Gonzalez v. Commissioner of Social Security
Memorandum Opinion and Order that the Court finds the decision of the Commissioner not supported by substantial evidence. Accordingly, the decision is VACATED and the case is REMANDED, pursuant to 42 U.S.C. § 405(g) sentence four, for further proceedings consistent with this opinion. Related document 1 Complaint filed by Tyesha M. Gonzalez. Signed by Magistrate Judge Greg White on 2/17/2015. (R,Sh)
IN THE UNITED STATES DISTRICT COURT
FOR THE NORTHERN DISTRICT OF OHIO
TYESHA M. GONZALEZ,
COMMISSIONER OF SOCIAL
CASE NO. 1:14-cv-00601
MAGISTRATE JUDGE GREG WHITE
MEMORANDUM OPINION & ORDER
Plaintiff Tyesha Gonzalez (“Gonzalez”) challenges the final decision of the Acting
Commissioner of Social Security, Carolyn W. Colvin (“Commissioner”), denying Gonzalez’s
claim for Supplemental Security Income (“SSI”) under Title(s) XVI of the Social Security Act
(“Act”), 42 U.S.C. § 1381 et seq. This matter is before the Court pursuant to 42 U.S.C. § 405(g)
and the consent of the parties entered under the authority of 28 U.S.C. § 636(c)(2).
For the reasons set forth below, the final decision of the Commissioner is VACATED
and the case is REMANDED for further proceedings consistent with this opinion.
I. Procedural History
On March 30, 2009, Gonzalez filed an application for SSI alleging a disability onset date
of February 20, 2006. Her application was denied both initially and upon reconsideration.
Gonzalez timely requested an administrative hearing. (Tr. 18.)
On December 14, 2012, an Administrative Law Judge (“ALJ”) held a hearing during
which Gonzalez, represented by counsel, and an impartial vocational expert (“VE”) testified.
(Tr. 18.) On January 17, 2013, the ALJ found Gonzalez was able to perform a significant
number of jobs in the national economy and, therefore, was not disabled. (Tr. 24A-24B.) The
ALJ’s decision became final when the Appeals Council denied further review.
Personal and Vocational Evidence
Age thirty-five (35) at the time of her administrative hearing, Gonzalez is a “younger”
person under social security regulations. See 20 C.F.R. § 416.963(c). (Tr. 24A.) Gonzalez has a
limited education and no past relevant work. Id.
III. Standard for Disability
A disabled claimant may also be entitled to receive SSI benefits. 20 C.F.R. § 416.905;
Kirk v. Sec’y of Health & Human Servs., 667 F.2d 524 (6th Cir. 1981). To receive SSI benefits, a
claimant must meet certain income and resource limitations. 20 C.F.R. §§ 416.1100 and
416.1201. The entire process entails a five-step analysis as follows: First, the claimant must not
be engaged in “substantial gainful activity.” Second, the claimant must suffer from a “severe
impairment.” A “severe impairment” is one which “significantly limits ... physical or mental
ability to do basic work activities.” 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, or combination of impairments, meets a required listing under 20 C.F.R. § 404,
Subpt. P, App. 1, 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)(2000). Fourth, if the claimant’s
impairment does not prevent the performance of past relevant work, the claimant is not disabled.
For the fifth and final step, even though the claimant’s impairment does prevent performance of
past relevant work, if other work exists in the national economy that can be performed, the
claimant is not disabled. Abbott v. Sullivan, 905 F.2d 918, 923 (6th Cir. 1990).
IV. Summary of Commissioner’s Decision
The ALJ found Gonzalez established medically determinable, severe impairments, due to
affective disorder and limited vision of the left eye; however, her impairments, either singularly
or in combination, did not meet or equal one listed in 20 C.F.R. Pt. 404, Subpt. P, App. 1. (Tr.
20-21.) Gonzalez was determined to have a Residual Functional Capacity (“RFC”) for a full
range of work at all exertional levels with a number of non-exertional limitations. (Tr. 22.) The
ALJ then used the Medical Vocational Guidelines (“the grid”) as a framework and VE testimony
to determine that Gonzalez was not disabled. (Tr. 24A-24B.)
V. Standard of Review
This Court’s review is limited to determining whether there is substantial evidence in the
record to support the ALJ’s findings of fact and whether the correct legal standards were applied.
See Elam v. Comm’r of Soc. Sec., 348 F.3d 124, 125 (6th Cir. 2003) (“decision must be affirmed
if the administrative law judge’s findings and inferences are reasonably drawn from the record or
supported by substantial evidence, even if that evidence could support a contrary decision.”);
Kinsella v. Schweiker, 708 F.2d 1058, 1059 (6th Cir. 1983). Substantial evidence has been
defined as “[e]vidence which a reasoning mind would accept as sufficient to support a particular
conclusion. It consists of more than a mere scintilla of evidence but may be somewhat less than
a preponderance.” Laws v. Celebrezze, 368 F.2d 640, 642 (4th Cir. 1966); see also Richardson v.
Perales, 402 U.S. 389 (1971).
The findings of the Commissioner are not subject to reversal merely because there exists
in the record substantial evidence to support a different conclusion. Buxton v. Halter, 246 F.3d
762, 772-3 (6th Cir. 2001) (citing Mullen v. Bowen, 800 F.2d 535, 545 (6th Cir. 1986)); see also
Her v. Comm’r of Soc. Sec., 203 F.3d 388, 389-90 (6th Cir. 1999) (“Even if the evidence could
also support another conclusion, the decision of the Administrative Law Judge must stand if the
evidence could reasonably support the conclusion reached. See Key v. Callahan, 109 F.3d 270,
273 (6th Cir. 1997).”) This is so because there is a “zone of choice” within which the
Commissioner can act, without the fear of court interference. Mullen, 800 F.2d at 545 (citing
Baker v. Heckler, 730 F.2d 1147, 1150 (8th Cir. 1984)).
In addition to considering whether the Commissioner’s decision was supported by
substantial evidence, the Court must determine whether proper legal standards were applied.
Failure of the Commissioner to apply the correct legal standards as promulgated by the
regulations is grounds for reversal. See, e.g.,White v. Comm’r of Soc. Sec., 572 F.3d 272, 281
(6th Cir. 2009); Bowen v. Comm’r of Soc. Sec., 478 F.3d 742, 746 (6th Cir. 2006) (“Even if
supported by substantial evidence, however, a decision of the Commissioner will not be upheld
where the SSA fails to follow its own regulations and where that error prejudices a claimant on
the merits or deprives the claimant of a substantial right.”)
Finally, a district court cannot uphold an ALJ’s decision, even if there “is enough evidence
in the record to support the decision, [where] the reasons given by the trier of fact do not build an
accurate and logical bridge between the evidence and the result.” Fleischer v. Astrue, 774 F.
Supp. 2d 875, 877 (N.D. Ohio 2011) (quoting Sarchet v. Chater, 78 F.3d 305, 307 (7th Cir.1996);
accord Shrader v. Astrue, 2012 WL 5383120 (E.D. Mich. Nov. 1, 2012) (“If relevant evidence is
not mentioned, the Court cannot determine if it was discounted or merely overlooked.”);
McHugh v. Astrue, 2011 WL 6130824 (S.D. Ohio Nov. 15, 2011); Gilliam v. Astrue, 2010 WL
2837260 (E.D. Tenn. July 19, 2010); Hook v. Astrue, 2010 WL 2929562 (N.D. Ohio July 9,
Treating Physician Rule
Gonzalez argues that the ALJ violated the treating physician rule by failing to provide
reasonably adequate explanations for rejecting the opinions of a treating psychiatrist – Achala
Patel, M.D. (ECF No.16 at 18-21.) The Commissioner asserts that the ALJ adequately
explained her reasons for discounting Dr. Patel’s opinions. (ECF No. 18 at 9-10.)
Under Social Security regulations, the opinion of a treating physician is entitled to
controlling weight if such opinion (1) “is well-supported by medically acceptable clinical and
laboratory diagnostic techniques” and (2) “is not inconsistent with the other substantial evidence
in [the] case record.” Meece v. Barnhart, 2006 WL 2271336 at * 4 (6th Cir. Aug. 8, 2006); 20
C.F.R. § 404.1527(c)(2). “[A] finding that a treating source medical opinion . . . is inconsistent
with the other substantial evidence in the case record means only that the opinion is not entitled
to ‘controlling weight,’ not that the opinion should be rejected.” Blakley v. Comm’r of Soc. Sec.,
581 F.3d 399 (6th Cir. 2009) (quoting Soc. Sec. Rul. 96-2p, 1996 SSR LEXIS 9 at *9); Meece,
2006 WL 2271336 at * 4 (Even if not entitled to controlling weight, the opinion of a treating
physician is generally entitled to more weight than other medical opinions.) Indeed, “[t]reating
source medical opinions are still entitled to deference and must be weighed using all of the
factors provided in 20 C.F.R. § 404.1527 and 416.927.” Blakley, 581 F.3d at 408.1
If the ALJ determines a treating source opinion is not entitled to controlling weight, “the
ALJ must provide ‘good reasons’ for discounting [the opinion], reasons that are ‘sufficiently
specific to make clear to any subsequent reviewers the weight the adjudicator gave to the treating
source’s medical opinion and the reasons for that weight.’” Rogers, 486 F.3d at 242 (quoting
Soc. Sec. Ruling 96-2p, 1996 SSR LEXIS 9 at *5). The purpose of this requirement is two-fold.
First, a sufficiently clear explanation “‘let[s] claimants understand the disposition of their cases,’
particularly where a claimant knows that his physician has deemed him disabled and therefore
‘might be bewildered when told by an administrative bureaucracy that she is not, unless some
reason for the agency’s decision is supplied.’” Id. (quoting Wilson v. Comm’r of Soc. Sec., 378
F.3d 541, 544 (6th Cir. 2004)). Second, the explanation “ensures that the ALJ applies the treating
physician rule and permits meaningful appellate review of the ALJ’s application of the rule.”
Wilson, 378 F.3d at 544. Because of the significance of this requirement, the Sixth Circuit has
held that the failure to articulate “good reasons” for discounting a treating physician’s opinion
“denotes a lack of substantial evidence, even where the conclusion of the ALJ may be justified
based upon the record.” Rogers, 486 F.3d at 243.
Nevertheless, the opinion of a treating physician must be based on sufficient medical data,
Pursuant to 20 C.F.R. § 416.927(c)(2), when not assigning controlling weight to a treating
physician’s opinion, the Commissioner should consider the length of the relationship and
frequency of examination, the nature and extent of the treatment relationship, how
well-supported the opinion is by medical signs and laboratory findings, its consistency with the
record as a whole, the treating source’s specialization, the source’s familiarity with the Social
Security program and understanding of its evidentiary requirements, and the extent to which
the source is familiar with other information in the case record relevant to the decision.
and upon detailed clinical and diagnostic test evidence. See Harris v. Heckler, 756 F.2d 431,
435 (6th Cir. 1985); Bogle v. Sullivan, 998 F.2d 342, 347-48 (6th Cir. 1993); Blakley, 581 F.3d at
406. The ALJ is not bound by conclusory statements of a treating physician that a claimant is
disabled, but may reject such determinations when good reasons are identified for not accepting
them. King v. Heckler, 742 F.2d 968, 973 (6th Cir. 1984); Duncan v. Sec’y of Health & Human
Servs., 801 F.2d 847, 855 (6th Cir. 1986); Garner v. Heckler, 745 F.2d 383, 391 (6th Cir. 1984).
According to 20 C.F.R. § 404.1527(d)(1), the Social Security Commissioner makes the
determination whether a claimant meets the statutory definition of disability. This necessarily
includes a review of all the medical findings and other evidence that support a medical source’s
statement that one is disabled. “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.” Id. It is the
Commissioner who must make the final decision on the ultimate issue of disability. Duncan,
801 F.2d at 855; Harris, 756 F.2d at 435; Watkins v. Schweiker, 667 F.2d 954, 958 n. 1 (11th Cir.
Gonzalez asserts that the ALJ failed to give appropriate weight to the opinions of Dr.
Patel, her treating psychiatrist, specifically opinions she rendered in 2011 and 2012. (ECF No.
16 at 19.) The record contains four statements from Dr. Patel relating to Gonzalez’s mental
ability to sustain basic work functions.
The first Mental Functional Capacity Assessment is dated April 3, 2007, wherein Dr. Patel
opined that Gonzalez was markedly limited in her ability to interact appropriately with the
general public and moderately limited in her ability to maintain attention and concentration for
extended periods. (Tr. 449.) Dr. Patel found no other significant limitations in the other
eighteen categories and opined that Gonzalez was employable. Id.
Over four years later, on May 9, 2011, Dr. Patel completed a second assessment wherein
she found that Gonzalez was markedly limited in eight of twenty categories, moderately limited
in ten others, and not significantly limited in the remaining two. (Tr. 453.)
On September 29, 2011, Dr. Patel stated that Gonzalez’s ability to sustain concentration,
persist at tasks, and complete tasks in a timely fashion was poor to fair. (Tr. 299.) She further
explained that Gonzalez had low frustration tolerance, difficulty adapting to changes, and
difficulty interacting with others. Id.
On February 24, 2012, Karin Biggs, a licensed social worker, and Dr. Patel, as the
supervising doctor, completed a medical source statement concerning the nature and severity of
Gonzalez’s mental impairments. (Tr. 457-58.) Therein, it was indicated that Gonzalez was
markedly limited in her ability to interact appropriately with others (e.g., public, supervisors, coworkers) and in her ability to withstand the stresses and pressures of routine simple unskilled
work, as well as moderately limited in her ability to maintain attention and concentration for
two-hour periods of time. (Tr. 457-58.)
The ALJ addressed Dr. Patel’s opinions as follows:
In May 2011, Dr. Patel listed marked limitations in the ability to maintain
attention and concentration for extended periods; in the ability to perform
activities within a schedule, maintain regular attendance, and be punctual within
customary tolerances, in the ability to work in coordination with or proximity to
others without being distracted by them; in the ability to interact appropriately
with general public; in the ability to ask simple questions or request assistance; in
the ability to accept instructions and respond appropriately to criticism from
supervisors; in the ability to get along with coworkers or peers without distracting
them or exhibiting behavioral extremes; and in the ability to respond
appropriately to changes in the work setting (Exhibit B26F). This is in contrast to
a similar report filled out by Dr. Patel in 2007 at Exhibit 25F in which Dr. Patel
only listed one marked limitation, in the ability to interact appropriately with the
general public (Exhibit B25F).2 In September 2011, Dr. Patel stated that Ms.
Gonzalez's concentration was good to fair (Exhibit B9F).
Karin Biggs, LSW, reported in February 2012 that Ms. Gonzalez had dysthymic
disorder (Exhibit B27F). She stated that Ms. Gonzalez had marked limitation in
the ability to interact appropriately with others and marked limitations in the
ability to withstand the stresses and pressures of routine simple unskilled work
(Exhibit B27F). Despite these marked limitations, Karin Biggs, LSW, reported
that she had not witnessed Ms. Gonzalez in an employment setting
and offered no additional information in support of the marked limitations.
I accept the report filled out by Dr. Patel in 2007 at Exhibit 25F in which Dr.
Patel only listed one marked limitation, in the ability to interact appropriately
with the general public to be supported by the evidence (Exhibit B25F). The
record does not support the numerous marked limitations Dr. Patel later suggests
in 2011 at Exhibit B26F, although, I accept the same marked limitation recorded
at both exhibits with respect to dealing with others to the extent that Ms.
Gonzalez is limited to low stress unskilled simple tasks. In September 2011, Dr.
Patel stated that Ms. Gonzalez had difficulty interacting with others due to
anxiety and low frustration tolerance (Exhibit B9F).
With respect to the assessment of Karin Biggs, LSW, in February 2012, I accept
that Ms. Gonzalez is not motivated in recovery and that this undermines her
credibility (Exhibit B27F).
The Commissioner does not challenge Gonzalez’s assertion that Dr. Patel qualifies as a
treating physician. (ECF No. 18.) The ALJ, therefore, was required to provide good reasons for
rejecting the limitations she assessed. Without any meaningful analysis or discussion, the ALJ
offered three reasons for effectively rejecting Dr. Patel’s May 2011 opinion: (1) it was “in
The Court notes that it is unclear from the decision which time period the ALJ is
considering. Gonzalez alleged a disability onset date of February 26, 2006. (Tr. 18.)
Gonzalez concedes that she had a prior application for SSI denied on September 12, 2007.
(ECF No. 16 at 2.) Gonzalez further avers that the ALJ was permitted to reopen the 2007
application for “good cause.” Id. There is no indication that the ALJ reopened the prior
determination for good cause. At the same time, there is also no indication that the ALJ found
the previous decision to be res judicata, and she did discuss Dr. Patel’s 2007 opinion predating
the earlier SSI denial.
contrast” to a similar report completed by Dr. Patel in 2007; (2) in September 2011, Dr. Patel
stated that Gonzalez’s concentration was good to fair (Exh. B9F); and, (3) a blanket statement
that the record does not support the numerous marked limitations contained in Dr. Patel’s May
2011 opinion. (Tr. 23-24.)
The ALJ’s primary reason for rejecting the opinions contained in the May 2011
questionnaire completed by Dr. Patel is the inconsistency with an assessment she completed over
four years earlier in 2007. The Court finds this conclusion perplexing. It appears to be based on
the assumption that an individual’s psychological impairments are static in nature, incapable of
improving or deteriorating. The Court finds this a dubious assumption, but this Court, like the
ALJ, has no medical expertise. ALJs are not medical experts and it is well-established that an
ALJ may not substitute personal opinions for those of medical professionals. See, e.g., Meece v.
Barnhart, 192 Fed. App’x. 456, 465 (6th Cir. 2006) (“[T]he ALJ may not substitute his own
medical judgment for that of the treating physician where the opinion of the treating physician is
supported by the medical evidence.”) (citing McCain v. Dir., Office of Workers’ Comp.
Programs, 58 Fed. App’x 184, 193 (6th Cir. 2003) (citation omitted); Pietrunti v. Director, Office
of Workers’ Comp. Programs, United States DOL, 119 F.3d 1035, 1044 (2d Cir. 1997); Schmidt
v. Sullivan, 914 F.2d 117, 118 (7th Cir. 1990) (“But judges, including [ALJs] of the Social
Security Administration, must be careful not to succumb to the temptation to play doctor.”));
accord Winning v. Comm'r of Soc. Sec., 661 F. Supp. 2d 807, 823-24 (N.D. Ohio 2009)
(“Although the ALJ is charged with making credibility determinations, an ALJ ‘does not have
the expertise to make medical judgments.’”); Stallworth v. Astrue, 2009 U.S. Dist. LEXIS
131119, 2009 WL 2271336 at *9 (S.D. Ohio, Feb. 10, 2009) (“[A]n ALJ must not substitute his
own judgment for a physician’s opinion without relying on other evidence or authority in the
record.”) (quoting Clifford v. Apfel, 227 F.3d 863, 870 (7th Cir. 2000)). The ALJ’s conclusion
that Dr. Patel’s May 2011 was untenable because Dr. Patel proffered a different opinion four
years earlier, without any explanation, is unreasonable. If Gonzalez’s diagnoses, course of
treatment, and examination results remained identical over the same four years, the ALJ’s
decision to discredit the later opinion might be reasonable. However, the decision contains no
such comparison or discussion. Rather, the ALJ offered no meaningful explanation as to why
she chose to credit Dr. Patel’s 2007 opinion while discrediting her May 2011 opinion, aside from
the fact that the limitations contained in the latter were more restrictive. Absent any explanation
or discussion, the Court cannot follow the ALJ’s reasoning. As such, the ALJ failed to give
good reasons for discounting Dr. Patel’s May 2011 opinion.
As noted by the ALJ, on September 29, 2011, Dr. Patel stated that Gonzalez’s
concentration was good to fair. On its surface, this statement appears to be somewhat
inconsistent with Dr. Patel’s May 2011 opinion. However, the May 2011 questionnaire is
considerably more detailed. In the broad category of “Sustained Concentration and Persistence,”
Dr. Patel noted that Gonzalez was moderately limited in her ability to carry out both detailed
instructions, as well as short and simple instructions. (Tr. 453.) Dr. Patel also found only
moderate limitations in Gonzalez’s ability to make simple work related decisions and in her
ability to complete a normal workday and workweek without interruptions from psychologically
based symptoms. Id. However, Dr. Patel also opined that Gonzalez was markedly limited in her
ability to (1) maintain attention and concentration for extended periods; (2) perform activities
within a schedule, maintain regular attendance, and be punctual within customary tolerance; and,
(3) work in coordination with or proximity to others without being distracted by them. Id.
These conclusions are consistent with other portions of the September 29, 2011 opinion cited by
the ALJ, which states that Gonzalez’s “persistence would be expected to be poor to fair.” (Tr.
299.) To the extent the ALJ discredited the more specific opinions in Dr. Patel’s May 2011
opinion due to a superficial inconsistency with a more generalized statement made a few months
later, the Court finds that “good reason” is lacking under the requirements of the treating
The ALJ’s final reason for rejecting Dr. Patel’s opinion – that it is not supported by the
record – is conclusory and devoid of explanation, thereby depriving this Court of the ability to
conduct a meaningful review. The ALJ failed to reference specific facts in the record that were
ostensibly inconsistent with Dr. Patel’s 2011 opinion. Accordingly, this Court cannot accept the
ALJ’s blanket assertion that Dr. Patel’s opinion was not well supported by the record as a whole
as a good reason for rejection. Accepting such a general, boilerplate statement, without any
explanation, would effectively eviscerate the treating physician rule.
Finally, the Commissioner suggests that Dr. Patel’s 2011 opinion was based on Gonzalez’s
subjective and self-reported complaints. (ECF No. 18 at 9.) The Commissioner further points
out that “[i]n the portion of the mental functional capacity assessment form that asked Dr. Patel
to describe Plaintiff’s medical conditions, Dr. Patel wrote only ‘irritability, low frustration
tolerance, sleeping 15-16 hrs a day.’” (ECF No. 18 at 9, citing Tr. 455.) However, the ALJ did
not offer these explanations in his decision. Accordingly, these arguments constitute post hoc
rationale that this Court cannot rely on to supplement the reasoning set forth in the ALJ’s
decision. See, e.g., Bable v. Astrue, 2007 U.S. Dist. LEXIS 83635, 27-28 (N.D. Ohio Oct. 31,
2007) (citing NLRB v. Ky. River Cmty. Care, Inc., 532 U.S. 706, 715, n. 1, 121 S.Ct. 1861, 149
L.Ed.2d 939 (2001)); Sarchet v. Chater,78 F.3d 305 (7th Cir. 1986) (rejecting Defendant’s post
hoc rationale that obesity is per se remediable where there was no factual basis or findings of
fact in the record to support such an argument).
The Court finds that the ALJ erred by failing to give good reasons for rejecting the
limitations assessed by Dr. Patel. As such, in the interests of judicial economy, the Court
declines to address Gonzalez’s remaining assignments of error. Nonetheless, as the
Commissioner has not argued that the medical records, which Gonzalez references in her first
assignment of error, were improperly submitted, the ALJ should consider those records as well.
For the foregoing reasons, the Court finds the decision of the Commissioner not supported
by substantial evidence. Accordingly, the decision is VACATED and the case is REMANDED,
pursuant to 42 U.S.C. § 405(g) sentence four, for further proceedings consistent with this
IT IS SO ORDERED.
/s/ Greg White
U.S. Magistrate Judge
Date: February 17, 2015
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