Smith v. Colvin
Filing
18
ORDER Granting 11 Motion for Summary Judgment; Denying 15 Motion for Summary Judgment. The Decision of the Commissioner that Plaintiff was not Disabled Within the Meaning of the Act is Vacated and Remanded. Signed by Senior Judge Graham Mullen on 11/21/2017. (jaw)
UNITED STATES DISTRICT COURT
WESTERN DISTRICT OF NORTH CAROLINA
CHARLOTTE DIVISION
DOCKET NO. 3:16-cv-272
))
ALICIA Y. SMITH
Plaintiff,
v.
NANCY A. BERRYHILL, Acting
Commissioner of Social Security,
Defendant.
)
)
)
)
)
)
)
)
)
)
ORDER
THIS MATTER is before the Court upon Plaintiff’s Motion for Summary Judgment
(Doc. No. 11) and Commissioner’s Motion for Summary Judgment (Doc. No. 15). Having
carefully considered such motions and reviewed the pleadings, the court enters the following
findings, conclusions, and Order.
FINDINGS AND CONCLUSIONS
I.
Administrative History
Plaintiff Alicia Y. Smith (“Smith” or “Plaintiff”) filed her application for Disability
Insurance Benefits in August 2011, alleging a disability onset date of August 1, 2010. After
Plaintiff’s claim was denied both initially and on reconsideration, she requested and was granted
a hearing before Administrative Law Judge Wendell M. Sims (“the ALJ”). The ALJ issued a
decision on March 22, 2013, that Plaintiff was not disabled, from which Plaintiff appealed to the
Appeals Council. The Appeals Council remanded the case for further consideration on April 18,
2014. A second hearing was held before the ALJ on November 19, 2014. At this hearing,
Plaintiff amended her onset date to February 28, 2013, making the relevant period of disability
1
February 28, 2013, through the date last insured, December 31, 2013. On January 28, 2015, the
ALJ issued his determination that Plaintiff was not disabled under the Act. On April 1, 2016,
Plaintiff’s request for review was denied, making the ALJ’s decision the final decision of the
Commissioner of Social Security (“Commissioner”).
Thereafter, Plaintiff timely filed this action, seeking judicial review of the ALJ’s
decision.
II.
Factual Background
In his decision, the ALJ at the first step determined that Plaintiff had not engaged in
substantial gainful activity during the period from her alleged onset date through her date last
insured. (Tr. 34). At the second step, the ALJ concluded that Plaintiff has the following severe
impairment: ulcerative colitis. (Id.). At the third step, the ALJ found that the Plaintiff did not
have an impairment or combination of impairments that meet or medically equal the severity of
one the listed impairments in 20 C.F.R. § 404, Subpart P, Appendix 1. (Tr. 35).
The ALJ then found that Plaintiff has the residual functional capacity (RFC) to perform
medium work “except that she is limited to frequent climbing, balancing, stooping and
crouching.” (Id.). Based on these limitations, the ALJ found in the fourth step that Plaintiff is is
capable of performing her past relevant work as a stock clerk. (Tr. 40). Further, at the fifth step,
the ALJ concluded that there are other jobs that exist in significant numbers in the national
economy that Plaintiff can perform as well. (Tr. 40–41). Accordingly, the ALJ found that
Plaintiff was not disabled under the Act. (Tr. 42).
III.
Standard of Review
The only issues on review are whether the Commissioner applied the correct legal
standards and whether the Commissioner’s decision is supported by substantial evidence.
2
Richardson v. Perales, 402 U.S. 389, 390 (1971); Hays v. Sullivan, 907 F.2d 1453, 1456 (4th
Cir. 1990). Review by a federal court is not de novo, Smith v. Schweiker, 795 F.2d 343, 345 (4th
Cir. 1986); rather, inquiry is limited to whether there was “such relevant evidence as a
reasonable mind might accept as adequate to support a conclusion,” Richardson, 402 U.S. at 400.
Even if the undersigned were to find that a preponderance of the evidence weighed against the
Commissioner’s decision, the Commissioner’s decision would have to be affirmed if supported
by substantial evidence. Hays, 907 F.2d at 1456.
IV.
Discussion
Plaintiff’s first assignment of error is that the ALJ failed to give proper weight to the
opinion of her treating physician, Dr. Hanson.
A treating physician is a physician who has observed the plaintiff’s condition over a
prolonged period of time. Mitchell v. Schweiker, 699 F.2d 185, 187 (4th Cir. 1983). Under
Social Security regulations, an ALJ “is required to give ‘controlling weight’ to opinions
proffered by a claimant’s treating physicians so long as the opinion is ‘well-supported by
medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with
the other substantial evidence in [the claimant’s] case record.” Lewis v. Berryhill, 858 F.3d 858,
867 (4th Cir. 2017) (quoting 20 C.F.R. § 404.1527(c)(2)) (alterations in original). “The
regulation’s treating physician rule accords the greatest weight—controlling weight—to the
opinions of treating sources, because those ‘sources are likely to be the medical professionals
most able to provide a detailed, longitudinal picture of your medical impairment(s) and may
bring a unique perspective to the medical evidence that cannot be obtained from the objective
medical findings alone or from reports of individual examinations.’” Brown v. Comm’r Soc. Sec.
Admin., 873 F.3d 251, 268 (4th Cir. 2017) (quoting 20 C.F.R. § 404.1527(c)(2)).
3
It is undisputed that Dr. Hanson qualifies as a treating physician, and thus that his opinion
is entitled to controlling weight unless the ALJ finds his opinion to either be not “wellsupported” by appropriate techniques or inconsistent with the rest of the medical record. (Tr.
39). Dr. Hanson opined that Plaintiff has severe active colitis, is incapable of performing “even
low stress jobs” because of her frequent diarrhea, would need 3–7 breaks of 15 minutes each day,
and would likely to be absent from work more than four days per month as a result of her
impairments or treatment needs. (Tr. 596–99).
However, the ALJ did not include the limitations recommended by Dr. Hanson in his
RFC or in his hypothetical question to the Vocational Expert (VE). Rather, the ALJ gave the
opinion of Dr. Hanson “less weight.” (Tr. 39). Plaintiff argues (1) that this opinion should have
been given controlling weight, and (2) that even if it was not entitled to controlling weight, the
ALJ failed to give “good reasons” for why he did not assign it controlling weight. The Court
agrees with Plaintiff’s latter argument and remands on that basis.
When assigning weight to a treating source’s medical opinion, an ALJ must provide
“good reasons” based on specific evidence for his or her decision. 20 C.F.R. § 404.1527(c)(2);
SSR 96-2p. Specifically, an ALJ is to assess the following factors in weighing a treating
source’s opinion: length of treatment relationship, nature and extent of treatment relationship,
supportability of the opinion, consistency with the record as a whole, specialization of the
source, and other relevant factors. 20 C.F.R. §§ 404.1527(c)(2–6).
The only reason that the ALJ stated for assigning less weight to Dr. Hanson’s opinion is
that Dr. Hanson did not provide “treatment records, objective findings or clinical signs to support
his opinions.” (Tr. 39). However, the ALJ had twenty-five pages of treatment records in front of
him showing the results of Dr. Hanson’s examinations. (Tr. 531–56). These records show that
4
Dr. Hanson found her to have “severe active colitis” (Tr. 543) and “severe active inflammation”
(Tr. 531) following a colonoscopy in June 2014 and a sigmoidoscopy in August 2014, and that
he diagnosed her with ulcerative colitis (Tr. 537, 551). Dr. Hanson repeated these findings in his
RFC questionnaire, where he stated his opinion about Plaintiff’s functionality based on her
diagnosis and the severity of her symptoms.
In light of the fact that Dr. Hanson provided treatment records stating objective findings
and clinical signs and consistently applied them in his RFC assessment, the ALJ’s summary
dismissal of his opinion was in error. The record must include “a discussion of which evidence
the ALJ found credible and why.” Radford v. Colvin, 734 F.3d 288, 295 (4th Cir. 2013). Instead
of discussing why he did not find Dr. Hanson’s opinion to be credible, the ALJ merely made a
one-sentence statement to justify his decision, without mentioning any of the factors listed in 20
C.F.R. §§ 404.1527(c). By performing such a “perfunctory” analysis, the ALJ failed to
adequately explain the reason why he accorded less weight to Dr. Hanson’s opinion. See Lewis,
858 F.3d at 867 (finding a “perfunctory” rejection of a treating physician’s opinion inadequate
when the ALJ’s analysis spanned “only four lines” and overlooked “critical aspects” of the
plaintiff’s treatment history). And contrary to the Commissioner’s argument, it is not the role of
this Court to supply an explanation based on other findings in the ALJ’s decision. This would
lead the Court to impermissibly substitute its judgment for that of the ALJ. Radford, 734 F.3d at
296. Rather, the ALJ must explain with specificity his reasons for not giving Dr. Hanson’s
opinion controlling weight.
Finally, this error is not harmless. Based on the RFC and hypothetical question given by
the ALJ—which did not include the limitations found by Dr. Hanson—the VE in this case found
that Plaintiff could hypothetically perform her prior work and three other positions that are
5
available in sufficient numbers nationally and in the state of North Carolina. (Tr. 88). However,
when Plaintiff’s attorney asked the VE if those same jobs could be performed if the Plaintiff
needed “three to four extra breaks for 15 minutes” or “if she was absent more than four days a
month,” the VE responded negatively. (Tr. 89). Thus, if the ALJ had given controlling weight
to Dr. Hanson’s opinion of Plaintiff’s functionality, the ALJ would not have been able to rely on
these hypothetical jobs to determine that Plaintiff was not disabled in steps four and five.
V.
Conclusion
For the foregoing reasons, the Court is unable to find that the ALJ’s decision is supported
by substantial evidence. This case is remanded for the ALJ to reassess the opinion testimony of
Dr. Hudson and fully explain the rationale for the weight given to Plaintiff’s treating physicians.
Accordingly, Plaintiff’s Motion for Summary Judgment (Doc. No. 11) is GRANTED,
the Commissioner’s Motion for Summary Judgment (Doc. No. 15) is DENIED, and the decision
of the Commissioner that Plaintiff was not disabled within the meaning of the Act is VACATED
AND REMANDED.
SO ORDERED.
Signed: November 21, 2017
6
Disclaimer: Justia Dockets & Filings provides public litigation records from the federal appellate and district courts. These filings and docket sheets should not be considered findings of fact or liability, nor do they necessarily reflect the view of Justia.
Why Is My Information Online?