Robinson v. Colvin
ORDER GRANTING 20 Plaintiff's Motion for Judgment on the Pleadings, and DENYING 23 Defendant's Motion for Judgment on the Pleadings. The decision of the Administrative Law Judge is reversed and this matter is remanded to the Commissioner for an award of benefits. Signed by US District Judge Terrence W. Boyle on 7/10/2014. (Fisher, M.)
IN THE UNITED STATES DISTRICT COURT
FOR THE EASTERN DISTRICT OF NORTH CAROLINA
DONNA LYNN ROBINSON,
CAROLYN W. COL YIN,
Acting Commissioner ofSocial Security,
This cause comes before the Court on cross-motions for judgment on the pleadings. A
hearing was held on these matters before the undersigned on July 2, 2014, at Raleigh, North
Carolina. For the reasons discussed below, the decision of the Commissioner is reversed.
Plaintiff brought this action under 42 U.S.C. §§ 405(g) and 1383(c)(3) for review of the
final decision of the Commissioner denying her claim for disability and disability insurance
benefits (DIB) and supplemental security income (SSI) pursuant to Titles II and XVI of the
Social Security Act. Plaintiff filed for DIB and SSI on June 4, 2009, alleging disability since
September 30, 2006. After initial denials, a hearing was held before an Administrative Law
Judge (ALJ) who then issued an unfavorable ruling. The decision of the ALJ became the final
decision of the Commissioner when the Appeals Council denied plaintiffs request for review.
Plaintiff then timely sought review of the Commissioner's decision in this Court.
Under the Social Security Act, 42 U.S.C. § 405(g), and 1383(c)(3), this Court's review of
the Commissioner's decision is limited to determining whether the decision, as a whole, is
supported by substantial evidence and whether the Commissioner employed the correct legal
standard. Richardson v. Perales, 402 U.S. 389, 401 (1971).
Substantial evidence is "such
relevant evidence as a reasonable mind might accept as adequate to support a conclusion."
Johnson v. Barnhart, 434 F.3d 650, 653 (4th Cir. 2005) (per curiam) (internal quotation and
An individual is considered disabled if he is unable "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." 42 U.S.C. § 1382c(a)(3)(A). The Act further provides that an
individual "shall be determined to be under a disability only if his physical or mental impairment
or 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 line of substantial
gainful work which exists in the national economy." 42 U.S.C. § 1382c(a)(3)(B).
Regulations issued by the Commissioner establish a five-step sequential evaluation
process to be followed in a disability case. 20 C.F.R. §§ 404.1520(a)(4), 416.920(a)(4). The
claimant bears the burden of proof at steps one through four, but the burden shifts to the
Commissioner at step five. See Bowen v. Yuckert, 482 U.S. 137, 146 n.5 (1987). If a decision
regarding disability can be made at any step of the process, however, the inquiry ceases. See 20
C.F.R. §§ 404.1520(a)(4), 416.920(a)(4).
At step one, if the Social Security Administration determines that the claimant is
currently engaged in substantial gainful activity, the claim is denied. If not, then step two asks
whether the claimant has a severe impairment or combination of impairments. If the claimant
has a severe impairment, it is compared at step three to those in the Listing of Impairments
("Listing") in 20 C.P.R. Pt. 404, Subpt. P, App. 1.
If the claimant's impairment meets or
medically equals a Listing, disability is conclusively presumed.
If not, at step four, the
claimant's residual functional capacity (RFC) is assessed to determine if the claimant can
perform his past relevant work. If so, the claim is denied. If the claimant cannot perform past
relevant work, then the burden shifts to the Commissioner at step five to show that the claimant,
based on his age, education, work experience, and RFC, can perform other substantial gainful
work. If the claimant cannot perform other work, then he is found to be disabled. See 20 C.F .R.
At step one, the ALJ determined that plaintiff met the insured status requirements and
had not engaged in substantial gainful activity since her alleged onset date.
degenerative disc disease of the lumbar spine, cervical/neck pain, obesity, history of right-sided
Bell's palsy, status-post open reduction and internal fixation of the left wrist, status-post right
ankle fracture, right knee pain due to history of torn ligament, chronic pain syndrome, mood
disorder, post-traumatic stress disorder (PTSD), and substance abuse were considered severe
impairments at step two but were not found alone or in combination to meet or equal a listing at
step three. After finding plaintiffs statements not entirely credible, the ALJ concluded that
plaintiff could perform a greatly reduced range of light work and that she could return to her past
The ALJ then made an alternative finding that, considering plaintiffs age,
education, work experience, and RFC, there were other jobs that exist in significant numbers in
the national economy that plaintiff could perform. Thus, the ALJ determined that plaintiff was
not disabled as of the date of his opinion.
An ALJ makes an RFC assessment based on all of the relevant medical and other
evidence. 20 C.F.R. § 404.1545(a)(3). In determining plaintiff's RFC, the ALJ considered the
opinions of several of plaintiff's physicians. The opinion of a treating physician must be given
controlling weight if it is not inconsistent with substantial evidence in the record and may be
disregarded only ifthere is persuasive contradictory evidence. Coffman v. Bowen, 829 F .2d 514,
517 (4th Cir. 1987); Mitchell v. Schweiker, 699 F.2d 185 (4th Cir. 1983). Even if a treating
physician's opinion is not entitled to controlling weight, it still may be entitled to the greatest of
weight. SSR 96-2p. An ALJ must provide specific reasons for the weight given to a treating
physician's opinion. Id.
In August 2011, plaintiff's treating neurologist provided a detailed opinion regarding
plaintiff's medical impairments, ultimately opining that plaintiff was disabled. Tr. 388-390. The
ALJ gave little weight to this opinion, however, finding that it was based primarily on plaintiff's
subjective complaints and was not consistent with the neurologist's, Dr. Cook's, own treatment
notes. Tr. 22. In his opinion, Dr. Cook notes that he has followed plaintiff for almost two years
regarding several complex pain complaints. His opinion thoroughly discusses each of plaintiff's
underlying injuries and, while the ALJ correctly notes that Dr. Cook may have lacked first-hand
information about plaintiff's knee and ankle complaints in that he himself did not initially treat
plaintiff for these injuries, his opinion makes clear that it is based on his history of managing
plaintiff's overall pain picture, not merely on review of the records in plaintiff's medical history.
While the ALJ further relies on the fact that Dr. Cook had found normal strength, sensation, and
reflexes on exam in order to discount Dr. Cook's opinion, the ALJ does not explain why such
findings would necessarily negate Dr. Cook's assessments regarding plaintiff's pain.
example, Dr. Cook notes that plaintiff continues to experience migraine headaches on a regular
basis, and that while her headaches are helped with medication, the medication causes plaintiffto
not be able to participate in routine activities due to residual malaise.
The ALI's reliance on
normal strength and reflexes to discount Dr. Cook's opinion would have no bearing on plaintiffs
limitations due to migraine headaches.
Additionally, though the ALJ failed to consider
plaintiffs migraines when determining which of her impairments were severe at step two, the
evidence of migraines in the record was still required to be considered when formulating
plaintiffs RFC. 20 C.F.R. § 1545(a)(2). 1
Also in August 2011, plaintiffs treating therapist submitted an opinion statement
regarding plaintiffs mental health limitations. Tr. 382-387. The ALJ afforded this opinion little
weight as it was provided by a licensed clinical social worker, not a psychologist or psychiatrist,
and because her opinion was inconsistent with her treatment notes.
Licensed clinical social
workers are medical sources who do not fall within the Commissioner's list of acceptable
medical sources. See 20 C.F.R. § 404.1513(d) and § 416.913; SSR 06-03p. Social Security
Ruling (SSR) 06-03p clarifies how the Commissioner is to consider the opinions of providers
who are not considered acceptable medical sources. Specifically, the opinions of non-acceptable
medical sources, who often have "close contact with . . . individuals and have personal
knowledge and expertise to make judgments about their impairment(s), activities, and level of
functioning over a period of time," are to be considered as "valuable sources of evidence for
assessing impairment severity and functioning." SSR 06-03p. Additionally, depending on the
As plaintiff correctly notes in reply to defendant's response, evidence of migraines and other
headaches does not normally or necessarily appear on standard imaging tests, and thus there will
often be no "objective" evidence of migraine headaches. See e.g. Duncan v. Astrue, No. 4:06CV-230-FL, 2008 WL 111158 *7 (E.D.N.C. Jan. 8, 2008) (noting that migraine headaches are a
condition that cannot be diagnosed or confirmed through laboratory or diagnostic testing and
listing cases holding same).
facts of a particular case, "an opinion from a medical source who is not an 'acceptable medical
source' may outweigh the opinion of an acceptable medical source, including the medical
opinion of a treating source." !d.
Plaintiff's therapist notes in her assessment that plaintiff has a substantial loss of ability
m making judgments commensurate with unskilled work and responding appropriately to
supervisors, co-workers, and routine work situations. This opinion was based on a longitudinal
assessment of her mental health treatment of plaintiff. This is precisely the kind of treatment
information contemplated by SSR 06-03p when the Administration stated that such nonacceptable sources are to be considered as valuable sources of evidence. That one consultative
physician opined after a single visit that plaintiff did not appear depressed is inconsistent with
the weight of the medical evidence and an improper basis upon which to disregard the opinion of
plaintiff's therapist. Another consultative examiner, whose opinion was provided before the
alleged onset date, noted that plaintiff exhibited severe emotional lability. Tr. 250.
Ultimately, the question for this Court is whether substantial evidence supports the ALI's
finding that plaintiff could either return to her past work or perform work in the national
economy on a regular and consistent basis.
In light of the opinions of plaintiff's treating
physician and therapist, which are not contradicted by the longitudinal record or the objective
medical evidence in this case, the Court holds that the ALJ' s finding is unsupported. To the
contrary, the record supports a finding that the combination of plaintiff's physical and mental
impairments, as well as her pain, would result in her being able to perform work at a less than
Additionally, a finding that the Commissioner has satisfied her burden at step five
requires not only a finding that a claimant can perform a job, but also a finding that the claimant
can "hold whatever job he finds for a significant period of time." Singletary v. Bowen, 798 F.2d
818, 822 (5th Cir. 1986) (emphasis in original). The treating physician opinions in this case,
which are entitled to great even if not controlling weight, and the record simply do not support
such a conclusion.
Reversal for Award of Benefits
The decision of whether to reverse and remand for benefits or reverse and remand for a
new hearing is one that "lies within the sound discretion of the district court." Edwards v.
Bowen, 672 F. Supp. 230,237 (E.D.N.C. 1987); see also Evans v. Heckler, 734 F.2d 1012, 1015
(4th Cir. 1984). When "[ o]n the state of the record, [plaintiffs] entitlement to benefits is wholly
established," reversal for award of benefits rather than remand is appropriate. Crider v. Harris,
624 F.2d 15, 17 (4th Cir. 1980). The Fourth Circuit has held that it is appropriate for a federal
court to "reverse without remanding where the record does not contain substantial evidence to
support a decision denying coverage under the correct legal standard and when reopening the
record for more evidence would serve no purpose." Breeden v. Weinberger, 493 F.2d 1002,
1012 (4th Cir. 1974). Remand, rather than reversal, is required when the ALJ fails to explain his
reasoning and there is ambivalence in the medical record, precluding a court from "meaningful
review." Radfordv. Colvin, 734 F.3d 288,296 (4th Cir. 2013).
The Court in its discretion finds that reversal and remand for an award of benefits is
appropriate in this instance as the ALJ has clearly explained his basis for rejecting treating
source opinions that would otherwise be entitled to controlling or great weight, though his
rationale for doing so was flawed. In light of the longitudinal record and the nature of plaintiffs
impairments the Court finds that no benefit would be gained from remanding this matter for
Plaintiffs motion for judgment on the pleadings [DE 20] is GRANTED and defendant's
motion for judgment on the pleadings [DE 23] is DENIED. The decision of the ALJ is
REVERSED and this matter is REMANDED to the Acting Commissioner for an award of
SO ORDERED, this
day of July, 2014.
ERRENCE w. BOYLE
UNITED STATES DISTRI
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