Coleman v. Social Security Administration

Filing 24

OPINION AND ORDER by Magistrate Judge Kimberly E. West REVERSING and REMANDING the decision of the ALJ. (tjm, Deputy Clerk)

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IN THE UNITED STATES DISTRICT COURT FOR THE
EASTERN DISTRICT OF OKLAHOMA
ANNETTE MARIE COLEMAN,

)
)
)
)
)
)
)
)
)
)

Plaintiff,

COMMISSIONER OF THE SOCIAL
SECURITY ADMINISTRATION,
Defendant.

Case No. CIV-20-174-KEW

OPINION AND ORDER
Plaintiff Annette Marie Coleman (the “Claimant”) requests
judicial review of the decision of the Commissioner of the Social
Security

Administration

(the

“Commissioner”)

denying

her

application for disability benefits under the Social Security Act.
Claimant appeals the decision of the Administrative Law Judge
(“ALJ”) and asserts that the Commissioner erred because the ALJ
incorrectly determined she was not disabled. For the reasons
discussed

below,

it

is

the

finding

of

this

Court

that

the

Commissioner’s decision should be and is REVERSED and the case is
REMANDED for further proceedings.
Social Security Law and Standard of Review
Disability under the Social Security Act is defined as the
“inability to engage in any substantial gainful activity by reason
of any medically determinable physical or mental impairment. . .”
42 U.S.C. § 423(d)(1)(A). A claimant is disabled under the Social
Security Act “only if his physical or mental impairments are of

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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 kind of substantial gainful work which exists
in the national economy. . .” 42 U.S.C. § 423(d)(2)(A). Social
Security regulations implement a five-step sequential process to
evaluate a disability claim. See 20 C.F.R. §§ 404.1520, 416.920. 1
Judicial

review

of

the

Commissioner’s

determination

is

limited in scope by 42 U.S.C. § 405(g). This Court’s review is
limited to two inquiries: first, whether the decision was supported
by substantial evidence; and, second, whether the correct legal
standards were applied. Hawkins v. Chater, 113 F.3d 1162, 1164
(10th

Cir.

1997)

(citation

omitted).

The

term

“substantial

evidence” has been interpreted by the United States Supreme Court
Step one requires the claimant to establish that he is not
engaged in substantial gainful activity, as defined by 20 C.F.R. §§
404.1510, 416.910. Step two requires that the claimant establish that
he has a medically severe impairment or combination of impairments that
significantly limit his ability to do basic work activities. 20 C.F.R.
§§ 404.1521, 416.921. If the claimant is engaged in substantial gainful
activity (step one) or if the claimant’s impairment is not medically
severe (step two), disability benefits are denied. At step three, the
claimant’s impairment is compared with certain impairments listed in 20
C.F.R. Pt. 404, Subpt. P, App. 1. A claimant suffering from a listed
impairment or impairments “medically equivalent” to a listed impairment
is determined to be disabled without further inquiry. If not, the
evaluation proceeds to step four, where claimant must establish that he
does not retain the residual functional capacity (“RFC”) to perform his
past relevant work. If the claimant’s step four burden is met, the burden
shifts to the Commissioner to establish at step five that work exists in
significant numbers in the national economy which the claimant – taking
into account his age, education, work experience, and RFC – can perform.
Disability benefits are denied if the Commissioner shows that the
impairment which precluded the performance of past relevant work does not
preclude alternative work. See generally, Williams v. Bowen, 844 F.2d
748, 750-51 (10th Cir. 1988).
1

2

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to require “more than a mere scintilla. It means such relevant
evidence as a reasonable mind might accept as adequate to support
a conclusion.” Richardson v. Perales, 402 U.S. 389, 401 (1971),
quoting Consolidated Edison Co. v. NLRB, 305 U.S. 197, 229 (1938).
The

court

may

not

re-weigh

the

evidence

nor

substitute

its

discretion for that of the agency. Casias v. Secretary of Health
& Human Servs., 933 F.2d 799, 800 (10th Cir. 1991). Nevertheless,
the

court

must

review

the

record

as

a

whole,

and

the

“substantiality of the evidence must take into account whatever in
the record fairly detracts from its weight.” Universal Camera Corp.
v. NLRB, 340 U.S. 474, 488 (1951); see also, Casias, 933 F.2d at
800-01.
Claimant’s Background
Claimant was 55 years old at the time of the ALJ’s decision.
She has an eleventh-grade education and worked in the past as a
breakfast laborer at a hotel, restaurant cook, and housekeeper.
Claimant alleges an inability to work beginning on July 2, 2013,
due to limitations resulting from depression, anxiety disorder,
learning disability, heart problems, high blood pressure, and acid
reflux.
Procedural History
On June 6, 2017, Claimant filed an application for disability
insurance benefits under Title II (42 U.S.C. § 401, et seq.) of
the

Social

Security

Act

and

an
3

application

for

supplemental

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security income benefits pursuant to Title XVI (42 U.S.C. § 1381,
et seq.) of the Social Security Act. Claimant’s applications were
denied initially and upon reconsideration. On April 8, 2019, ALJ
Jana Kinkade

conducted

Claimant testified.

On

a

hearing

May

20,

in

2019,

Dallas,
ALJ

Texas,

Kinkade

at

which

entered

an

unfavorable decision. Claimant requested review by the Appeals
Council, and on April 6, 2020, it denied review. As a result, the
decision of the ALJ represents the Commissioner’s final decision
for purposes of further appeal. 20 C.F.R. §§ 404.981, 416.1481.
Decision of the Administrative Law Judge
The ALJ made her decision at step four of the sequential
evaluation. She determined that while Claimant suffered from severe
impairments, she did not meet a listing and retained the residual
functional capacity (“RFC”) to perform work at all exertional
levels with additional limitations.
Errors Alleged for Review
Claimant asserts (1) the RFC determination is unsupported by
substantial evidence because the ALJ inappropriately relied on a
lack of treatment, and (2) the ALJ’s step four finding is not
supported by substantial evidence because the VE’s testimony is
not consistent with the Dictionary of Occupational Titles (“DOT”).
Evaluation of Subjective Complaints
In her decision, the ALJ found Claimant suffered from severe
impairments of major depressive disorder and anxiety disorder.
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(Tr.

15).

She

determined

Claimant

could

perform

work

at

all

exertional levels with additional limitations, including never
climbing ladders, ropes, or scaffolds and avoiding exposure to
extremes of heat and unprotected heights. She also limited Claimant
to

“simple,

routine

environment

that

tasks

involves

and
few,

simple
if

decision-making

any,

workplace

in

an

changes.”

Claimant was limited to occasional interaction with supervisors,
co-workers, and the public. (Tr. 19).
After consultation with a vocational expert (“VE”), the ALJ
determined Claimant could perform her past work as a cleaner as
she

actually

performed

the

position

and

as

it

is

generally

performed. (Tr. 22). As a result, the ALJ concluded Claimant has
not been under a disability from July 2, 2013, through the date of
the decision. (Tr. 22).
Claimant contends that the ALJ improperly relied upon her
lack

of

treatment

when

determining

that

Claimant’s

mental

impairment was not as limiting as alleged. She further argues that
the ALJ failed to consider whether Claimant’s mental impairment
prevented her from obtaining treatment.
Social Security Ruling 16-3p, 2017 WL 5180304 (Oct. 25, 2017),
provides specific guidance regarding how an ALJ should consider a
claimant’s subjective complaints when she determines that “the
frequency or extent of the treatment sought by [a claimant] is not
comparable

with

the

degree

of
5

the

[claimant’s]

subjective

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complaints[.]” Id. at *9. It provides that the ALJ will not “find
[a claimant’s] symptoms inconsistent with the evidence in the
record on this basis without considering possible reasons he or
she may not comply with treatment or seek treatment consistent
with the degree of his or her complaints.” Id. One of the reasons
to consider for why a claimant does not pursue treatment is whether
the claimant can afford treatment and whether he or she has access
to “free or low-cost medical services.” Id. at *10. The ALJ is
required to explain how he or she considered the reason in the
evaluation of a claimant’s symptoms. Id. at *10.
As part of her evaluation of Claimant’s symptoms, the ALJ
noted the two-step process for the evaluation of symptoms set forth
in Social Security Ruling 16-3p and the requirements under 20
C.F.R. §§ 404.1529, 416.929. She determined Claimant’s medically
determinable

impairments

could

reasonably

cause

her

alleged

symptoms, but the ALJ found that Claimant’s statements regarding
the intensity, persistence, and limiting effects of her symptoms
were not entirely consistent with the evidence in the record. (Tr.
19-20). In reaching this determination, the ALJ primarily relied
upon Claimant’s lack of treatment when determining the consistency
of Claimant’s subjective statements. The ALJ stated:
While the claimant has had a number of hospital
admissions due to suicidal ideations . . ., she has not
received much follow up treatment. Indeed, the most
recent treatment is from a follow-up at JPS on March 8,
2018. Then, she was oriented to person, place, time, and
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situation. She exhibited a depressed mood and reduced
affect; goal directed thought processes; and her insight
and judgment were fair. . . . The undersigned reasons
that someone who alleges such restrictive limitations as
the claimant would seek some type of treatment. Yet,
there is no evidence of the claimant receiving treatment
from a counselor, therapist, psychiatrist, or any other
mental health professional since March of 2018. Also,
the claimant has not presented herself to any emergency
department – voluntarily or otherwise, since March of
2018. This indicates that her impairments did not cause
the symptoms that she alleges.
(Tr. 20). 2
At the hearing, the ALJ and Claimant’s attorney questioned
Claimant about her treatment. The ALJ asked whether Claimant had
received any treatment for her medical conditions in the last year,
and Claimant responded that she had not. (Tr. 38). Claimant’s
attorney asked if she had experienced problems with her insurance,
and

she

responded,

“Yes.”

(Tr.

40).

The

ALJ

then

questioned

Claimant about how long she had lived in Oklahoma, wherein Claimant
testified she had not been in Oklahoma for a year, but she did not

The ALJ also mentioned Claimant’s lack of treatment when
discussing her mental impairment when assessing the “paragraph B”
criteria and broad areas of functioning. When finding that Claimant had
a moderate limitation in interacting with others, the ALJ stated:
2

This last exam was more than one year prior to the date of
this decision. The undersigned reasons that if someone had
such limiting impairments as the claimant alleges, one would
have sought some type of treatment in the interim period.
Nevertheless, the undersigned interprets the evidence with
the widest latitude possible and finds that the claimant has
a moderate limitation in this area.
(Tr. 18).

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know when she moved. When the ALJ asked if Claimant had “tried to
get medical treatment” since moving, Claimant responded “I, this
one place[,] they want insurance. I don’t know if they have free
clinics there ‘cuz it’s a small town.” (Tr. 47).
Although
administrative

some

questions

hearing

about

were
her

asked
lack

of

of

Claimant

treatment,

at

the

and

her

response suggested the reason was possibly financial, the ALJ did
not ask any further questions. But most importantly, the ALJ’s
decision

does

not

reflect

how

she

considered

Claimant’s

explanation for the lack of medical treatment as required under
Soc. Sec. Ruling 16-3p.
The

Commissioner

argues

that

even

if

the

ALJ

failed

to

properly address Claimant’s lack of treatment, she provided other
reasons for finding Claimant’s symptoms were inconsistent with the
record as a whole. She asserts that the ALJ found Claimant’s
alleged

symptoms

were

inconsistent

with

prior

administrative

medical findings, and the ALJ also considered several of the
regulatory factors to evaluate Claimant’s symptoms.
Although deference must be given to an ALJ’s evaluation of
Claimant’s symptoms, unless there is an indication the ALJ misread
the medical evidence as a whole, see Casias, 933 F.2d at 801, any
findings by the ALJ “should be closely and affirmatively linked to
substantial evidence and not just a conclusion in the guise of
findings.” Kepler v. Chater, 68 F.3d 387, 391 (10th Cir. 1995)
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(quotation omitted). The ALJ’s decision “must contain specific
reasons for the weight given to the [claimant’s] symptoms, be
consistent with and supported by the evidence, and be clearly
articulated so the [claimant] and any subsequent reviewer can
assess how the [ALJ] evaluated the [claimant’s] symptoms.” Soc.
Sec. Rul. 16-3p, 2017 WL 5180304, at *10. An ALJ, however, is not
required to conduct a “formalistic factor-by-factor recitation of
the evidence[,]” but she must set forth the specific evidence upon
which she relied. Qualls v. Apfel, 206 F.3d 1368, 1372 (10th Cir.
2000).
Although the ALJ mentioned that Claimant’s symptoms were
inconsistent

with

prior

administrative

medical

findings

when

discussing the opinion evidence, she partly relied upon Claimant’s
treatment history in reaching this conclusion:
The treatment history further supports these findings:
there has been little follow up with outpatient after
her last hospitalization and there have been no ER visits
or other emergency treatment, which suggests that the
claimant’s condition stabilized.
(Tr. 21). Moreover, the ALJ merely listed certain regulatory
factors and summarized Claimant’s testimony or statements from her
function

reports. 3

She

did

not,

however,

“closely

and

The ALJ stated that she considered Claimant’s statements and
assessed whether they were consistent with the medical evidence or other
evidence in the record. She specifically indicated she considered “some”
of the factors and then listed the factors, including daily activities;
the location, duration, frequency, and intensity of pain or other
symptoms; factors that precipitate and aggravate symptoms; the type,
dosage, effectiveness, and side effects of any medication the individual
3

9

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affirmatively” link her findings to substantial evidence in the
record or articulate how these factors influenced her findings.
See Kepler, 68 F.3d at 391 (“[T]he link between the evidence and
credibility determination is missing; all we have is the ALJ’s
conclusion.”).
On remand, the ALJ should conduct a proper symptom evaluation.
She should properly consider Claimant’s reasons for the lack of
medical

treatment

Claimant’s

and

symptoms.

clearly

articulate

Moreover,

because

how

she

the

evaluated

ALJ’s

symptom

evaluation affects the overall RFC determination, this Court finds
the RFC is unsupported by substantial evidence, and the ALJ must
reconsider the RFC on remand. See Poppa v. Astrue, 569 F.3d 1167,
1171

(10th

Cir.

2009)

(“Since

the

purpose

of

the

[symptom]

evaluation is to help the ALJ access a claimant’s RFC, the ALJ’s
[symptom

evaluation]

and

RFC

determinations

are

inherently

intertwined.”). Based on the RFC determination, the ALJ should
then determine whether Claimant can perform her past relevant work
and/or other work in the national economy.
Conclusion
The

decision

of

the

Commissioner

is

not

supported

by

substantial evidence and the correct legal standards were not

takes or has taken to alleviate pain or other symptoms; and treatment,
other than medication, the individual receives or has received for relief
of pain or other symptoms. Under each of these headings, the ALJ
summarized Claimant’s statements. (Tr. 21-22).

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applied. Therefore, this Court finds, in accordance with the fourth
sentence of 42 U.S.C. § 405(g), the ruling of the Commissioner of
Social Security Administration should be and is REVERSED and the
case is REMANDED for further proceedings consistent with the
Opinion and Order.
IT IS SO ORDERED this 29th day of September, 2022.

KIMBERLY E. WEST
UNITED STATES MAGISTRATE JUDGE

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