Oliva v. Colvin

Filing 45

ORDER granting 32 Motion for Judgment on the Pleadings and denying 36 Motion for Judgment on the Pleadings. Signed by US District Judge Terrence W. Boyle on 3/29/2017. (Stouch, L.)

IN THE UNITED STATES DISTRICT COURT
FOR THE EASTERN DISTRICT OF NORTH CAROLINA
SOUTHERN DIVISION
No. 7:16-CV-14-BO

MARIA E. OLIVA,
Plaintiff,

v.
NANCY A. BERRYHILL,
Acting Commissioner of Social 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 March 15, 2017, in Raleigh, North
Carolina. For the reasons discussed below, this matter is remanded to the Acting Commissioner
for further proceedings.
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") and supplemental security income ("SSI") pursuant to Titles II and XVI of the
Social Security Act. Plaintiff protectively filed her applications on January 26, 2012, alleging
disability beginning January 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). Ifa 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).

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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. I. 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 her alleged onset date. Plaintiff's back
disorder, obesity, migraines, sleep disorder, and chronic obstructive pulmonary disease 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
sedentary work with additional exertional limitations. The ALJ then found that plaintiff was able
to return to her past relevant work. In the alternative, at step five, the ALJ considered plaintiff's
age, education, work experience, and RFC, along with the testimony of the vocational expert
("VE"), to determine that plaintiff was capable of making a successful adjustment to other work
that exists in significant numbers in the national economy. Accordingly, the ALJ found that
plaintiff had not been under a disability as defined in the Act.

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The ALJ's decision in this instance is not supported by substantial evidence. An ALJ
makes an RFC assessment based on all of the relevant medical and other evidence. 20 C.F.R.

§ 404. l 545(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 found that plaintiff was limited to a restricted range of sedentary work activities, with
limitations to only occasionally climb stairs; that she must be allowed to use a handheld device
for prolonged ambulation; she must avoid irritants; and that plaintiff is limited to simple, routine
tasks in a low stress job. Tr. 33.
The Fourth Circuit has found that in Social Security disability cases, "[t]he record should
include a discussion of which evidence the ALJ found credible and why, and specific application
of the pertinent legal requirements to the record evidence." Radford v. Colvin, 734 F.3d 288, 295
(4th Cir. 2013) (citing Hines v. Bowen, 872 F.2d 56, 59 (4th Cir. 1989)). "If the reviewing court
has no way of evaluating the basis for the ALJ's decision, then 'the proper course, except in rare
circumstances, is to remand to the agency for additional investigation or explanation."' Radford
at 295 (citing Florida Power & Light Co. v. Lorion, 470 U.S. 729, 744 (1985)).
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

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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 regulations require that the ALJ consider the combined effect of all of claimant's
impairments, "without regard to whether any such impairment if considered separately" would
be sufficiently severe. 42 U.S.C. § 423(d)(2)(c). The Fourth Circuit has accordingly held that in
determining whether an individual's impairments are of sufficient severity to prohibit basic work
related activities, an ALJ must consider the combined effect of a claimant's impairments. See,
e.g., Reichenbach v. Heckler, 808 F.2d 309, 312 (4th Cir. 1985).
Medical evidence showed that plaintiff suffered from back disorder, obesity, migraines,
sleep disorder, and chronic obstructive pulmonary disease. These conditions were found by the
ALJ to be severe conditions. However the evidence also showed that claimant was a Type II
diabetic and suffered from diabetic neuropathy which was diagnosed by Dr. Gootman, a pain
management specialist. Tr. 1542, 1548, 1553. 1556, 1559, 1566, 1572. There is also evidence
that plaintiffs suffered from an anxiety disorder, which was diagnosed and treated by her
personal care physicians at Bladen Medical Associates, Tr. 1591, 1604, 1611, 1614, 1618, 1620,
2404, and diagnosed as a co-morbid condition related to her chronic back pain by Dr. Gootman.
Tr. 1542, 1548, 1553. 1556, 1559, 1566, 1573, 1583. Neither condition was discussed or
considered in the ALJ' s opinion, nor any limitations related thereto discussed.
The ALJ is required to adequately explain his or her evaluation of the combined effect of
impairments. Reichenbach, 808 F.2d at 312. The failure of the ALJ to mention or weigh the

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above evidence and testimony in determining whether plaintiffs diabetic or anxiety problems
were

~evere

or whether they imposed additional limitations upon plaintiffs residual capacity to

work was in error. Even if such conditions do not support any additional limitations or are not
"severe" under the Act, the failure to explain why such conditions were disregarded leaves the
Court unable to fully review the basis of the ALJ's opinion. "If the reviewing court has no way
of evaluating the basis for the ALJ' s decision, then 'the proper course, except in rare
circumstances, is to remand to the agency for additional investigation or explanation."' Radford
at 295 (citing Florida Power & Light Co. v. Lorion, 470 U.S. 729, 744 (1985)). Therefore, the
ALJ's failure to consider claimant's diabetic or anxiety problems or even mention them in the
decision requires was not harmless error and the matter should be remanded for further
consideration.
CONCLUSION
Accordingly, plaintiffs motion for judgment on the pleadings [DE 32] is GRANTED and
defendant's motion for judgment on the pleadings [DE 36] is DENIED. The decision of the ALJ
is REMANDED to the Commissioner for further proceedings consistent with the foregoing.

SO ORDERED, this¢-! day of March, 2017.

1~ 0.
RRENCE W. BOYLE

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UNITED STATES DISTRICT JUDGE

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