreme cold, wetness and vibrations. The ALJ found that
Plaintiff’s impairments would not preclude her from performing work that exists in significant
numbers in the national economy, including work as a mail clerk and office helper.
Based on the ALJ’s findings, the ALJ found that the claimant is not disabled under
sections 216(i) and 223(d) of the Social Security Act. On January 23, 2014, SSA’s Appeals
Council denied Plaintiff’s request for review.
Plaintiff’s current appeal argues the following alleged errors: the ALJ failed to provide
an appropriate narrative link between the evidence of record and his RFC finding; the ALJ failed

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to appropriately weigh the identifiable and supported opinion of Dr. Singhal; and the ALJ failed
to fully and fairly develop the record resulting in an RFC finding that did not account for
Copeland’s mental limitation and was thus not supported by substantial evidence.
DISCUSSION
The Court’s role in reviewing an ALJ’s decision is to determine whether the “findings are
supported by substantial evidence in the record as a whole.” Page v. Astrue, 484 F.3d 1040,
1042-43 (8th Cir. 2007), citing, Haggard v. Apfel, 175 F.3d 591, 594 (8th Cir.1999).
“Substantial evidence is relevant evidence which a reasonable mind would accept as adequate to
support the Commissioner’s conclusion.” Id. “The fact that some evidence may support a
conclusion opposite from that reached by the Commissioner does not alone permit our reversal
of the Commissioner’s decision.” Id., citing, Kelley v. Barnhart, 372 F.3d 958, 961 (8th Cir.
2004); and Travis v. Astrue, 477 F.3d 1037, 1040 (8th Cir. 2007).  If the record contains
substantial evidence to support the Commissioner’s decision, the Court may not reverse the
decision simply because substantial evidence exists in the record that would have supported a
contrary outcome. Krogmeier v. Barnhart, 294 F.3d 1019, 1022 (8th Cir. 2002). In other words,
the Court cannot reverse simply because it would have decided the case differently. Id., citing,
Woolf v. Shalala, 3 F.3d 1210, 1213 (8th Cir. 1993). Further, the Court defers to the ALJ’s
determinations of the credibility of witness testimony, as long as the ALJ’s determinations are
supported by good reasons and substantial evidence. Pelkey v. Barnhart, 433 F.3d 575, 578 (8th
Cir. 2006).
In order to qualify for benefits under the Social Security Act and the accompanying
regulations, Plaintiff must establish she is disabled. Halverson v. Astrue, 600 F.3d 922, 929 (8th
Cir. 2010); citing, Pate–Fires v. Astrue, 564 F.3d 935, 942 (8th Cir.2009). “Disability is defined

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as the inability ‘to engage in 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 twelve months.’” Id.,
quoting 42 U.S.C. § 1382c(a)(3)(A). To determine disability, the ALJ follows an established
five-step process that considers whether: (1) the claimant was employed; (2) she was severely
impaired; (3) her impairment was, or was comparable to, a listed impairment; (4) she could
perform past relevant work; and if not, (5) whether she could perform any other kind of work.
Id., citing, 20 C.F.R. § 404.1520(a)(4); 20 C.F.R. § 416.920(a).
In this case, the ALJ determined, among other things, Plaintiff was unable to perform
past relevant work as a waitress, fast food worker and psychiatric aide. However, the ALJ
concluded there was other work she could perform, giving the example of mail clerk or office
helper as representative occupations of light unskilled work. Therefore, the ALJ determined she
was not disabled and was not entitled to benefits.
A. Substantial Evidence Supports the ALJ’s RFC Assessment.
Plaintiff argues the ALJ’s Decision failed to provide a link between the more restrictive
RFC and the record as a whole. Further, the Plaintiff argues the ALJ “discounted the medical
information provided by Copeland in support of her RFC and found that she had failed to meet
her burden.” The ALJ’s Decision states “the above residual functional capacity assessment is
supported by the objective medical evidence contained in the record. The credibility of the
claimant’s allegations is weakened by the inconsistencies between her allegations, her statement
regarding daily activities, and the medical evidence. Although the inconsistent information
provided by the claimant may not be the result of a conscious intention to mislead, nevertheless

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the inconsistencies suggest that the information provided by the claimant generally may not be
entirely reliable.” Tr. at 19.
RFC assessments are reserved to the Commissioner and are based on the record as a
whole. 20 C.F.R. § 404.1527(d)(2). “RFC is defined as the most a claimant can still do despite
his or her physical or mental limitations.” Martise v. Astrue, 641 F.3d 909, 923 (8th Cir. 2011);
citing, Leckenby v. Astrue, 487 F.3d 626, 631 n. 5 (8th Cir. 2007)(internal quotations, alteration,
and citations omitted). “The ALJ bears the primary responsibility for determining a claimant’s
RFC and because RFC is a medical question, some medical evidence must support the
determination of the claimant’s RFC.” Vossen v. Astrue, 612 F.3d 1011, 1016 (8th Cir. 2010).
“However, the burden of persuasion to prove disability and demonstrate RFC remains on the
claimant.” Id. “The record must be evaluated as a whole to determine whether the treating
physician's opinion should control.” Id. When a treating physician’s opinions “are inconsistent
or contrary to the medical evidence as a whole, they are entitled to less weight.” Halverson v.
Astrue, 600 F.3d 922, 929-30 (8th Cir. 2010); citing, Krogmeier v. Barnhart, 294 F.3d 1019,
1023 (8th Cir. 2002). “It is the ALJ’s responsibility to determine a claimant’s RFC based on all
relevant evidence, including medical records, observations of treating physicians and others, and
claimant’s own descriptions of his limitations.” Tellez v. Barnhart, 403 F.3d 953, 957 (8th Cir.
2005), citing, Pearsall v. Massanari, 274 F.3d 1211, 1217 (8th Cir.2001). The ALJ must first
evaluate the claimant’s credibility before determining a claimant’s RFC. Id.
Here, the ALJ provided an extensive review and analysis based upon the statutes, medical
evidence and testimony. First, the ALJ evaluated Plaintiff’s credibility in determining the RFC
assessment. In determining credibility, an ALJ should consider the claimant’s prior work
history; observations by third parties and treating and examining physicians relating to daily

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activities; duration, frequency and intensity of the pain; dosage, effectiveness and side effects of
medications; precipitating and aggravating factors; and functional restrictions. Polaski v.
Heckler, 739 F.2d 1320 (8th Cir. 1984). However, an ALJ “need not explicitly discuss each
Polaski factor.” See Strongson v. Barnhart, 361 F.3d 1066, 1072 (8th Cir. 2004). If there are
inconsistencies as a whole, it is sufficient if he acknowledges and considers those factors before
discounting a claimant’s subjective complaints. Id.  “If an ALJ explicitly discredits the
claimant’s testimony and gives good reason for doing so, we will normally defer to the ALJ’s
credibility determination.” Halverson v. Astrue, 600 F.3d 922, 932 (8th Cir. 2010).
Here, the ALJ’s determination considered and discussed Claimant’s testimony regarding
these factors and found that the testimony was inconsistent with the allegations of disabling
symptoms and limitations, “which weakens her credibility.” Tr. at 17. For example, the ALJ
noted the Claimant testified she could walk a mile and lift twenty-five pounds. She also testified
she attends to her personal hygiene, washes laundry, drives, shops, pays bills and cares for her
disabled daughter. Id. Claimant claimed she suffers from hip pain, back pain, leg numbness,
degenerative joint disease, migraines and recurrent bronchitis and as a result cannot work.
However, the ALJ stated “the claimant has described daily activities that are inconsistent with
the claimant’s allegations of disabling symptoms and limitations…” Tr. 17-19.
Further, the ALJ went through an extensive and thorough review of the medical evidence
and stated “the objective findings in this case fail to provide strong support for the claimant’s
allegations of disabling symptoms and limitations.” Id. For purposes of this Order it is
unnecessary to restate the extensive analysis provided by the ALJ. However, the ALJ’s
Determination provides a thorough review of the medical records regarding Claimant’s history of
knee arthroscopy, recurrent bronchitis and headaches and noted that the medical records showed

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normal results. For example, claimant complained of headaches but had a normal CT scan
result. Claimant complained of recurrent bronchitis but has smoked a pack of cigarettes per day
for the past twenty-one years. Further, with regard to Claimant’s knee, the medical records
showed recommendations that Claimant use a knee brace. After analyzing both the objective
medical records, the opinion evidence submitted and the Claimant’s testimony, the ALJ found
“the residual functional capacity assessment is supported by the objective medical evidence
contained in the record. The credibility of the claimant’s allegations is weakened by
inconsistencies between her allegations, her statements regarding daily activities, and the
medical evidence.” Tr. at 20.
Here, the Court finds the ALJ did not commit error and was in a better position than this
Court to assess Plaintiff’s credibility. Therefore, the Court finds the ALJ’s determination
regarding Plaintiff’s RFC is supported by substantial evidence on the record as a whole.
B. Substantial Evidence Supports the ALJ’s Consideration of Dr. Singhal’s Opinions.
Plaintiff argues the ALJ “rejected” the opinions of Dr. Singhal. Specifically, Plaintiff
argues Dr. Singhal treated Plaintiff “several times” and that the ALJ did not give his medical
opinions significant and/or controlling weight in his determination.
Generally, a treating physician’s opinion is given at least substantial weight under the
Social Security Administration regulations. 20 C.F.R. §§ 404.1527(c), 416.927(c), see also,
Brown v. Colvin, 2014 WL 1687430 *2 (W.D. Mo. 2014). However, such an opinion “does not
automatically control or obviate the need to evaluate the record as a whole.” Brown v. Colvin,
2014 WL 1687430, at *2 (W.D. Mo. Apr. 29, 2014); citing, Brown v. Barnhart, 390 F.3d 535,
540 (8th Cir. 2004). Rather, an “ALJ may discount or disregard the opinion of a treating
physician where other medical assessments are more thoroughly supported or where a treating

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physician renders inconsistent opinions.” Id.; citing, Wildman v. Astrue, 596 F.3d 959, 964 (8th
Cir. 2010).
“In determining how much weight to accord a physician’s opinion, the ALJ must take
into account a variety of considerations including: whether the opinion is supported with facts
and evidence; whether the opinion is consistent with other evidence and opinions, including the
physician’s own notes; and whether the physician’s specialty gives her greater credibility.” Id,
citing, 20 C.F.R. §§ 404.1527(c), 416.927(c); and Renstrom v. Astrue, 680 F.3d 1057, 1065 (8th
Cir. 2012).
Here, Dr. Singhal saw Plaintiff twice in 2012 – on August 24, 2012 he saw her for
complaints of depression and on October 22, 2012 he saw her for complaints of migraines. Tr. at
390-91, 531-32. On October 22, 2012, during Plaintiff’s second visit, Dr. Singhal completed a
“Medical Source Statement – Physical.” Tr. at 400-01. This form states, in part, Plaintiff is
limited to lifting or carrying 5 lbs; can stand and/or walk continuously (without a break) for 30
minutes; and can stand and/or walk throughout an 8 hour day (with usual breaks) for 4 hours. Id.
The ALJ discounted the opinion given by Dr. Singhal after Plaintiff’s testimony
completely contradicted the records. For example, Dr. Singhal’s form states Plaintiff could not
lift any more than 5 pounds but Plaintiff testified she could lift 25 pounds. Tr. at 20, 40, 207,
400. Further, Plaintiff testified she could walk a mile and Dr. Singhal’s records reflect Plaintiff
had knee problems.1 However, Dr. Singhal’s initial records also reflect that Plaintiff did not
need any assistive device for ambulation or balance. Tr. at 401. Nonetheless, Dr. Singhal’s
medical records do not reflect any information inconsistent with the ALJ’s findings. In the

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Plaintiff argues the ALJ did not consider Dr. Singhal’s prescription for a cane that was given on
October 31, 2012. This prescription came approximately two weeks prior to the ALJ’s hearing.
However, as stated herein, Plaintiff’s own testimony was considered by the ALJ regarding any
alleged limitations and Plaintiff testified she could walk a mile along with other daily activities.
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August 24, 2012 medical records, Dr. Singhal evaluated Plaintiff for depsression, stating she
“complaints of depressed mood, difficulty concentrating fatigue and insomnia…. Onset was
approximately a few months ago.” Tr. at 390. Plaintiff was to follow up in four weeks, but no
other evaluations were given. Substantial evidence from both the medical records, and
Plaintiff’s testimony, support the ALJ’s determination.
Here, the ALJ resolved conflicts, if any, in the medical records by taking into account the
record as a whole, including Plaintiff’s own testimony. One of the ALJ’s functions is to resolve
any conflicts in the evidence. See Pearson v. Massanari, 274 F.3d 1211, 1219 (8th Cir. 2001).
Again, the Court finds the ALJ did not commit error and was in a better position than this Court
to assess Plaintiff’s credibility. Therefore, the Court finds the ALJ’s determination is supported
by substantial evidence on the record as a whole.
C. The Record Was Sufficiently Developed by the ALJ.
Finally, Plaintiff alleges the ALJ erred by not ordering a Wechsler Adult Intelligence
Scale. Plaintiff argues intelligence testing was necessary in light of Plaintiff’s educational
records and Dr. O’Neill’s examination findings. Plaintiff argues it is the ALJ’s burden to fully
and fairly develop the record.
“A disability claimant is entitled to a full and fair hearing under the Social Security Act.”
Hepp v. Astrue, 511 F.3d 798, 804 (8th Cir. 2008). As already stated herein, the ALJ’s
determination was based on the evidence in the record, including medical records, observations
of treating physicians and others, and plaintiff’s own description of her limitations. See
Krogmeier v. Barnhart, 294 F.3d 1019, 1024 (8th Cir. 2002). “The ALJ is required to order
medical examinations and tests only if the medical records presented to him do not give
sufficient medical evidence to determine whether the claimant is disabled.” Halverson v. Astrue,

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600 F.3d 922, 933 (8th Cir. 2010); citing, Barrett v. Shalala, 38 F.3d 1019, 1023 (8th Cir. 1994).
In this case, the ALJ considered the medical records, Plaintiff’s testimony, and other evidence in
making the determination Plaintiff was not entitled to disability benefits. As described above,
there was substantial evidence in the record as a whole to support the ALJ’s decision.
Further, the ALJ held that the Plaintiff did not have a mental impairment that limited the
Plaintiff’s ability to perform basic mental work activities. The ALJ found that the Plaintiff has
no limitations in her daily living, no more than a mild limitation in social functioning and a mild
limitation in concentration, persistence or pace. Plaintiff’s global assessment of functioning
scale reflected “serious symptoms” but the ALJ gave the GAF score little weight based on the
Plaintiff’s longitudinal medical record and additional evidence. Tr. at 13, 14, and 19.
While the Plaintiff has the burden to prove a disability, 20 C.F.R. § 404.1512, the ALJ
has the duty to develop a complete record. However, the ALJ has discretion in development of
the record, and as previously stated, this Court’s standard of review is whether the ALJ’s
determination is supported by substantial evidence on the record as a whole. As long as the
record contains enough evidence to support the determination, the ALJ is not required to seek
additional evidence. See Tellez v. Barnhart, 403 F.3d 953, 956-57 (8th Cir. 2005)(“there is no
indication that the ALJ felt unable to make the assessment he did and his conclusion is supported
by substantial evidence” therefore, there is no evidence further development of the record was
necessary.); see also Haley v. Massanari, 258 F.3d 742, 749-50 (8th Cir. 2001). If additional
evidence is necessary for the ALJ to make an informed decision than he must ensure the record
is fully developed. Haley, 258 F.3d at 749. However, when there is substantial evidence in the
record to allow the ALJ to make an informed decision no further evidence is necessary. Id.

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Here, the ALJ had sufficient evidence to make an informed decision. There was
insufficient evidence of any alleged mental limitations to find a disability. The ALJ had
evidence from Dr. O’Neill, Psy.D regarding a consultative psychological examination on
October 4, 2011.2 Tr. at 326-328. Further, the ALJ took into account the medical records
(which did not state any mental impairments), Plaintiff’s own testimony, and the fact that
Plaintiff had not previously alleged disability due to mental impairments. Tr. at 15, 73, and 168.
There is no evidence that the ALJ’s determination was not fully and fairly developed in the
record. Therefore, this Court again finds the ALJ’s Determination is supported by substantial
evidence in the record.
CONCLUSION
For the reasons set forth herein, there is substantial evidence on the record as a whole to
support the ALJ’s determination, and the Commissioner’s decision denying benefits is
AFFIRMED.

IT IS SO ORDERED.
DATED:

February 20, 2015
/s/ Douglas Harpool ________________
DOUGLAS HARPOOL
UNITED STATES DISTRICT JUDGE

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The Court notes that in Plaintiff’s October 2011 psychological exam, Plaintiff stated she “calms
down by walking alone for 1-2 hours.” Tr. at 326.
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