Ladner v. Colvin
ORDER granting 20 Motion for Judgment on the Pleadings. Signed by US District Judge Terrence W. Boyle on 3/2/2017. (Stouch, L.)
IN THE UNITED STATES DISTRICT COURT
FOR THE EASTERN DISTRICT OF NORTH CAROLINA
NANCY A. BERRYHILL,
Acting Commissioner of Social Security,
This cause comes before the Court on plaintiffs motion for judgment on the pleadings.
Defendant did not file a motion for judgment on the pleadings. A hearing was held on these
matters before the undersigned on February 24, 2017, in 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 his 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 protectively filed his applications on July 11, 2012, alleging
disability beginning June 6, 2012. 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 plaintiffs
request for review. Plaintiff then timely sought review of the Commissioner's decision in this
Court. Defendant filed a motion to remand to the Commissioner which was denied by 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 ifhe istlnable "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.
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 bilateral
rotator cuff tendinopathy with history ofright rotator cuff tear and surgical repair, lumbago and
degenerative disk disease of the lumbar spine, obesity, depressive disorder, and post-traumatic
stress disorder ("PTSD") 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 plaintiff
had the RFC to perform light work with additional exertional limitations. The ALJ then found
that plaintiff was unable to return to his past relevant work as a tractor trailer truck driver, 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 under the Act.
An ALJ makes an RFC assessment based on all of the relevant medical and other
evidence. 20 C.F.R. § 404.1545(a). An RFC should reflect the most that a claimant can do,
despite the claimant's limitations. Id. An RFC finding should also reflect the claimant's ability to
perform sustained work-related activities in a work setting on regular and continuing basis,
meaning eight-hours per day, five days per week. SSR 96-8p; Hines v. Barnhart, 453 F.3d 559,
562 (4th Cir. 2006). The ALJ must "explain how any material inconsistencies or ambiguities in
the evidence in the case record were considered and resolved." SSR 96-8p. If an opinion from a
treating source is well-supported by and consistent with the objective medical evidence in the
record, it may be entitled to controlling weight. 20 C.F.R. §§ 404.1527(c), 416.927(c). Where an
opinion is inconsistent with other evidence in the record, the ALJ need not give that opinion any
significant weight. Id.; see also Craig v. Chafer, 76 F.3d at 585, 590 (4th Cir. 1996) ("[I]f a
physician's opinion is not supported by clinical evidence or if it is inconsistent with other
substantial evidence, it should be accorded significantly less weight."). However, ALJ's decision
to do so must be accompanied by "a narrative discussion" that discusses "how the evidence
supports each conclusion," such that the ALJ's decision is sufficiently specific to make it clear to
a reviewing district court "why the opinion was not adopted." See SSR 96-8p.
The ALJ's decision in this instance is not supported by substantial evidence. The ALJ
found plaintiff capable of light work with the following limitations: that plaintiff can never climb
ladders, ropes and scaffolds; can occasionally climb ramps and stairs, stoop and crouch; can
frequently balance, kneel and crawl; can occasionally reach overhead with both arms; is limited
to simple, repetitive tasks in a low-stress job, defined as having only occasional changes in work
setting; and can have occasional interaction with his coworkers, but should have no interaction
with the public. Tr. 19. This conclusion is not supported by the record.
In this case, numerous medical opinions were submitted including two opinions rendered
by SSA's own consultative examiners ("CE"). Every one of them found plaintiff more
functionally restricted than the ALJ found in her decision. Instead of weighing this evidence, the
ALJ rejected each and every opinion. Though an ALJ is entitled to resolve inconsistencies
between examining medical opinions, SSR 96-8p, 1996 WL 374184, at *7, the ALJ's decision
must be supported by substantial evidence, and must adequately address the opinions of treating
and consulting physicians and properly explain deviancies between her opinion and the record
Dr. Newsam found in January of 2012 that the number of hours plaintiff could stand in an
eight hour workday was less than one hour. Dr. Newsam also found that the number of hours
plaintiff could walk in an eight hour workday was expected to be less than two hours. Plaintiff
could sit approximately two hours in an eight hour work day, and he could lift and carry fifteen
pounds occasionally and frequently. Frequent manipulation and only infrequent bending,
stooping, crouching or squatting was advised. There was no need for an assistive device. Tr. 980.
The ALJ rejected Dr. Newsam's opinion on the grounds that it was inconsistent with her
exam findings which "showed no objective or clinical deficits of function and only some reports
of pain on palpation." Tr. 25. However, Dr. Newsam's opinion was based on based upon
objective medical conditions known to result in the pain from which plaintiff suffers and Dr.
Newsam was aware of this when she rendered her opinion. Additionally, the record evidence
clearly shows an extensive history of surgery and unmanageable pain as noted by several treating
physicians and which was based on plaintiffs objectively verifiable shoulder and spinal
pathologies. As the Court noted in Mascio, "a claimant's pain and residual functional capacity
are not separate assessments to be compared with each other. Rather, an ALJ is required to
consider a claimant's pain as part of his analysis of residual functional capacity." Mascio v.
Colvin, 780 F.3d 632, 639 (4th Cir. 2015). In evaluating a claimant's subjective complaints of
pain, the ALJ is not to require objective clinical evidence of the existence and intensity of such
pain. Instead, once a claimant has "met [his] threshold obligation of showing by objective
medical evidence a condition reasonably likely to cause the pain claimed," the claimant is then
"entitled to rely exclusively on subjective evidence to prove the second part of the test, i.e., that
[his] pain is so continuous and/or so severe as to prevent [him] from working a full eight hour
day." Hines v. Barnhart, 453 F.3d 559, 565 (4th Cir. 2006). Indeed, "[b]ecause pain is not
readily susceptible of objective proof ... the absence of objective medical evidence of the
intensity, severity, degree or functional effect ofpain is not determinative." Hines, 453 F.3d at
564-65 (emphasis in original).
Similarly, SSA's second CE, Dr. Ramnik Zota, rendered a more restrictive functional
assessment than given by the ALJ in December of 2012. Tr. 1139. Dr. Zota found that plaintiff
could sit about 20-30 minutes at a time and about three to four hours total in an eight hour work
day, stand about 25 minutes at a time and for a total of three to four hours in an eight hour
workday (indicating frequent breaks) and that he could walk about half a mile. While plaintiff
could probably lift about 25 pounds in Dr. Zota's opinion, plaintiff would have trouble using his
right arm above his head. Id.
In December of 2011, plaintiff's primary physician, Dr. Gordon, issued a statement that
plaintiff was unable to work due to both his physical and psychological problems. Tr. 119. Dr.
Hanson, his treating surgeon, stated in December of 2012 that plaintiff may not return to work as
he "[h]as bilateral rotator cuff tears, early hip DJD (degenerative joint disease) and chronic LBP
(lower back pain). Would likely benefit from home assist with ADLs (activities of daily living)."
Tr. 1154. He then prescribed him a home health aide "given his multiple orthopedic and medical
problems." Tr. 1144.
The ALJ also rejected the medical opinions of plaintiffs long time treating therapist (Ms.
Cordell) and psychiatrist (Dr. Smith). On October 11, 2011, Ms. Cordell opined:
I do not believe Mr. Ladner is capable of working due to physical and emotional
limitations. Emotionally he suffers from depression, low self-esteem and ADD.
As evidenced in the attached documents I believe he has poor concentration,
distractibility and difficulty completing sustained tasks. Further, he is socially
isolated. I believe Mr. Ladner is in need of disability.
Tr. 135. Dr. Smith issued his opinion in April of 2013. He noted plaintiff had a diagnosis of
major depressive disorder ("MDD") with a global assessment of functioning score ("GAF") of
45-50. Dr. Smith noted that plaintiff suffers from depressive symptomology as well as panic
attacks and recurrent and marked recollections of past traumatic experience which are a source of
marked distress. As a result, plaintiff experienced extreme limitation in activities of daily living,
extreme difficulty maintaining social functioning and deficiencies in concentration, persistence
or pace resulting in frequent failure to complete tasks in a timely manner. Tr. 1173. Dr. Smith
noted that plaintiff suffered from moderate impairment in simple and detailed instructions and
marked impairment in maintaining attention and concentration for extended periods and being
able to perform activities within a schedule. Plaintiff also had marked impairment in his ability to
interact appropriately with the general public, maintain socially appropriate behavior and make
plans independently of others. Tr. 1174.
The ALJ rejected both opinions arguing that plaintiffs mental status examinations
("MSEs") were essentially normal. Tr. 27-28. A review of the record reveals this is not accurate
as plaintiff has suffered from significant mental problems for an extensive period of time and
which has been documented in detail by his treating physicians. The ALJ' s depiction of
plaintiffs mental health treatment is inaccurate and lacks substantial support from the record,
and the medical opinions of Dr. Smith and Ms. Cordell are supported by their treatment notes
and should have been given greater weight. Per Dr. Smith's opinion, plaintiff meets the
requirements of Listing 12.04 for MDD as he suffers from the requisite depressive
symptomology with at least marked limitation in at least two of the functional domains. Tr.
1173-74; 20 C.F.R. Pt. 404, Subpt. P, Appendix I§ 12.04.
In addition to rejecting all the examining medical opinions, the ALJ also gave little
weight to the VA disability rating for plaintiffs mental disorders. The ALJ held that "the overall
treatment records do not indicate functional limitations or mental health symptoms as severe as
the claimant alleges, and Social Security uses a more stringent standard to evaluate 'disability'
than the VA." Tr. 29. This holding is in error. Plaintiffs treatment records are consistent with
significant mental health disorders which have been largely resistant to treatment. Additionally,
the Fourth Circuit has held that "in making a disability determination, the SSA must give
substantial weight to a VA disability rating." Bird v. Commissioner, 699 F.3d 337, 343 (4th Cir.
2012). Only where the ALJ points to clear reasons for deviation can the ALJ give less weight to
a VA rating. The ALJ did not do so here, and her disregard of the rating was therefore in error.
Defendant does not dispute that the ALJ's RFC does not enjoy support from any of the
medical sources on record or that every treating and consulting physician in the record opined
functional restrictions greater than that found in the ALJ's RFC. Additionally, if plaintiffs
complaints were properly regarded as credible, and if the above medical opinion evidence was
properly addressed and weighed, including the V A's disability determination, then the record
evidence would clearly show that plaintiff would be limited to performing no greater than
sedentary work. 20 C.F.R. § 404.1567 (defining the exertional requirements for sedentary work).
Were the record medical evidence properly weighed, given that plaintiff was 50 years old as of
his alleged onset date and had past work as a truck driver with a restriction to unskilled mental
functioning and a GED education level, a finding of disabled would have been directed by the
grids. See 20 C.F .R. Pt. 404, Subpt. P, Appendix II § 201.10. Therefore, the result of the ALJ' s
failures to address or weigh the above evidence in accordance with the principles discussed was
not harmless error.
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, however, 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 as the ALJ has clearly explained the basis for his decision and there
is no ambivalence in the record. The record properly supports a finding that plaintiff is disabled
under the Act. Accordingly, there is no benefit to be gained from remanding this matter for
further consideration and reversal is appropriate.
Accordingly, plaintiffs motion for judgment on the pleadings [DE 20] is GRANTED.
The decision of the ALJ is REVERSED and the matter is REMANDED to the Commissioner for
an award of benefits.
SO ORDERED, this* day of March, 2017.
TEfilIBNCE W. BOYLE
UNITED STATES DISTRICT JUDGE
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