MCCRACKEN v. COMMISSIONER OF SOCIAL SECURITY

Filing 21

OPINION. Signed by Judge Claire C. Cecchi on 3/28/2019. (sms)

NOT FOR PUBLICATION
UNITED STATES DISTRICT COURT
DISTRICT OF NEW JERSEY

ANDREW A. McCRACKEN,

Civil Action No.: 17-cv-6701

Plaintiff,
OPINION
V.

COMISSIONER OF SOCIAL SECURITY,
Defendant.
CECCHI, District Judge.
I.

INTRODUCTION

Before the Court is Plaintiff Andrew A. McCracken’s appeal seeking review of a final
determination by the Commissioner of the Social Security Administration (“Commissioner” or
“Defendant”) denying his application for Disability Insurance Benefits (“DIB”) pursuant to Title
II of the Social Security Act (“SSA” or the “Act”). This matter is decided without oral argument
pursuant to Federal Rule of Civil Procedure 78. For the reasons set forth below, the decision of
the Administrative Law Judge (“ALl”) is vacated and the case is remanded for further
administrative proceedings.
II.
A.

BACKGROUND

Factual Background

Plaintiff, an adult male, was born on July 6, 1960. (Tr. at 29).’ Plaintiff is a college
graduate, and has previously worked as a computer systems maintenance administrator. (Id. at

‘“Tr.” refers to the certified record of the administrative proceedings. (ECF No. 8).

39). Plaintiff testified that he suffers from mental illnesses that make him unable to adapt to
change. (Id. at 43). Plaintiff further testified that he suffers from social anxiety that makes it
difficult for him to interact with people. (Id). Plaintiff alleged that as a result of his condition he
has been unable to work since August 2012. (Id. at 41). Plaintiff reports that his difficulties with
attention and social interaction previously caused him to be fired from at least one job. (Id. at 43).
Plaintiff further stated that he is depressed and often does not want to get out of bed. (Id. at 45).
Additionally, Plaintiff represented that he has lost interest in his usual activities, (Id. at 46), that
his ability to receive information from others is impaired, (Id), and that he is frequently unable to
finish tasks that he begins. (Id. at 4$). finally, Plaintiffs wife is disabled, and he testified that he
provides her care at home. (Id. at 47-4$).
B.

Procedural Background

On April 10, 2014, Plaintiff filed an application for a period of disability and DIB pursuant
to Title II of the SSA. (Id. at 154). On July 25, 2014, Plaintiffs application was initially denied.
(Id. at 66). On October 23, 2014, Plaintiffs application was once again denied on reconsideration.
(Id. at 7$). Plaintiff requested an AU hearing, and such hearing was conducted on November 23,
2016. (Id. at 35-65). On February 7, 2017, the AU issued his opinion concluding that Plaintiff
was not disabled within the meaning of the $$A at any point from his alleged onset date of August
30, 2012 through the date of the decision. (Id. at 19-30). Plaintiff next sought review by the
Appeals Council, which denied review on July 6, 2017. (Id. at I). Thereafter, Plaintiff instituted
this action seeking judicial review of the AU decision.

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III.
A.

LEGAL STANDARD

Standard of Review

This Court has jurisdiction to review the Commissioner’s decision under 42 U.s.c.

§ 405(g)

and 1383(c)(3). The Court is not “permitted to re-weigh the evidence or impose [itsi

own factual determinations,” but must give deference to the administrative findings. Chandler v.
Comm ‘r ofSoc. Sec., 667 F.3d 356, 359 (3d Cir. 201 1); see also 42 U.S.C.

§ 405(g).

Nevertheless,

the Court must “scrutinize the record as a whole to determine whether the conclusions reached are
rational” and supported by substantial evidence. Gober v. Matthews, 574 F.2d 772, 776 (3d Cir.
197$) (citations omitted). Substantial evidence is more than a mere scintilla, and is “such relevant
evidence as a reasonable mind might accept as adequate to support a conclusion.” Chandler, 667
F.3d at 359 (citing Richardson v. Perales, 402 U.S. 389, 401 (1971)). If the factual record is
adequately developed, substantial evidence “may be ‘something less than the weight of the
evidence, and the possibility of drawing two inconsistent conclusions from the evidence does not
prevent an administrative agency’s finding from being supported by substantial evidence.”
Daniels v. Astrue, No. 08-1676, 2009 WL 1011587, at *2 (M.D. Pa. Apr. 15, 2009) (quoting
Consolo v. Fed. Mar. Comm ‘ii, 383 U.S. 607, 620 (1966)). In other words, under this deferential
standard of review, the Court may not set aside the AU’s decision merely because it would have
come to a different conclusion. Cruz v. Comm ‘r ofSoc. Sec., 244 F. App’x 475, 479 (3d Cir. 2007)
(citing Hartranft v. Apfel, 181 F.3d 358, 360 (3d Cir. 1999)).
B.

Determining Disability

In order to be eligible for benefits under the SSA, a plaintiff must show he is disabled by
demonstrating an 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

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lasted or can be expected to last for a continuous period of not less than twelve months.” 42 U.S.C.

§

423(d)(1)(A), 1382c(a)(3)(A). Taking into account the plaintiffs age, education, and work

experience, disability will be evaluated by the plaintiffs ability to engage in his previous work or
any other form of substantial gainful activity existing in the national economy.

§ 423(d)(2)(A),

42 U.S.C.

l3$2c(a)(3)(B). A person is disabled for $SA purposes only if his physical or

mental impairments are “of such severity that he is not only unable to do his previous work, but
cannot, considering his age, education, and work experience, engage in any other kind of
substantial gainful work which exists in the national economy

.

.

.

.“

42 U.S.C.

§

1382c(a)(3)(B).

Decisions regarding disability will be made individually and will be “based on evidence
adduced at a hearing.” Sykes v. Apfel, 228 f.3d 259, 262 (3d Cir. 2000) (citing Heckler v.
Campbell, 461 U.S. 458, 467 (1983)). Congress has established the type of evidence necessary to
prove the existence of a disabling impairment by defining a physical or mental impairment as “an
impairment that results from anatomical, physiological, or psychological abnormalities which are
demonstrable by medically acceptable clinical and laboratory diagnostic techniques.” 42 U.S.C.

§ 423(d)(3),
C.

1382(a)(3)(D).
Sequential Evaluation Process

The Social Security Administration follows a five-step, sequential evaluation to determine
whether a plaintiff is disabled within the meaning of the statute. 20 C.F.R.

§ 404.1520. 416.920.

first, the AU must determine whether the plaintiff is currently engaged in gainful activity. Sykes,
228 f.3d at 262. Second, if he is not, the AU determines whether the Plaintiff has an impairment
that limits his ability to work. Id. Third, if he has such an impairment, the AU considers the
medical evidence to determine whether the impairment is listed in 20 C.F.R. Part 404, Subpart P.
Appendix 1 (the “Listings”). If it is, this results in a presumption of disability. Id.

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If the

impairment is not in the Listings, the AU must determine how much residual functional capacity
(“RFC”) the applicant retains in spite of his impairment. Id. at 263. fourth, the AU must consider
whether the plaintiffs RFC is enough to perform his past relevant work. Id. Fifth, if his RFC is
not enough, the AU must determine whether there is other work in the national economy the
plaintiff can perform. Id.
The evaluation continues through each step unless it is determined at any point the plaintiff
is or is not disabled. 20 C.F.R.

§

404.1520(a)(4), 416.920(a)(4). The plaintiff bears the burden

of proof at steps one, two, and four, upon which the burden shifts to the Commissioner at step five.
Sykes, 228 f.3d at 263. Neither party bears the burden at step three. Id. at 263 n.2.
IV.
A.

DISCUSSION

Summary of the AU decision.

At step one, the AU found that Plaintiff had not engaged in substantial gainful activity
between August 30, 2012, Plaintiffs alleged onset date, and June 30, 2016, Plaintiffs last insured
date. (Tr. at 21). At step two, the AU found that Plaintiff suffered from six severe impairments:
bipolar disorder, depressive disorder, anxiety disorder, post-traumatic stress disorder, personality
disorder, and attention deficit hyperactivity disorder (“ADHD”). (Id.). However, at step three, the
AU found that Plaintiff did not have an impairment or combination of impairments that met or
medically equaled the severity of a listed impairment. (Id. at 22).
In reviewing Plaintiffs claims, the AU considered the medical evidence of record. Of
particular note, the AU considered the opinion of Mehr Iqbal, M.D., a psychiatrist at Bergen
Regional Medical Center who treated Plaintiff. On October 23, 2014, Dr. lqbal completed a mental
health assessment of Plaintiff and concluded, based on her treatment of Plaintiff between .1 uly and
October 2014, that Plaintiff suffered from “a persistent and irrational fear of a specific object.

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activity, or situation, which results in a compelling desire to avoid the dreaded object, activity, or
situation” and “[r]ecurrant intrusive recollections of a traumatic experience, which are a source of
marked distress[.]” (Id. at 307). further, Dr. Iqbal indicated that Plaintiff suffered moderate
restrictions of daily living, marked difficulties maintaining social functioning, and marked
difficulties maintaining concentration, persistence, or pace. (Id. at 308). Although the above
indications were made by check-box, Dr. Iqbal also opined by hand-written notation that Plaintiff
was “unable to manage his affairs without [illegible] help.

.

.

he has limited social [and] cognitive

ability.” (Id.). Finally, Dr. Iqbal indicated that Plaintiffs condition was expected to last for at
least one year. (Id.).
Upon consideration of Plaintiffs RFC, the AU reviewed Dr. Iqbal’s opinion, but did not
provide it with conclusive weight. The AU indicated that Dr. Iqbal’s opinion was afforded
“[s]ome weight,” in consideration of the fact that Dr. Iqbal was Plaintiffs treating psychiatrist.
(Id. at 2$). However, the AU concluded that portions of Dr. Iqbal’s opinion were inconsistent
with the remainder of the record. (Id.). Having afforded limited weight to Dr. Iqbal’s conclusions,
the AU relied upon other evidence in reaching his RFC conclusion. In particular, the AU afforded
“substantial weight” to two State agency consultants, who each concluded that Plaintiff was not
disabled and could perform simple, unskilled work. (Id. at 28-29). The AU then found that
Plaintiff retained the RFC to perform medium work as defined by 20 CFR

§

404.1567(c), with

additional non-exertional limitations. (Id. at 23).
At step four, the AU found that through the last date insured, Plaintiff was unable to
perform any past relevant work. (Id. at 28). At step five, the AU found that considering Plaintiffs
age, education, work experience, and RFC, there were jobs that existed in significant numbers in
the national economy that Plaintiff could have performed. (Id. at 29). Thus, the AU concluded

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that Plaintiff was not disabled, within the meaning of the SSA. at any point from the alleged onset
date through Plaintiff’s date last insured. (Id. at 30).
B.

Analysis

As noted above, the AU afforded only limited weight to Dr. Iqbal’s opinion upon
consideration of Plaintiff’s RFC. The AU remarked:
Some weight is accorded [Dr. Iqbal’s opinion] as [she] has provided the claimant
mental health treatment at Bergen Regional Medical Center. However, in
reviewing treatment records, it is reported that [Plaintiff] is stable with treatment
with no signs of psychosis, intact memory, attention and concentration. The extent
of limitations assessed as “marked” is not consistent with treatment records or
claimant’s daily activities. [Plaintiff] reported that he handles most household
chores and provides care for his physically ill wife.

(Id. at 2$) (citations omitted). Plaintiff contends that the AU’s decision regarding the appropriate
weight to be given to Dr. Iqbal’s opinion was unreasonable and insufficiently explained. He
therefore maintains that the AU’s opinion should be vacated and remanded for further
consideration of Dr. Iqbal’s opinion. (ECF No. 16 at 12-21). The Court agrees.
‘Where, as here, the record contains conflicting medical evidence, “the AU may choose
whom to credit but cannot reject evidence for no reason or for the wrong reason.” Flummer v.
Apfel, 186 f.3d 422, 429 (3d Cir. 1999) (citing Mason v. Shalala, 994 f.2d 1058, 1066 (3d Cir.
1993)). “The AU must consider all the evidence and give some reason for discounting the
evidence [Jhe rejects.” Id. (citing Stewart v. Sec’y ofl-JE. W, 714 f.2d 287, 290 (3d Cir. 1983)).
Here, the Court finds that the AU’s decision to grant only “some weight” to the opinion of Dr.
Iqbal, Plaintiff’s treating physician, was not supported by substantial evidence because the
supposedly contradictory findings cited by the AU did not actually contradict Dr. Iqbal’s opinions.
First, the AU found that Dr. Iqbal’s opinion was contradicted by Plaintiffs treatment
records. In particular, the AU noted that Plaintiff was “stable with treatment,” had “no signs of

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psychosis,” and “intact memory, attention and concentration”. (Tr. at 28). Although, among the
several hundred pages of medical records cited without specificity by the AU, there do appear
records of mental status exams noting that Plaintiff had “intact” memory, attention span, and
concentration, see e.g. (Id. at 424), no explanation of the significance of such findings is apparent
from the record. What is apparent to the Court is that these findings, without more, do not represent
substantial evidence contradicting Dr. Iqbal’s opinions because the records in which such findings
appear, read holistically, are not inconsistent with marked impairment of Plaintiffs ability to
maintain concentration in a work setting. For example, in treatment notes from Plaintiffs August,
12, 2015 appointment, alongside the findings that Plaintiffs concentration and attention span were
“intact,” (Id. at 28), there appears the conclusion that Plaintiffs dosage of Ritalin, a stimulant used
to treat attention disorders, should be increased based on Plaintiffs report that his ability to
concentrate diminished significantly in the afternoon. (Id. at 422). Thus, whatever the notations
about “intact” concentration span and memory may mean, the record as a whole does not support
the AU’s conclusion that they signified that Plaintiff experienced only relatively mild difficulties
with concentration, persistence, or pace. See Holohan

V.

Massanari, 246 f,3d 1195, 1205(9th

Cir. 2001) (“[The treating physician]’s statements must be read in context of the overall diagnostic
picture he draws.”).
As further evidence that Dr. Iqbal’s opinion was inconsistent with Plaintiffs treatment
records, the AU states that treating physicians noted Plaintiff to be “stable with treatment”. (Tr.
at 28). Although such remarks do appear in the record, see e.g. (Id. at 416) (noting that Plaintiffs
symptoms were “well under control” with treatment), precedent in this Circuit has established that
such general statements indicating that a patient is stable in the context of treatment are not
necessarily incompatible with either disability or a treating physician’s opinion finding disability.

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For instance, in Morales v. Apfel, the Third Circuit held that an AU improperly discounted opinion
evidence from the plaintiffs treating physician on the basis of statements similar to those relied
upon by the AU here:
[It was improper] for the AU to reject [a treating physician]’s opinion based on
[his] notation that [the plaintiff] was stable with medication. The relevant inquiry
with regard to a disability determination is whether the claimant’s condition
prevents him from engaging in substantial gainful activity. See 42 U.S.C. §
423(d)(1)(A). for a person, such as [the plaintiff], who suffers from an affective or
personality disorder marked by anxiety, the work environment is completely
different from home or a mental health clinic. [The treating physician]’s
observations that [the plaintiff] is “stable and well controlled with medication”
during treatment does not support the medical conclusion that [the plaintiff] can
return to work. [The treating physician], despite his notation, opined that [the
plaintiff]’s mental impairment rendered him markedly limited in a number of
relevant work-related activities. Other information in the treatment records supports
this opinion. Thus, [the treating physician]’s opinion that [the plaintiff]’s ability to
function is seriously impaired or nonexistent in every area related to work shall not
be supplanted by an inference gleaned from treatment records reporting on the
claimant in an environment absent of the stresses that accompany the work setting.
225 f.3d 310, 319 (3d Cir. 2000). Here, as in Morales, the AU has taken a summary statement
regarding Plaintiffs functioning in the context of the treatment environment and applied it,
inappropriately, to conclude that Plaintiff could function adequately in a work environment. Thus,
the Court finds that the AU’s conclusion that Plaintiffs treatment records were inconsistent with
Dr. Iqbal’s opinion was unreasonable.2
Second, the AU found Dr. Iqbal’s opinion to be inconsistent with reports of his daily
activities. (Tr. at 28). The AU notes that Plaintiff has reported being able to help with household
chores, do laundry, drive a car, and go grocery shopping. (Id. at 27). The AU further noted that
Plaintiff testified about caring for his physically disabled wife. (Id. at 2$). The AU refers to such

2

for the finding that Plaintiff had no signs ofpsychosis, since Plaintiff does not allege psychosis
and the AU did not find psychotic symptoms to be among Plaintiffs severe impairments, such
finding is simply irrelevant.
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activities as contradicting “the extent of limitations assessed as ‘marked” by Dr. Iqbal, (Id.);
regarding Plaintiffs restrictions of daily living, however, Dr. Iqbal merely concluded that Plaintiff
suffered “moderate” restrictions. (Id. at 30$). The AU does not explain why the record evidence
of Plaintiffs daily activities contradicts Dr. Iqbal’s findings regarding Plaintiffs limitations in
other areas where “marked” limitation was found, specifically his difficulties in maintaining social
functioning and in maintaining concentration, persistence, and pace. This omission is especially
important in light of Plaintiff s testimony about his limitations in performing housework and caring
for his wife.
For instance, the record does not reflect that the AU considered, in the context of assessing
the consistency of Dr. Iqbal’s opinion with the record, Plaintiffs testimony that he is unable to
complete many household chores because his attentional issues lead him to abandon many tasks
prior to completion. (Tr. at 4$). Nor does the record reflect consideration, in this context, of
Plaintiffs testimony that although he is able to take care of his wife, he would not be able to
perform such services for a person other than his wife because of his social difficulties. (Id.).
Because the AU does not adequately explain why reports that Plaintiff performed chores, with
limitations, and took care of his wife were inconsistent with Dr. Iqbal’s findings about limitations
in areas other than his activities of daily living, and because the AU does not appear to have
conducted a complete examination of the record, the Court cannot conclude that the AU’s decision
that the record evidence was in conflict with Dr. Iqbal’s opinion was supported by substantial
evidence. See Greco v. Berryhill, No. 16-7829, 2018 WL 6716840, at *4 (D.N.J. Dec. 20, 2018)
(remanding where the AU, upon discounting a physician’s opinion because of inconsistency with
reports of the plaintiffs daily activities, failed to conduct a full examination of the record including
the plaintiffs testimony about her limitations and related record evidence).

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Therefore, the Court cannot conclude that the AU’s decision about the appropriate level
of weight to provide to Dr. Iqbal’s opinion was rational and supported by substantial evidence.
Accordingly, the Court will remand to the AU for further consideration of Dr. lqbal’s opinion.
On remand, the AU is not required to accept Dr. Iqbal’s opinion, but must provide a rational
explanation for the level of weight he chooses to afford to it. See Plummer, 186 F.3d at 429 (“An
AU may reject a treating physician’s opinion outright only on the basis of contradictory medical
evidence, but may afford a treating physician’s opinion more or less weight depending upon the
extent to which supporting explanations are provided.”).
C.

Plaintiffs Other Arguments

Plaintiff makes other arguments as to why the AU’s decision should be remanded.
Because the Court finds that the AU’s opinion was not supported by substantial evidence, it will
remand and need not consider such arguments at this juncture.

However, the Court notes

Plaintiffs suggestion that some of his treatment records from Bergen Regional Medical Center are
missing from the record. (ECF No. 16 at 15-16). To ensure an appropriate and expeditious
resolution of this matter on remand, the parties should take care that the AU possesses a complete
record upon which he is able to render a decision based on substantial evidence.
V.

CONCLUSION

For the foregoing reasons, the Court will vacate the AUJ’s decision and remand this case
for further administrative proceedings consistent with this Opinion. An appropriate Order follows.

DATED:

°

(
CLAIRE C. CE CCIII, U.S.D.J.

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