Daniels v. Colvin

Filing 37

ORDER granting 32 Motion for Judgment on the Pleadings and denying 27 Motion for Judgment on the Pleadings. Signed by District Judge Terrence W. Boyle on 5/3/2016. (Romine, L.)

IN THE UNITED STATES DISTRICT COURT
FOR THE EASTERN DISTRICT OF NORTH CAROLINA
WESTERN DIVISION
No. 5:15-CV-118-BO

MACLOLM DANIELS,
Plaintiff,
V.

CAROLYN W. COLVIN,
Acting Commissioner ofSocial Security,
Defendant.

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ORDER

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 April 6, 2015, at Raleigh, North
Carolina.

For the reasons discussed below, the decision of the Commissioner is reversed and

this matter is remanded for an award ofbenefits.
BACKGROUND
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 his claim for disability and disability insurance
benefits (DIB) pursuant to Title II of the Social Security Act.

Plaintiff filed for DIB on

December 28, 2011, alleging disability since November 1, 2010. After initial denials, a hearing
was held before an Administrative Law Judge (ALJ) who issued an unfavorable ruling. The
decision of the ALJ became the final decision of the Commissioner when the Appeals Council
denied plaintiff's request for review. Plaintiff then timely sought review of the Commissioner's
decision in this Court.

DISCUSSION
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
citation omitted).
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.F.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.

§ 416.920(a)(4).
At step one, the ALJ determined that plaintiff met the insured status requirements and
had not engaged in substantial gainful activity since his alleged onset date.

Plaintiffs

osteoarthritic changes of the cervical spine with stenosis, cervical spondylosis, and right knee
osteoarthritis were considered severe impairments at step two but were not found alone or in
combination to meet or equal a Listing at step three. The ALJ concluded that plaintiffs RFC
would allow him to perform a wide range of light work. The ALJ found that plaintiff could not
return to his past relevant work, but that, considering plaintiffs age, education, work experience,
and RFC, there were other jobs that existed 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 her decision.

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Substantial evidence does not support the ALJ' s finding that plaintiff could perform light
work. 1 An ALJ makes an RFC assessment based on all of the relevant medical and other
evidence. 20 C.F.R. § 404.1545(a)(3). Light work requires a claimant to be able to lift no more
than twenty pounds at a time with frequent lifting or carrying of objects up to ten pounds. 20
C.F.R. § 404.1567(b). Light work also requires either a good deal ofwalking or standing, or
sitting most of the time with some pushing and pulling of controls. !d.
Plaintiff has a history of knee pain and in July 2010 suffered an exacerbating injury to his
knees while at work. Tr. 337. After conservative treatments, including arthroscopic surgery [Tr.
31 0], failed, plaintiff underwent a total left knee replacement in April 2011. Tr. 756-7. Plaintiff
sustained a MRSA infection following surgery and was treated extensively with antibiotics and
draining treatments. See, e.g. Tr. 349. Plaintiffs treating orthopedist, Dr. Ruark, opined in
December 2011 that plaintiff could walk for no more than ten minutes at a time, stand for no
more than thirty minutes, and could stand and walk for no more than an hour total each day. Tr.
709. In March 2012 plaintiff complained to his primary care physician Dr. Diaz of worsening
left knee pain and swelling. Tr. 411. In August 2012, Dr. Ruark found that the "end result of
[plaintiffs] surgery has not been great" and that he did not expect significant improvement. Tr.
723. Dr. Ruark prescribed a cane, recommended symptomatic treatment, and restricted plaintiff
to lifting less than forty pounds as well as from climbing, kneeling, and squatting. Tr. 721-24.
In February 2013, plaintiff continued to report eight-out-of-ten to ten-out-of-ten pain related to
his knee, neck, and hips. Tr. 744.
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The ALJ also erred by failing to consider plaintiffs left knee pain a severe impairment. In
declining to do so, the ALJ noted that plaintiffs MRSA infection had resolved and that the
condition did not persist for more than one year. Tr. 104. The record is replete with plaintiffs
complaints related to his left knee after his total knee replacement surgery and subsequent
infection. However, because the ALJ did consider plaintiffs left knee pain when formulating
plaintiffs RFC, this error is not the basis for reversal.
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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 if there 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). The ALJ failed to consider Dr. Ruark's

standing and walking limitations which are consistent with sedentary work. 20 C.F.R. §
404.1567(a). Defendant suggests that the error was harmless because Dr. Ruark also noted that
plaintiff could return to "light duty" work, which is inconsistent with his standing and walking
limitations that suggest sedentary work. Whether a claimant can perform light work as that term
is defined by the Social Security Administration is, however, a decision reserved to the
Commissioner and not to be afforded any special significance when opined upon in a medical
source opinion. SSR 96-5p. Defendant further contends that Dr. Ruark's 2011 opinion is
inconsistent with his 2012 opinion which limited plaintiff to lifting less than forty pounds. Dr.
Ruark's 2012 opinion does not address plaintiffs ability to stand and walk, nor does it opine
about the frequency with which plaintiff would be able to lift any weight or expressly amend his
prior opinion regarding plaintiffs exertionallimitations.
In further support of a limitation to sedentary work are the opinions of state medical
consultants Drs. Hartman and Leigh who assessed plaintiff at the initial level with a restriction to
not more than four hours of standing and walking per day. Tr. 60-70. A Disability
Determination Services (DDS) examiner noted that such limitation significantly erodes the
occupational base and is appropriately classified as sedentary. Tr. 59, 70. The ALJ afforded the
opinions of Drs. Hartman and Leigh significant weight. Tr. 111. Although the ALJ was not
bound by the DDS examiner's decision regarding the effect of the erosion of the occupational

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base, see SSR 83-12, it can be properly considered as not in conflict with the opinion of Dr.
Ruark, plaintiffs treating physician.
Dr. Ruark's limitations are further supported by plaintiffs testimony. The ALJ found
plaintiffs allegations of left knee pain to be less than credible because his MRSA infection had
resolved. Tr. 112. Such conclusion is an erroneous exercise of"expertise [s]he did not possess
inthefieldoforthopedicmedicine." Wilsonv. Heckler, 743 F.2d218,221 (4thCir.1984).
Indeed, the record supports that plaintiff continued to complain of pain well-after the infection
had resolved, and none of plaintiffs treating providers suggested that his complaints were
imagined because the MRSA infection had resolved. Plaintiffs activities of daily living do not
suggest that he is capable of work beyond the sedentary level. Plaintiff testified that he could
stand for two hours out of an eight hour day, Tr. 42, that he spends six hours a day watching
television, Tr. 22, and that he plays video games with friends. Tr. 23.
Affording the proper weight to the opinion of Dr. Ruark and to plaintiffs testimony
results in a limitation to sedentary work, and there is no persuasive evidence to the contrary.
Due to plaintiffs age and other factors, an RFC of sedentary work would result in a finding of
disability under Grid Rule 201.14. 20 C.P.R. Pt. 404, Subpart P., App. 2 § 202.14.

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,

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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." Radford v. 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. The ALJ has adequately explained her reasoning but the record
before this Court properly supports a finding that plaintiff is limited to sedentary work. Because
the Medical Vocational Rules direct a finding of disability, there is no benefit to be gained from
remanding this matter for further consideration and reversal is appropriate.
CONCLUSION
For the foregoing reasons, plaintiffs motion for judgment on the pleadings [DE 27] is
GRANTED and defendant's motion for judgment on the pleadings [DE 32] is DENIED. The
decision of the ALJ is REVERSED and this matter is REMANDED to the Commissioner for an
award of benefits.

SO ORDERED, this~

day

of/'1

r-016.
RRENCE W. BOYLE
UNITED STATES DISTRI

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