Escobar v. Commissioner of Social Security
Filing
21
Memorandum Opinion and Order reversing and remanding the Commissioner's final decision for further proceedings. Magistrate Judge Nancy A. Vecchiarelli on 12/9/2014. (G,W)
IN THE UNITED STATES DISTRICT COURT
FOR THE NORTHERN DISTRICT OF OHIO
EASTERN DIVISION
JESSICA M. ESCOBAR,
Plaintiff,
v.
CAROLYN W. COLVIN,
Acting Commissioner of Social
Security,
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)
)
)
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)
)
)
)
CASE NO. 1:13-CV-02508
MAGISTRATE JUDGE
VECCHIARELLI
MEMORANDUM OPINION AND
ORDER
Defendant.
Plaintiff, Jessica M. Escobar (“Plaintiff”), challenges the final decision of Defendant,
Carolyn W. Colvin, Acting Commissioner of Social Security (“Commissioner”), denying
her applications for Period of Disability (“POD”), Disability Insurance Benefits (“DIB”), and
Supplemental Security Income (“SSI”) under Titles II and XVI of the Social Security Act, 42
U.S.C. §§ 416(i), 423, 1381 et seq. (“Act”). This case is before the undersigned United
States Magistrate Judge pursuant to the consent of the parties entered under the authority
of 28 U.S.C. § 636(c)(2). For the reasons set forth below, the Commissioner’s final
decision is REVERSED and REMANDED for further proceedings consistent with this
Memorandum Opinion and Order
I.
PROCEDURAL HISTORY
On December 2, 2010, Plaintiff filed her applications for POD, DIB, and SSI,
alleging a disability onset date of June 15, 2005. (Transcript (“Tr.”) 146.) The claims were
denied initially and upon reconsideration, and Plaintiff requested a hearing before an
administrative law judge (“ALJ”). (Id.) On March 28, 2012, an ALJ held Plaintiff’s hearing.
(Id.) Plaintiff participated in the hearing, was represented by counsel, and testified. (Id.) A
vocational expert (“VE”) also participated and testified. (Id.) On April 13, 2012, the ALJ
found Plaintiff not disabled. (Tr. 143.) On September 16, 2013, the Appeals Council
declined to review the ALJ’s decision, and the ALJ’s decision became the Commissioner’s
final decision. (Tr. 1.)
On November 12, 2013, Plaintiff filed her complaint to challenge the
Commissioner’s final decision. (Doc. No. 1.) The parties have completed briefing in this
case. (Doc. Nos. 18, 19, 20.)
Plaintiff asserts the following assignments of error: (1) The ALJ erred in evaluating
the opinions of state agency reviewing psychologists Drs. Steiger and Warren; and (2) the
ALJ erred in evaluating the opinions of Plaintiff’s treating psychiatrist Dr. Gomes.
II.
A.
EVIDENCE
Personal and Vocational Evidence
Plaintiff was born in June 1977 was 27-years-old on the alleged disability onset
date. (Tr. 152.) She had a high school education and was able to communicate in
English. (Tr. 153.) She had no past relevant work. (Id.)
B.
Medical Evidence 1
1.
Medical Reports
On November 21, 2010, local police transported Plaintiff to Mercy Regional Medical
Center (“Mercy”) for alcohol intoxication and bizarre behavior. (Tr. 475-487.) After drinking
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Plaintiff expressly notes in her Brief on the Merits that she does not
challenge the ALJ’s decision with respect to her physical limitations.
(Plaintiff’s Brief (“Pl.’s Br.”) at 10.) Accordingly, the Court will limit its
summary of the medical evidence to evidence relating to Plaintiff’s mental
impairments.
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an excessive amount of alcohol at a bar, Plaintiff drove her friend home. (Tr. 482.) While
doing so, Plaintiff noticed a flat tire and called 911. (Id.) Police arrive and arrested her for
driving under the influence (“DUI”). (Id.) Plaintiff then began to act bizarrely. (Id.) At
Mercy, Plaintiff reported that she was looking for a job in the area. (Id.) She described
herself as a former medical school student and hypochondriac. (Id.) She stated “that if
she is around someone that [complains of] medical problems, she will claim that she has
the same medical problems as well.” (Id.)
Plaintiff was given Ativan and transferred to the Nord Center Crisis Stabilization Unit
(“Nord”). (Tr. 485-486.) A clinical counselor and social worker performed a diagnostic
assessment. (Tr. 346-355.) Plaintiff described herself as homeless and stated that she
could attend to daily activities and household chores. (Tr. 346.) For leisure, she went to
clubs and had fun. (Tr. 347.) Regarding current symptoms, Plaintiff reported anxiety and
depression but denied anger, aggression, oppositional behaviors, psychosis, mood
swings, or deficits in attention and concentration. (Tr. 351.) Plaintiff admitted to acting
impulsively, but she did not think that it was a problem. (Id.) On examination, Plaintiff
displayed a mildly seductive demeanor. (Tr. 354.) She had mildly intense eye contact and
spoke clearly. (Id.) Her activity level was average. (Id.) She denied delusions and
hallucinations. (Id.) She posed no risk of suicide or violence. (Id.) She had a moderately
circumstantial and resistant mood but displayed average intelligence. (Tr. 355.) Her
insight and judgment were poor. (Id.)
The Nord staff commented that Plaintiff “is used to confabulating and nothing she
says can be taken at face value.” (Tr. 353, 355.) Plaintiff was dramatic, seductive,
exaggerative, and childish for her age. (Id.) She reported no significant symptoms of
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depression, anxiety, mood swings, hallucinations, or delusions. (Tr. 353, 355.) It
appeared that she had not worked in years. (Tr. 355.) The Nord staff noted that “[d]espite
[Plaintiff’s] bizarre behavior at the time of her DUI and her apparent response to internal
stimulation, this very likely was alcohol induced.” (Id.) Plaintiff was diagnosed with
alcohol-induced psychotic disorder with delusions, alcohol abuse, and historic personality
disorder, with a rule-out diagnosis of bipolar I disorder, single manic episode, severe with
psychotic features. (Tr. 353.)
On November 23, 2010, Plaintiff underwent a psychiatric evaluation by the Nord
staff, which was signed by Dominic Gomes, M.D., on November 26, 2010. (Tr. 643-646.)
On examination, Plaintiff displayed a mildly seductive demeanor and had mildly intense
eye contact and clear speech. (Tr. 645.) She demonstrated mildly grandiose delusions
but denied hallucinations. (Id.) Her thought process was moderately circumstantial and
she displayed moderately resistant behavior. (Tr. 645-646.) She posed no risk to herself
or others. (Tr. 645.) Her mood was euthymic and her affect was full. (Id.) Plaintiff had
poor insight and judgment but exhibited average intelligence and reported no cognitive
impairments. (Tr. 646.) The Nord staff repeated that Plaintiff “is used to confabulating and
nothing she says can be taken at face value.” (Id.)
Dr. Gomes continued to treat Plaintiff for bipolar disorder, with visits approximately
monthly from January 2011 to January 2012. (Tr. 396-397, 400-401, 410-411, 424-425,
579-580, 604-605, 817-818, 831-832, 849-850, 363-364.) He prescribed Plaintiff antimanic agents and mood stabilizers, anti-anxiety medications, and anti-depressants. (Tr.
410, 429, 647, 769-770, 867.)
Plaintiff also treated with Laurie Price, a therapist at Nord. (Tr. 372-375, 389, 637,
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639, 641-642, 765, 767.) Ms. Price assisted Plaintiff with meeting her basic needs,
including budgeting food stamps, keeping medical appointments, and obtaining clothing
and food. (Tr. 577, 593, 614.) Ms. Price also assisted Plaintiff with court hearings for
criminal charges in December 2010 and December 2011 and with hearings at Job and
Family Services for benefits. (Tr. 368, 595, 835, 839.)
On December 8, 2010, the Nord staff found that Plaintiff needed no assistance with
social/recreational needs or daily activities. (Tr. 389.) Despite being homeless and
complaining of depression, anxiety, insomnia, and mood instability, Plaintiff saw friends
daily, attended AA meetings, read, watched movies, and independently completed daily
activities. (Tr. 389.) Throughout Plaintiff’s treatment at Nord, she had good mood/affect,
denied current crisis, was oriented, and behaved/functioned appropriately. (Tr. 372, 637,
639.) On some occasions, Plaintiff noted that her mood was agitated. (Tr. 633.) Plaintiff
reported that her medications helped improve her mood. (Id.)
On December 16, 2010, Dr. Gomes completed a Medical Functional Capacity
Assessment wherein he opined that Plaintiff had mental limitations that ranged from not
significant to marked. (Tr. 761-763.) Specifically, Dr. Gomes opined that Plaintiff had
moderate limitations in the following abilities: remembering locations and work-like
procedures; carrying out very short and simple instructions; carrying out detailed
instructions; and maintaining concentration for extended periods. (Tr. 761.) Dr. Gomes
further opined that Plaintiff was markedly limited in the ability to: understand and remember
very short and simple instructions; understand and remember detailed instructions; and
complete a normal workday and workweek without interruptions from psychologically
based symptoms and to perform at a consistent pace without an unreasonable number
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and length of rest periods. (Tr. 761.)
From December 17, 2010, to December 29, 2010, Plaintiff reported to Nord several
more times. (Tr. 360-371.) On December 17, Plaintiff reported that she was close to
earning a cosmetology license and wished to pursue it after she stabilized. (Tr. 368.) On
December 20, Plaintiff described her main symptoms as anxiety and depression. (Tr.
366.) The following day, she stated that her anxiety was more under control with
medication. (Tr. 362.) Plaintiff reported that her medications made her unable to
concentrate and caused her to feel “loopy,” but stated they had been “very helpful so far.”
(Id.) On December 29, Plaintiff reported that she was adhering to her medications and
that they were “working well.” (Tr. 360.) She indicated that she felt a lot of anxiety due to
being homeless but that her medications helped keep her balanced. (Id.)
On December 29, 2010, Ms. Price completed a Daily Activities Questionnaire. (Tr.
379-380.) She stated that Plaintiff got along well with others. (Tr. 379.) Ms. Price opined
that Plaintiff’s forgetfulness, anxiety, and poor concentration might prevent her from
performing work activities. (Id.) Ms. Price stated that Plaintiff had good abilities in
preparing food, performing household chores, caring for her hygiene, driving/taking public
transportation, banking, and paying bills. (Tr. 380.) Ms. Price further noted that Plaintiff
read, walked, involved herself in music, and spent time with her family. (Id.)
On January 3, 2011, Dr. Gomes completed a Mental Status Questionnaire on
Plaintiff’s behalf. (Tr. 376-378.) Dr. Gomes opined that Plaintiff had poor to average
mental functional abilities. (Tr. 377.) He also asserted that Plaintiff had poor memory and
needed directions repeated. (Id.) He further stated that Plaintiff had poor concentration
and average attention skills. (Id.) He noted that Plaintiff experienced panic attacks under
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high pressure and was anxious around a large number of people. (Id.) He noted no
deficiencies in adaption. (Id.)
On August 15, 2011, Dr. Gomes completed a medical source statement on
Plaintiff’s behalf. (Tr. 571-572.) Dr. Gomes opined that Plaintiff had extreme limitations in
the ability to maintain attention and concentration for two-hour periods of time and in the
ability to perform work activities at a reasonable pace. (Tr. 571.) He further opined that
Plaintiff had the following marked limitations: the ability to remember, understand, and
follow simple directions; keep a regular work schedule and maintain punctual attendance;
withstand the stresses and pressures of routine, simple, unskilled work; make judgments
that are commensurate with the functions of unskilled work, i.e., make simple work-related
decisions. (Tr. 571-572.) Dr. Gomes noted that Plaintiff was moderately limited in the
ability to interact appropriately with others. (Tr. 571.) Dr. Gomes opined that Plaintiff’s
limitations had lasted, or were expected to last, at least 12 months. (Tr. 572.) He noted
that Plaintiff’s mental limitations were severe enough to prevent her from successfully
completing work functions. (Id.)
2.
Agency Reports
On June 2, 2011, state agency reviewing physician Karen Steiger, Ph.D., opined
that Plaintiff had mild restriction in activities of daily living and moderate difficulties in
maintaining social functioning and maintaining concentration, persistence, or pace. (Tr.
76.) Dr. Steiger reported that Plaintiff was moderately limited in the following abilities:
understanding and remembering detailed instructions; carrying out detailed instructions;
maintaining attention and concentration for extended periods; completing a normal
workday and workweek without interruptions from psychologically based symptoms and
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performing at a consistent pace without an unreasonable number and length of rest
periods; interacting appropriately with the general public; getting along with coworkers or
peers without distracting them or exhibiting behavioral extremes; and responding
appropriately to changes in the work setting. (Tr. 80-82.) Dr. Steiger concluded that
Plaintiff could understand and recall simple instructions; carry out simple, routine tasks to
completion without strict time pressures; interact in a setting with superficial interactions
expected; and adapt to minor changes in a calm setting with few changes. (Id.) She
further opined that Plaintiff could perform routine, up to four-step tasks in a predictable
environment where expectations are clear and consistent, and have brief superficial
contact with others, but could not have strict production quotas. (Tr. 82.) On October 4,
2011, Vicki Warren, Ph.D., affirmed Dr. Steiger’s opinions. (Tr. 113, 117-118.)
C.
Hearing Testimony
1.
Plaintiff’s Hearing Testimony
Plaintiff testified that she can no longer work due to a back injury; pain in both legs;
and depression. (Tr. 24.) She testified that her main problem was her back. (Id.) She
stated that her medications made her feel “halfway asleep.” (Tr. 25.) Plaintiff treated with
Dr. Gomes once per month for depression and bipolar disorder. (Tr. 30.) She stated that
her depression made her not want to leave her home and caused her to hear voices, but
that “with the medication, it takes that all away.” (Id.)
Plaintiff watched TV and could follow the programs. (Tr. 32-33.) She could take
care of her personal hygiene on her own. (Tr. 34.) She could use the microwave to
prepare meals. (Tr. 35.) She could clean, dust, vacuum, and shop. (Tr. 36.) She testified
that she had problems dealing with crowds of people. (Tr. 33.) Plaintiff visited with her
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children every other weekend. (Tr. 35.) She enjoyed decorating flowers and painting
pictures for her kids. (Tr. 36.) She went for walks around her neighborhood. (Tr. 35.)
Plaintiff described a typical day as follows:
Okay, when I get up in the morning, I go and make me coffee, I
feed my cat. I go [sic] my backroom and take my medication, and
then I’ll sit down, and I put a movie on in my DVD player, and I
watch “Underworld” and–that’s my favorite movie. And then after
that, I just stay in my house all day unless I have an appointment
with Nord or something.
(Id.)
2.
Vocational Expert’s Hearing Testimony
Ted Macy, a vocational expert, testified at Plaintiff’s hearing. The ALJ asked the VE
to assume a hypothetical individual of Plaintiff’s age, education, and past work experience.
(Tr. 45.) The hypothetical individual would be capable of performing light work with the
following additional limitations: no climbing of ladders, ropes, or scaffolds; occasional
climbing of ramps and stairs; occasional stooping, kneeling, crouching, and crawling;
frequent balancing; and no concentrated exposure to temperature and/or humidity
extremes, vibration, environmental pollutants and hazards such as heights, machinery,
and commercial driving. (Id.) The individual could understand and recall simple
instructions and carry out simple, routine tasks without strict time pressures in a lowstress setting with few changes and superficial interpersonal interactions with others. (Id.)
The VE testified that the individual would be capable of performing such jobs as a wire
worker, an electronics worker, and a bench assembler. (Tr. 46.) The VE further testified
that there would be no jobs existing in significant numbers in the economy that the
hypothetical individual could perform if the individual would be off-task at least 20 percent of
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the time. (Tr. 47.)
III.
STANDARD FOR DISABILITY
A claimant is entitled to receive benefits under the Social Security Act when she
establishes disability within the meaning of the Act. 20 C.F.R. § 416.905; Kirk v. Sec’y of
Health & Human Servs., 667 F.2d 524 (6th Cir. 1981). A claimant is considered disabled
when she cannot perform “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 12
months.” 20 C.F.R. § 416.905(a).
The Commissioner reaches a determination as to whether a claimant is disabled by
way of a five-stage process. 20 C.F.R. §§ 404.1520(a)(4) and 416.920(a)(4); Abbott v.
Sullivan, 905 F.2d 918, 923 (6th Cir. 1990). First, the claimant must demonstrate that she
is not currently engaged in “substantial gainful activity” at the time she seeks disability
benefits. 20 C.F.R. §§ 404.1520(b) and 416.920(b). Second, the claimant must show that
she suffers from a “severe impairment” in order to warrant a finding of disability. 20 C.F.R.
§§ 404.1520(c) and 416.920(c). A “severe impairment” is one that “significantly limits . . .
physical or mental ability to do basic work activities.” Abbot, 905 F.2d at 923. Third, if the
claimant is not performing substantial gainful activity, has a severe impairment that is
expected to last for at least twelve months, and the impairment meets a listed impairment,
the claimant is presumed to be disabled regardless of age, education or work experience.
20 C.F.R. §§ 404.1520(d) and 416.920(d). Fourth, if the claimant’s impairment does not
prevent her from doing her past relevant work, the claimant is not disabled. 20 C.F.R. §§
404.1520(e)-(f) and 416.920(e)-(f). For the fifth and final step, even if the claimant’s
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impairment does prevent her from doing her past relevant work, if other work exists in the
national economy that the claimant can perform, the claimant is not disabled. 20 C.F.R. §§
404.1520(g), 404.1560(c), and 416.920(g).
IV.
SUMMARY OF COMMISSIONER’S DECISION
The ALJ made the following findings of fact and conclusions of law:
1.
The claimant meets the insured status requirements of the Social
Security Act through September 30, 2011.
2.
The claimant has not engaged in substantial gainful activity since June
15, 2005, the alleged onset date.
3.
The claimant has the following severe impairments: bipolar disorder,
histrionic personality disorder, and multiple joint strain.
4.
The claimant does not have an impairment or combination of
impairments that meets or medically equals the severity of one of the
listed impairments in 20 CFR Part 404, Subpart P, Appendix 1.
5.
After careful consideration of the entire record, the undersigned finds
that the claimant has the residual functional capacity to perform less
than a full range of light work as defined in 20 CFR 404.1567(b) and
416.967(b). Specifically, while she can frequently balance and can
occasionally stoop, kneel, crouch, crawl, and climb ramps or stairs, she
can never climb ladders, ropes, or scaffolds. Furthermore, she must
avoid concentrated exposure to temperature and/or humidity extremes,
vibration, environmental pollutants, and hazards, such as heights,
machinery, and commercial driving. Mentally, she can understand and
recall simple instructions and carry out simple, routine tasks. She must
work in a low stress environment with few changes, no strict time
pressures, and no more than superficial interpersonal interactions with
others.
6.
The claimant has no past relevant work.
7.
The claimant was born on June 28, 1977, and was 27-years-old, which
is defined as a younger individual age 18-49, on the alleged disability
onset date.
8.
The claimant has at least a high school education and is able to
communicate in English.
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9.
Transferability of job skills is not an issue because the claimant does not
have past relevant work.
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Considering the claimant’s age, education, work experience, and
residual functional capacity, there are jobs that exist in significant
numbers in the national economy that the claimant can perform.
11.
The claimant has not been under a disability, as defined in the Act, from
June 15, 2005, through the date of this decision.
(Tr. 148-154.)
V.
A.
LAW & ANALYSIS
Standard of Review
Judicial review of the Commissioner’s decision is limited to determining whether the
Commissioner's decision is supported by substantial evidence and was made pursuant to
proper legal standards. Ealy v. Comm’r of Soc. Sec., 594 F.3d 504, 512 (6th Cir. 2010).
Review must be based on the record as a whole. Heston v. Comm’r of Soc. Sec., 245
F.3d 528, 535 (6th Cir. 2001). The court may look into any evidence in the record to
determine if the ALJ’s decision is supported by substantial evidence, regardless of whether
it has actually been cited by the ALJ. Id. However, the court does not review the evidence
de novo, make credibility determinations, or weigh the evidence. Brainard v. Sec’y of
Health & Human Servs., 889 F.2d 679, 681 (6th Cir. 1989).
The Commissioner’s conclusions must be affirmed absent a determination that the
ALJ failed to apply the correct legal standards or made findings of fact unsupported by
substantial evidence in the record. White v. Comm’r of Soc. Sec., 572 F.3d 272, 281 (6th
Cir. 2009). Substantial evidence is more than a scintilla of evidence but less than a
preponderance and is such relevant evidence as a reasonable mind might accept as
adequate to support a conclusion. Brainard, 889 F.2d at 681. A decision supported by
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substantial evidence will not be overturned even though substantial evidence supports the
opposite conclusion. Ealy, 594 F.3d at 512.
B.
Plaintiff’s Assignments of Error
1.
The ALJ Erred in Evaluating the Opinions of State Agency
Reviewing Psychologists Drs. Steiger and Warren.
State agency reviewing psychologists Drs. Steiger and Warren opined that Plaintiff
is limited to a “calm setting,” where “expectations are clear and consistent,” and only “brief”
superficial contact with others. (Tr. 82, 118.) Plaintiff argues that the ALJ erred by giving
“great weight” to the aforementioned opinions yet failing to account for those specific
restrictions in Plaintiff’s residual functional capacity (RFC) or providing reasons for
discounting them. For the following reasons, Plaintiff’s argument has merit.
It is well established that an ALJ is not required to discuss each and every piece of
evidence in the record for his decision to stand. See, e.g., Thacker v. Comm’r of Soc.
Sec., 99 F. App’x 661, 665 (6th Cir. 2004). However, where the opinion of a medical
source contradicts his RFC finding, an ALJ must explain why he did not include its
limitations in his determination of a claimant’s RFC. See, e.g., Fleischer v. Astrue, 774 F.
Supp. 2d 875, 881 (N.D. Ohio 2011) (Lioi, J.) (“In rendering his RFC decision, the ALJ must
give some indication of the evidence upon which he is relying, and he may not ignore
evidence that does not support his decision, especially when that evidence, if accepted,
would change his analysis.”). Social Security Ruling 96-8p provides, “[t]he RFC
assessment must always consider and address medical source opinions. If the RFC
assessment conflicts with an opinion from a medical source, the adjudicator must explain
why the opinion was not adopted.” SSR 96-8p, 1996 WL 374184, *7 (July 2, 1996).
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Here, the ALJ’s RFC determination directly conflicts with the opinions of Drs. Steiger
and Warren, and the ALJ fails to explain, or even address, these inconsistencies. Dr.
Steiger opined that Plaintiff could have “brief superficial contact with others.” (Tr. 82.) In
his RFC determination, the ALJ limited Plaintiff to work with “no more than superficial
interpersonal interactions with others.” (Tr. 150.) The ALJ does not explain why he omitted
Dr. Steiger’s limitation of Plaintiff to brief superficial interactions. As Plaintiff explains in her
Brief, the term “superficial” refers to the nature of social interactions but does not address
the duration of those interactions. At Plaintiff’s hearing, the VE testified that he interpreted
the term “superficial” to mean “[i]nteractions not requiring any negotiation, not being–not
worrying about the, you know, the responsibility for someone else’s safety, not having to
negotiate or explain extensive changes.” (Tr. 53.) When questioned by Plaintiff’s attorney,
the VE agreed that “superficial” means “no negotiation, arbitration, or confrontation, no
responsibility for the health and safety of others, and no supervision of others. . . .” (Tr. 54.)
Thus, the VE’s testimony, on which the ALJ relied, clearly indicates that the term
“superficial” refers to the nature, not duration, or social interaction. Dr. Steiger found that
Plaintiff was limited not only in the quality of social interaction in which she may engage, but
in quantity as well by limiting Plaintiff to “brief” superficial contact with others. Because the
ALJ’s RFC does not adequately account for this restriction and the ALJ did not explain his
reasons for rejecting this portion of Dr. Steiger’s opinion, the ALJ erred.
Furthermore, the ALJ’s RFC does not account for Dr. Warren’s restriction of
Plaintiff to work in a “calm setting” where “expectations are clear and consistent.” (Tr.
118.) At Plaintiff’s hearing, the VE testified that a person who would need to be in a “calm”
work setting would be unable to work, as no work setting is always calm. (Tr. 56.) The VE
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further testified that he could not provide any jobs that an individual who required clear and
consistent expectations could perform, because “consistency and clarity of expectations
are subjective,” therefore “there’s no way a job is going to be able to meet that for every
individual. (Tr. 57.) Thus, Dr. Warren opined that Plaintiff had two limitations that,
according to the VE, would preclude her from performing work existing in significant
numbers in the national economy. In determining Plaintiff’s RFC, however, the ALJ does
not account for those limitations or explain his reasons for rejecting that portion of Dr.
Warren’s opinion which found such restrictions. Accordingly, the ALJ erred in his
evaluation of Dr. Warren’s opinion. For the foregoing reasons, Plaintiff’s first assignment
of error presents a basis for remand of her case.
2.
The ALJ Erred in Evaluating the Opinions of Plaintiff’s Treating
Psychiatrist.
Plaintiff argues that the ALJ erred in rejecting the opinions of Dr. Gomes, Plaintiff’s
treating psychiatrist. “An ALJ must give the opinion of a treating source controlling weight
if he finds the opinion ‘well-supported by medically acceptable clinical and laboratory
diagnostic techniques’ and ‘not inconsistent with the other substantial evidence in the case
record.” Wilson v. Comm’r of Soc. Sec., 378 F.3d 541, 544 (6th Cir. 2004) (quoting 20
C.F.R. § 404.1527(d)(2)) (internal quotes omitted). If an ALJ decides to give a treating
source’s opinion less than controlling weight, he must give “good reasons” for doing so that
are sufficiently specific to make clear to any subsequent reviewers the weight given to the
treating physician’s opinion and the reasons for that weight. See Wilson, 378 F.3d at 544
(quoting S.S.R. 96-2p, 1996 WL 374188, at *5 (S.S.A.)). This “clear elaboration
requirement” is “imposed explicitly by the regulations,” Bowie v. Comm’r of Soc. Sec., 539
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F.3d 395, 400 (6th Cir. 2008), and its purpose is to “let claimants understand the
disposition of their cases” and to allow for “meaningful review” of the ALJ’s decision,
Wilson, 378 F.3d at 544 (internal quotation marks omitted). Where an ALJ fails to explain
his reasons for assigning a treating physician’s opinion less than controlling weight, the
error is not harmless and the appropriate remedy is remand. Id.
Here, although the ALJ considered Dr. Gomes a treating source, he did not give Dr.
Gomes’ opinions regarding Plaintiff’s mental capabilities controlling weight. (Tr. 152.) In
rejecting Dr. Gomes’ opinions, the ALJ explained:
[T]he undersigned does not accord evidentiary weight to the
opinions of treating provider Dominic Gomes, M.D. According to
him, [Plaintiff] has marked limitations with her abilities to
remember, understand, and follow simple directions, keep a
regular schedule, interact with others, and make simple workrelated decisions, and extreme limitations of her abilities to
maintain attention and concentration for two-hour periods and
perform activities at a reasonable pace. Finally, he believes she
is unable to work (Exhibits 4F, 5F, 12F, 14F/5-7, 15F), which is a
medical opinion on an issue that is reserved for the Commissioner
(SSR 96-5p). This assessment is inconsistent with the objective
findings, which include a good mood and affect, coherent speech,
appropriate behavior, a normal thought process, average
reasoning skills, and average intelligence, as well as the
claimant’s activities, which include paying bills, handling a
checking account, reading, walking, using public transportation,
attending meetings, dating, maintaining several friendships, and
traveling. Accordingly, the opinions of Dr. Gomes are rejected.
(Tr. 152.)
The ALJ’s rationale for assigning less than controlling weight to Dr. Gomes’ opinions
satisfies the good reasons requirement of the treating physician rule. First, the ALJ was
correct in noting that Dr. Gomes’ opinion that Plaintiff cannot work due to her mental
condition is not an opinion of a medical condition, but rather is an opinion of disability that is
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reserved for the ALJ. It is well established that certain issues are reserved to the
Commissioner for determination. See 20 C.F.R. § 416.927(d). Among these are whether
a claimant is disabled. See 20 C.F.R. § 416.927(d)(1) (“We are responsible for making the
determination or decision whether you meet the statutory definition of disability. . . . A
statement by a medical source that you are ‘disabled’ or ‘unable to work’ does not mean
that we will determine that you are disabled.”). Accordingly, the ALJ did not err in giving
less than controlling weight to Dr. Gomes’ opinion that Plaintiff is unable to work, as the ALJ
was not required to defer to Dr. Gomes’ opinion on that subject.
Furthermore, the ALJ did not err in rejecting Dr. Gomes’ opinion regarding Plaintiff’s
functional limitations, because the ALJ reasonably concluded that the opinions were not
consistent with other substantial evidence in the record. (Tr. 152.) The ALJ discussed the
following evidence supporting his conclusion that Dr. Gomes’ opinions were not supported
by the record:
•
The ALJ noted that Plaintiff’s daily activities suggest that she does not
have more than moderate limitations with her activities of daily living,
social functioning, or concentration, persistence, or pace, and she does
not live in a highly supportive living arrangement. (Tr. 149.) “As
evidenced by the record, the claimant cares for her personal needs,
prepares simple meals, performs light cleaning, shops, pays bills,
handles a checking account, reads, watches television, walks, uses
public transportation, attends meetings, dates, maintains several
friendships, and travels to Toledo, Ohio to visit her family.” (Id.)
•
The ALJ observed that “while some psychological examinations revealed
a depressed mood, rapid speech, a circumstantial thought process,
memory deficit, and poor insight and judgment, others revealed a good
mood, coherent speech, appropriate behavior, a normal thought
process, average reasoning skills, and average intelligence (Exhibits
3F/13, 14, 18, 20, 22, 4F/1, 6F/23, 27, 13F/63, 14F/5, 90).” (Tr. 151.)
•
The ALJ found that several factors diminished Plaintiff’s overall
credibility. (Tr. 151.) For example, at the hearing, she testified that she
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never had a DUI, but in November 2010, police cited her for that offense
after discovering her driving with a blood alcohol level of .150. (Id.)
Furthermore, one treating provider noted that Plaintiff is used to
confabulating and exaggerating and that nothing she said could be taken
at face value. (Id.) The ALJ further indicated that a review of Plaintiff’s
work history showed that she only worked sporadically prior to her
alleged onset date, raising a question of whether he continuing
unemployment was actually due to medical impairments. (Id.)
•
State agency reviewing physicians Drs. Steiger and Warren opined that
Plaintiff retained the capacity to understand and recall simple
instructions, carry out simple, routine tasks without strict time pressures,
work in a setting with superficial interactions, and adapt to minor
changes in a calm setting with few changes. (Tr. 152.)
Thus, the ALJ adequately explained how substantial evidence in Plaintiff's record did not
support Dr. Gomes’ extreme opinions regarding Plaintiff's mental limitations. While Plaintiff
has provided evidence to support her argument that Dr. Gomes’ opinions are supported, the
existence of such evidence alone would not be an appropriate reason to reverse the ALJ’s
decision: An ALJ’s decision that is supported by substantial evidence will not be overturned
even though substantial evidence supports the opposite conclusion. Ealy, 594 F.3d at 512.
According, Plaintiff’s second assignment of error is without merit.
VI.
CONCLUSION
For the foregoing reasons, the Commissioner’s final decision is REVERSED and
REMANDED for further proceedings consistent with this Memorandum Opinion and Order.
IT IS SO ORDERED.
s/ Nancy A. Vecchiarelli
U.S. Magistrate Judge
Date: December 9, 2014
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