DeJesus v. Astrue
MEMORANDUM re Complaint filed by Sonia DeJesus 1 , Answer 7 and administrative record 8 filed by Comm'r of SS (Order to follow as separate docket entry)Signed by Honorable Sylvia H. Rambo on 01/10/14. (ma)
IN THE UNITED STATES DISTRICT COURT
FOR THE MIDDLE DISTRICT OF PENNSYLVANIA
CAROLYN W. COLVIN,
Acting Comm’r of Soc. Sec.,
Civil No. 1:12-CV-2318
Judge Sylvia H. Rambo
In this appeal from a decision of the Commissioner of Social Security
denying Disability Insurance Benefits, Plaintiff claims the administrative decision
concluding that she has not been under a disability as defined by the Social Security
Act is not supported by substantial evidence and contains errors of law. For the
following reasons, the court will affirm the decision of the Commissioner.
On July 18, 2006, Plaintiff, Sonia DeJesus, protectively filed
applications for Disability Insurance Benefits (“DIB”) under Title II of the Social
Security Act. (See Doc. 8-5, p. 4 of 31.) Plaintiff claimed disability beginning on
January 1, 2003. (Id.) The Social Security Administration initially denied
Plaintiff’s application by decision dated September 27, 2006. (Doc. 8-4, p. 4 of
118.) On November 12, 2006, Plaintiff requested a hearing before an
Administrative Law Judge (“ALJ”). (Id. at p. 9 of 118.) ALJ George Yatron held a
hearing on February 27, 2008, at which Plaintiff and Daniel M. Rapucchi, a
vocational expert, testified. (Doc. 8-2, pp. 40-70 of 104.) ALJ Yatron issued an
unfavorable decision to Plaintiff on April 25, 2008 (Doc. 8-3, pp. 19-28 of 33), and
Plaintiff filed an appeal with the Appeals Council on June 13, 2008 (Doc. 8-4, pp.
25-27 of 118).
While the claim was pending on appeal, Plaintiff filed another
application for DIB on May 8, 2009. (See Doc. 8-5, pp. 23-31 of 31.) In this
application, Plaintiff claimed disability beginning on April 26, 2008. (Id. at p. 25 of
31.) The Social Security Administration initially denied this second application by
decision dated July 2, 2010. (Doc. 8-4, pp. 105-09 of 118.) On July 8, 2010,
Plaintiff requested another hearing before an ALJ. (Id. at pp. 117-18 of 118.) The
Appeals Council remanded the first claim, and directed the ALJ to adequately
consider Plaintiff’s maximum residual functional capacity during the entire period at
issue, and, in so doing, to evaluate the opinion of Plaintiff’s treating psychiatrist.
(Doc. 8-3, pp. 30-31 of 33.) The Appeals Council further directed the first and
second claims be consolidated. (Id.)
On January 5, 2011, ALJ Yatron held a second hearing on the
consolidated action, at which time both Plaintiff and Patricia Scott, an impartial
vocational expert, testified. (See Doc. 8-2, pp. 71-106 of 106.) The ALJ denied the
consolidated action in its entirety on March 10, 2011 (Id. at pp. 21-32 of 106), and
Plaintiff filed an unsuccessful appeal with the Appeals Council (Id. at p. 18 of 106).
The Appeals Council denied Plaintiff’s request on September 21, 2012 (Id. at p. 2 of
106), and Plaintiff commenced the instant action on November 20, 2012 (Doc. 1).
Plaintiff’s General Background
Plaintiff is a citizen of the United States, and was born on September
18, 1971 (Doc. 8-5, p. 25 of 31), and, at all times relevant to this matter, was
considered a “younger individual,”1 whose age would not seriously impact her
ability to adjust to other work. 20 C.F.R. § 404.1563(c). Plaintiff completed
secondary school and is able to communicate in English. (Doc. 8-2, p. 44 of 106.)
As of the date of the hearings, Plaintiff was approximately five feet and four inches
tall, and weighed 225 pounds as of the first hearing, and 178 pounds as of the
second hearing.2 (Doc. 8-2, pp. 43, 76 of 106.) Plaintiff lived with her five
children, four of whom were considered minors as of the date of the second hearing.
(Id. at p. 76 of 106.) Plaintiff had prior relevant work experience as a hand packager,
in which capacity she was last employed in 2002, and housekeeper, in which
capacity she was last employed in 2004. (Id. at pp. 46 of 106.)
The gravamen of Plaintiff’s instant action is the ALJ’s assessment of
her psychological impairments. (See Doc. 13, pp. 5-11 of 14.) Nevertheless, the
record contains evidence concerning Plaintiff’s physical medical conditions, and
demonstrates Plaintiff has several physical impairments.
Plaintiff received treatment by her primary care physician for various
physical ailments, including gastroesophageal reflux disease, obesity, osteoarthritis,
fibromyalgia, and cold/exercise-induced asthma. (See Doc. 8-7, p. 152 of 177.)
Plaintiff was advised that losing weight could help her physical ailments, and
exercising and altering her diet caused a decrease in her weight. (Id. at p. 173 of
The Social Security regulations use the term “younger individual” to denote an individual
aged 18 through 49 years. See 20 C.F.R. § 404.1563(c).
The decrease in Plaintiff’s weight is attributable, at least in part, to gastric bypass surgery
she underwent after her date of last insured.
177.) Plaintiff also suffered discomfort due to the weight of her breasts (Id. at p.
151 of 177), and was evaluated for a breast reduction surgery in 2006 (See id. at p. 5
of 177). Dr. Thomas Dibenedetto determined that Plaintiff did not have any
musculoskeletal reason for her experiencing pain in her back apart from her oversized breasts. (Id.)
In 2009, Plaintiff sought medical attention for chronic intermittent pain
in her hands, elbows, back, and knees. (Doc. 8-9, p. 67 of 95.) Plaintiff was
diagnosed with having fibromyalgia by her primary care physician. (Id. at pp. 66-67
of 95.) Plaintiff’s rhematologic laboratory test results were negative, and Plaintiff
was prescribed several medications to assist with the pain. (Id. at p. 66 of 95.)
With regard to Plaintiff’s mental health issues, records show that
Plaintiff was evaluated in early 2005, and diagnosed as having a major depressive
affective disorder, recurrent without psychotic features. (See Doc. 8-7, p. 123 of
177.) Plaintiff saw John Illingworth, LCSW, and Heather Zettlemoyer, LSW, for
individual psychological therapy from February 2005 through August 2008. (See
generally id. at p. 123 of 177; Doc. 8-9, pp. 78-83 of 95.) During these sessions,
Plaintiff’s therapists generally noted that Plaintiff had a depressed mood and
occasionally reported feeling anxious. (Doc. 8-7, p. 46 of 177.) Plaintiff had an
inconsistent history of attending therapy sessions, and frequently cancelled
scheduled appointments. (See, e.g., id. at pp. 51, 73 of 177.)
Plaintiff was treated by Dr. Kishorkumar Dedania, M.D., and Jennifer
Morrison, PA-C, for medication management between May 2005 and April 2009.
(See generally Doc. 8-7, p. 118 of 177; Doc. 8-9, p. 88 of 95.) Plaintiff continually
reported feeling depressed, anxious, and stressed, and attributed these feelings to her
having five children whom she raises herself. (See, e.g., Doc. 8-9, p. 89 of 95.)
During the course of treatment, Dr. Dedania prescribed various medications,
including Xanax, Abilify, and antidepressants, such as Zoloft, Wellbutrin, and
Effexor. (See, e.g., Doc. 8-9, p. 92 of 95.) Although Plaintiff reported that, while on
medication, she was doing much better and experienced less depression and anxiety
(see, e.g., Doc. 8-8, p. 13 of 42 (“[Plaintiff] stated that she’s less depressed and less
anxious as long as she takes her medication.”), Plaintiff inconsistently took the
medication (see, e.g., Doc. 8-7, p. 78 (“Taking Xanax infrequently.”), 79 (“Stated
that she stopped taking Zoloft and Abilify because of the weight problems and now
she’s been having more mood swings and depression.”) of 177).
Plaintiff was examined by Dr. Dedania on April 18, 2006, January 17,
2008, and April 7, 2009, for annual psychiatric evaluations. (Doc. 8-7, p. 79 of 177;
Doc. 8-8, p. 38 of 42; Doc. 8-9, p. 93 of 95.) On April 18, 2006, Dr. Dedania
reported that Plaintiff had an anxious mood and complained about feeling depressed,
which was in part attributed to Plaintiff’s unilateral decision to stop taking
medications. (Doc. 8-7, p. 79 of 177.) Dr. Dedania further reported that Plaintiff
was appropriately dressed and groomed, maintained good eye contact, had intact
attention, concentration, and memory, had an appropriate affect, had average
intellectual functioning, and had fair judgment and insight. (Id.) At this time, Dr.
Dedania reported Plaintiff had a global assessment functioning score of 46, and
again diagnosed Plaintiff as having major depression, without psychotic features,
and noted that financial concerns were Plaintiff’s Axis IV psycho-social and
environmental problems. (Id.)
On January 17, 2008, Dr. Dedania reported that Plaintiff had an anxious
mood and was still mildly depressed. (Doc. 8-8, p. 38 of 42.) Dr. Dedania further
reported that Plaintiff was cooperative, alert, oriented, appropriately dressed and
groomed, had a fairly intact attention and concentration, and fair memory,
intellectual functioning, judgment, and insight. (Id.) At this time, Dr. Dedania
reported Plaintiff had a global assessment functioning score of 48, diagnosed
Plaintiff as having major depression, without psychotic features, and an anxiety
disorder not otherwise specified, and noted that financial and family concerns were
Plaintiff’s Axis IV psycho-social and environmental problems. (Id.)
On April 7, 2009, Dr. Dedania reported that Plaintiff had an anxious
mood and was still mildly depressed. (Doc. 8-9, p. 93 of 95.) Dr. Dedania further
reported that Plaintiff was cooperative, alert, oriented, appropriately dressed and
groomed, had intact concentration and attention, and fair memory, intellectual
functioning, judgment, and insight. (Id.) At this time, Dr. Dedania reported
Plaintiff had a global assessment functioning score of 48, diagnosed Plaintiff as
having major depression, without psychotic features, and an anxiety disorder not
otherwise specified, and again noted that financial and family concerns were
Plaintiff’s Axis IV psycho-social and environmental problems. (Id.)
On February 2, 2007, Dr. Dedania completed a medical source
statement. (See generally Doc. 8-7, pp. 130-135 of 177.) According to Dr.
Dedania’s answers, she diagnosed Plaintiff with major depression. (Id. at p. 130 of
177.) Moreover, Dr. Dedania identified Plaintiff as having poor memory, sleep and
mood disturbances, emotional lability, difficulty thinking or concentrating,
decreased energy, generalized persistent anxiety, and somatization unexplained by
organic disturbance. (Id.) Dr. Dedania opined that Plaintiff’s impairments would
cause her to be absent from work more than three times per month. (Id. at p. 132 of
177.) He further opined that Plaintiff was seriously limited, but not precluded, in
her ability to maintain attention for two hour segments, maintain regular attendance,
sustain an ordinary routine without special supervision, work with others without
being unduly distracted, make simple work related decisions, complete a normal
workweek without interruptions, perform at a consistent pace without an
unreasonable number and length of rest periods, ask simple questions or request
assistance, accept instructions and respond appropriately to criticism from
supervisors, get along with co-workers or peers without unduly distracting them or
exhibiting behavioral extremes, respond appropriately to changes in a routine work
setting, deal with normal work stress, be aware of normal hazards and take
appropriate precautions. (Id. at p. 133 of 177.) Dr. Dedania’s explanation,
including the medical and clinical findings that supported his assessment of the
foregoing, was limited to a single word: “Depression.” (Id.) Dr. Dedania provided
the same to explain his opinions that Plaintiff had a “fair” ability to: understand and
remember detailed instructions, carry out detailed instructions, set realistic goals or
make plans independently of others, deal with stress of semiskilled and skilled work,
interact appropriately with the general public, maintain socially acceptable behavior,
adhere to basic standards of neatness and cleanliness, travel in an unfamiliar place,
and use public transportation. (Id.) Indeed, Dr. Dedania failed to explain or identify
the findings that supported his opinion that Plaintiff’s suffering from depression
would cause Plaintiff to be seriously limited in the abilities to do unskilled work.
(Id.)3 However, Dr. Dedania opined that Plaintiff had a satisfactory ability to
remember work-like procedures, and understand, remember, and carry out very short
and simple instructions. (Id.)
Dr. Dedania further opined that Plaintiff had marked limitations in
activities of daily living, difficulties in maintaining social functioning, difficulties of
concentration, persistence, or pace, and had three episodes of decompensation. (Id.
at p. 134 of 177.) On January 17, 2008, Dr. Dedania represented that Plaintiff’s
condition, symptoms, and limitations had not changed since February 27, 2007. (Id.
at p. 160 of 177.)
Dr. Sidney Segal, Ed.D., a state agency psychologist, performed an
evaluation of Plaintiff as part of a review for the Social Security Administration on
September 27, 2006, and completed a psychiatric review technique form and a
mental residual functional capacity assessment. (Id. at pp. 28-44 of 177.) Dr. Segal
opined that Plaintiff had mild restriction of activities of daily living, mild difficulties
in maintaining social functioning, moderate difficulties in maintaining
concentration, persistence, or pace, and no episodes of decompensation. (Id. at p. 38
of 177.) Dr. Segal also opined that Plaintiff’s limitations were due to her physical
pain rather than psychological problems. (Id. at p. 40 of 177.) In assessing
Plaintiff’s RFC, Dr. Segal found Plaintiff to be, at most, moderately limited. (Id. at
pp. 41-42 of 177.) Specifically, Dr. Segal found that Plaintiff’s ability to understand
and remember detailed instructions, carry out detailed instructions, maintain
attention and concentration for extended periods, complete a normal workweek
“[D]epression [and] anxiety” was provided by Dr. Dedania as his explanation or medical
and clinical findings to support his opinion regarding Plaintiff’s mental abilities needed to do particular
types of jobs. (Doc. 8-7, p. 133 of 177.)
without interruptions, perform at a consistent pace without unreasonable periods of
rest, and respond appropriately to changes in the work setting were moderately
impaired. (Id.) Dr. Segal opined that Plaintiff was capable of meeting the basic
demands of competitive work on a sustained basis despite the limitations resulting
from her having a depressive disorder. (Id. at p. 43 of 177.)
Arlene Rattan, Ph.D., another state agency psychologist, similarly
completed a psychiatric review technique form and mental RFC assessment
following her review of Plaintiff’s medical records on June 7, 2010. (Doc. 8-11, pp.
87-102 of 109.) Dr. Rattan opined that Plaintiff had mild restriction of activities of
daily living, mild difficulties in maintaining social functioning, moderate difficulties
in maintaining concentration, persistence, or pace, and no episodes of
decompensation. (Id. at p. 100 of 109.) In assessing Plaintiff’s RFC, Dr. Rattan
found Plaintiff to be, at most, moderately limited in certain activities. (Id. at pp. 8788 of 109.) Specifically, Dr. Rattan found that Plaintiff’s ability to maintain
attention and concentration for extended periods, perform activities within a
schedule, maintain regular attendance, be punctual, complete a normal workweek
without interruptions, perform at a consistent pace without unreasonable periods of
rest, and respond appropriately to changes in the work setting were each moderately
impaired. (Id.) Dr. Rattan opined that Plaintiff could make simple decisions,
sustain an ordinary routine without special supervision, and was unrestricted in her
understanding, memory, and social interaction abilities. (Id. at p.89 of 109.)
Plaintiff testified that she suffers from depression, anxiety, and panic
attacks. (Doc. 8-2, p. 46 of 106.) According to Plaintiff, her depression is
intermittent, but anxiety is constant. (Id. at p. 92.) Plaintiff testified that her
depression is related to her having a stillborn child in September 2002 (id. at p. 47 of
106), and gets worse when someone has a baby and around the time on which the
child was stillborn (id. at p. 56 of 106). Plaintiff testified that the majority of her
anxiety is related to her concern for the safety of her five children. (Id.) Plaintiff
explained that her anxiety is exacerbated by large numbers of people, and that she
alters her errands outside the house, i.e., grocery shopping, trips to her children’s
school, etc., to occur at “off-peak hours” as to minimize her exposure to large
crowds. (See id. at pp. 83-87 of 106.)
Plaintiff testified that she has both good and bad days. (Id. at p. 51 of
106.) On good days, Plaintiff wakes up and walks her younger children four blocks
to school, returns home and cleans her three story house. (Id.) On bad days, which
are far more frequent according to Plaintiff, she seldom gets out of bed, and her
children watch television with her in her bedroom. (Id. at pp. 54-55 of 106.)
Plaintiff has never been married, raises her children without assistance from their
father, but receives assistance with much of the housework from her adult son. (Id.
at p. 87 of 106.)
Plaintiff admitted that being on a medication regimen improves her
psychological condition and functioning. (See id. at p. 57 of 106.)
Plaintiff has not attempted employment since terminating her
employment as a housekeeper in 2004. (See Doc. 8-2, p. 93 of 106 (containing
Plaintiff’s testimony that she has not worked since she started the application for
DIB); Doc. 8-6, p. 6 of 88 (listing last employment in 2004). But see Doc. 8-5, p. 25
of 31 (alleging Plaintiff became unable to work because of her disabling condition
on April 26, 2008).) Plaintiff testified that she cannot go back to work yet because
she cannot concentrate, and is nervous, depressed, and unreliable. (Doc. 8-2, p. 58 of
106.) Specifically, Plaintiff explained her belief that she is unable to work due to
her feeling “panicked around everything” and medical appointments during the
Do you feel like you could work?
No. I think I - - they wouldn’t want someone like
me at work.
Because I think I’d be panicked around everything.
They probably wouldn’t want me to be excused
every time I got to go to the doctor’s or something.
(Doc. 8-2, p. 96 of 106.)
During the supplemental hearing in 2011, the ALJ posed the following
hypothetical to Patricia Scott, a vocational expert:
[C]onsider hypothetically an individual 39 years of age
with training, education, and experiences in the present
case who is able to lift 20 pounds, stand and walk six
hours in an eight-hour day, sit for six or more hours in an
eight hour day, non-exertional limitations, no detailed
instructions, temperature extremes, vibration, hazardous
machinery, heights, or climbing. Given those facts and
circumstances, is there any work the hypothetical
individual could perform on a sustained basis including
any of the past work of the Claimant?
(Id. at pp. 97-98 of 106.) Based on the hypothetical, Ms. Scott opined that the
hypothetical individual having the same limitations as Plaintiff could perform work
as a cashier and housekeeper. (Id. at 98 of 106.) Ms. Scott provided the following
testimony regarding available occupations in the northeast Pennsylvania region in
addition to Plaintiff’s past relevant work:
Packer. 920.685-026, light, SVP two, unskilled.
Nationally 146,900[,] and in this area, 750. Hand bander
which is by way of explanation banding of any materials
such as envelopes, packs of paper, the little strip that bands
them. 920.687-026. Light, SVP one, unskilled.
Nationally 410,100, and in this area, 640. Hospital
equipment plastic assembler. 712.687-010. Light, SVP
two, unskilled. Nationally 890,00, and in this area, 1,050.
(Id. at p. 98 of 106.) Thus, based on the hypothetical, Ms. Scott suggested that jobs
suitable for Plaintiff’s limitations as posed by ALJ Yatron existed in the regional
economy. (See id.) In response to a hypothetical presented by Plaintiff’s counsel,
which was based on her crediting Plaintiff’s limitations as set forth in Dr. Dedania’s
medical source statement and Plaintiff’s testimony, the vocational expert testified
that Plaintiff’s unscheduled absence two to three days per month would preclude her
from working in any position. (Id. at p. 100 of 106.) The vocational expert also
testified that the combination of Plaintiff’s abilities, as set forth on Dr. Dedania’s
medical source statement, would make it difficult for Plaintiff to sustain
employment, but not preclude her from being employed. (Id. at p. 101 of 106.)
Standard of Review
A district court’s review of the Commissioner’s decision is quite
limited. Rutherford v. Barnhart, 399 F.3d 546, 552 (3d Cir. 2005). The scope of
review by this court is restricted to determining whether the Commissioner applied
the correct legal standards and whether the record, as a whole, contains substantial
evidence to support the Commissioner’s findings of fact. 42 U.S.C. § 405(g);
Richardson v. Perales, 402 U.S. 389, 401 (1971). Findings of fact by the
Commissioner are considered conclusive provided they are supported by
“substantial evidence,” a standard that has been described as “such relevant
evidence as a reasonable mind might accept as adequate to support a conclusion.”
Reefer v. Barnhart, 326 F.3d 376, 379 (3d Cir. 2003) (quoting Smith v. Califano,
637 F.2d 968, 970 (3d Cir. 1981); Richardson, 402 U.S. at 401). “A single piece of
evidence will not satisfy the substantiality test if the [ALJ] ignores, or fails to
resolve, a conflict created by countervailing evidence.” Kent v. Schweiker, 710 F.2d
110, 114 (3d Cir. 1983).
This court does not undertake a de novo review of the decision and
does not re-weigh evidence presented to the Commissioner. Schoengarth v.
Barnhart, 416 F. Supp. 2d 260, 265 (D.Del. 2006) (citing Monsour Med. Ctr. v.
Heckler, 806 F.2d 1185, 1190 (3d Cir. 1986). The substantial evidence standard
gives deference to inferences drawn from the facts if they, in turn, are supported by
substantial evidence. See id. If the decision is supported by substantial evidence,
the reviewing court must affirm the decision, even if the record contains evidence
which would support a contrary conclusion, Panetis v. Barnhart, 95 F. App’x 454,
455 (3d Cir. 2004), or if the court itself “would have decided the factual inquiry
differently,” Hartranft v. Apfel, 181 F.3d 358, 360 (3d Cir. 1999).
At the core of both of Plaintiff’s arguments is the ALJ’s finding that
Plaintiff’s reports regarding the extent of her psychological impairments were
exaggerated and not credible. Before addressing Plaintiff’s arguments, the court
will first discuss the administrative framework applicable to determinations of
benefit eligibility and then set forth the key points of the ALJ’s decision.
In determining whether a claimant is eligible for disability insurance
benefits, the burden is on the claimant to show that she has a medically determinable
physical or mental impairment (or combination of such impairments) which is so
severe she is unable to pursue substantial gainful employment4 currently existing in
the national economy.5 Applicable to Plaintiff, a “disability” is defined as the
“inability 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. § 423(d)(1)(A); Ramirez v. Barnhart, 372 F.3d
546, 550 (3d Cir. 2004). A claimant is considered to be unable to engage in
substantial gainful activity “only if [her] physical or mental impairment or
impairments are of such severity that [she] is not only unable to do [her] previous
work but cannot, considering [her] 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), 1382c(a)(3)(B); Knepp v. Apfel, 204 F.3d 78, 83 (3d Cir.
2000). To receive disability insurance benefits, a claimant must show that [she]
contributed to the insurance program, is under retirement age, and became disabled
According to 20 C.F.R. 416.972, substantial employment is defined as “work activity that
involves doing significant physical or mental activities.” “Gainful work activity” is the type of work
usually done for pay or profit.
A claimant seeking supplemental security income benefits must also show that her income
and financial resources are below a certain level. 42 U.S.C. § 1382(a).
prior to the date on which [she] was last insured. 42 U.S.C. § 423(a); 20 C.F.R. §
404.131(a). The Commissioner does not dispute that Plaintiff satisfies the first two
non-medical requirements and the parties do not object to the ALJ’s finding that
Plaintiff’s date of last insured for purposes of receiving disability benefits was June
30, 2009 (Doc. 8-2, p. 26 of 106; Doc. 13, p. 1 n.2 of 14.)
To determine a claimant’s rights to DIB,6 the ALJ conducts a formal
five-step evaluation process:
(1) if the claimant is working or doing substantial gainful
activity, she cannot be considered disabled;
(2) if the claimant does not suffer from a severe
impairment or combination of impairments that
significantly limits her ability to do basic work activity,
she is not disabled;
(3) if the claimant does suffer from a severe impairment
which meets or equals criteria for an impairment listed in
20 C.F.R. part 404, Subpart P, Appendix 1 (“the Listings”)
and the condition has lasted or is expected to last
continually for at least twelve months, the claimant is
(4) if the claimant retains sufficient residual functional
capacity (“RFC”)7 to perform his past relevant work, she is
not disabled; and
(5) if, taking into account the claimant’s RFC, age,
education, and past work experience, the claimant can
The same test is used to determine disability for purposes of receiving either DIB or SSI
benefits. Burns v. Barnhart, 312 F.3d 113, 119 n.1 (3d Cir. 2002). Therefore, courts routinely consider
case law developed under both programs.
Briefly stated, RFC is the most a claimant can do despite his recognized limitations.
Social Security Ruling 96-9p defines RFC as “the individual’s maximum remaining ability to perform
work on a regular and continuing basis, i.e., 8 hours a day, for 5 days a week, or an equivalent work
perform other work that exists in the local, regional, or
national economy, she is not disabled.
See 20 C.F.R. § 416.920(a)(4); see also Morales v. Apfel, 225 F.3d 310, 316 (3d Cir.
2000). The claimant bears the burden of proof for steps one, two, and four of this
test. Sykes v. Apfel, 228 F.3d 259, 263 (3d Cir. 2000). The Commissioner bears the
burden of proof for the last step to show that the claimant is capable of performing
other jobs existing in significant numbers in the national economy. Id. (citing
Bowen v. Yuckert, 482 U.S. 137, 146 n.5 (1987).
When challenging the ALJ’s conclusion regarding the third step, the
claimant bears the burden of proof. See Crostly v. Astrue, Civ. No. 10-cv-0088,
2011 WL 5026341, *2 (W.D. Pa. Oct. 21, 2011) (citing Davis v. Commissioner of
Soc. Sec., 105 F. App’x 319, 323 (3d Cir. 2004)); see also Ramirez, 372 F.3d at 550.
Specifically, “[f]or a claimant to show that [her] impairment matches a listing, it
must meet all of the specified medical criteria. An impairment that manifests only
some of those criteria, no matter how severely, does not qualify.” Sullivan v. Zebley,
493 U.S. 521, 530 (1990) (emphasis in original). Moreover, for a claimant to prove
that her impairment is equivalent to a listing, she must “proffer medical findings
which are equal in severity to all the criteria for the one most similar listed
impairment.” Stremba v. Barnhart, 171 F. App’x 936, 938 (3d Cir. 2006) (citing
Sullivan, 493 U.S. at 530) (emphasis added).
Following the prescribed analysis, ALJ Yatron first concluded Plaintiff
has not engaged in substantial gainful activity since December 2004, which is nearly
two years after the January 1, 2003 onset date as alleged in Plaintiff’s application
dated July 18, 2006 (Doc. 8-5, p. 4 of 31), or nearly three and a half years before the
April 26, 2008 onset date as alleged in Plaintiff’s application dated May 8, 2009 (Id.
at p. 25 of 31.). (Doc. 8-2, p. 26 of 106.) In resolving step two, the ALJ found that,
as of the date of the hearing, Plaintiff suffered from four severe impairments: mood
disorders, obesity, osteoarthritis, and fibromyalgia. (Id.)
At step three, the ALJ concluded none of Plaintiff’s impairments,
considered singly or in combination, satisfied the criteria of any relevant Listing.
(Id. at p. 27 of 106.) That is, ALJ Yatron found that Plaintiff’s physical impairments
did not meet or medically equal Listing 1.02, finding that she could ambulate
effectively and was able to perform fine and gross movements. (Id.) Such a finding
was certainly supported by substantial evidence. (See Doc. 8-7, pp. 22-27 of 177.)
With regard to Plaintiff’s psychological impairments, although she reported
experiencing significant depression and anxiety, the ALJ found that Plaintiff’s
medical records did not demonstrate she met or medically equaled the criteria of
Listing 12.04. (Doc. 8-2, p. 27 of 106.) In support of his conclusion, the ALJ found
that Plaintiff only had mild restrictions in activities of daily living and social
functioning, and moderate limitations with regard to concentration, persistence, and
pace. (Id.) ALJ Yatron also found that Plaintiff had not experienced any episodes
of decompensation. (Id.) Because the ALJ found that Plaintiff did not have any
marked difficulties, he concluded that the Paragraph B criteria4 were not satisfied.
ALJ further found that Plaintiff did not satisfy the Paragraph C criteria, concluding
that there was no evidence that Plaintiff experienced any episodes of
To qualify under Listing 12.04, a claimant’s mental impairment must result in at least two
of the following: marked restriction of activities of daily living, marked difficulties in maintaining social
functioning, marked difficulties in maintaining concentration, persistence or pace, or repeated episodes
of decompensation, each of extended duration.
decompensation, that a minimal increase in the mental demands or change in
environment would cause her to decompensate, or that she could not function
outside a highly supportive living arrangement. (Id.) Thus, ALJ Yatron concluded
that Plaintiff’s impairments did not satisfy the third step of the sequential evaluation
At step four, the ALJ concluded Plaintiff:
[H]ad the residual functional capacity to perform light
work as defined in 20 CFR 404.1567(b), except that she
could not follow detailed instructions, she could not climb,
and she could not be exposed to hazardous machinery,
temperature extremes, heights, and vibration.
(Id. at p. 28 of 106.) The ALJ further concluded that Plaintiff could perform her
past relevant work as a housekeeper, which was classified as light in exertion and
unskilled in nature. (Id. at p. 31 of 106.) Moreover, based on Plaintiff’s young age,
level of education, work experience, and residual functional capacity, as well as the
vocational expert’s testimony, the ALJ concluded that there were numerous light,
unskilled jobs existing in the national and regional economies that Plaintiff could
perform despite her limitations, such as, a packer, hand bander, and hospital
equipment assembler. (See id. at p. 32 of 106.)
The ALJ further acknowledged Plaintiff’s claims of experiencing
depression and anxiety, and noted that Plaintiff underwent a course of psychopharmaceutical treatment that was effective, although Plaintiff had a history of
noncompliance with her psychiatric treatment. (Id. at p. 29 of 106.) The ALJ also
noted that Dr. Dedania found Plaintiff had numerous marked restrictions and three
episodes of decompensation, but did not credit Dr. Dedania’s opinion because it was
neither internally consistent nor consistent with the medical record. (Id. at p. 30 of
106.) Instead, the ALJ credited the opinion of Dr. Segal, the state agency
psychiatrist, finding it more consistent with the objective medical evidence, which
indicated, inter alia, that Plaintiff had only mild to moderate difficulties with
relevant abilities, and no repeated episodes of decompensation. (Id. at p. 29 of 106.)
Finally, although the ALJ found that Plaintiff’s medically determinable impairments
could reasonably be expected to produce the alleged symptoms, he discredited
Plaintiff’s statements concerning the intensity, duration, and limiting effects of the
alleged symptoms as inconsistent with the balance of the record. (See id.)
Plaintiff raises two arguments in support of her appeal. Specifically,
she contends that the ALJ improperly: (1) disregarded the opinion of Plaintiff’s
treating psychiatrist; and (2) assessed the credibility of Plaintiff. The court will
address these contentions in an order to facilitate their discussion.
Plaintiff contends that the ALJ did not properly assess her credibility.
Essentially, Plaintiff contends that the ALJ erred in finding that Plaintiff’s testimony
concerning the intensity, duration, and limiting effects of her depression and anxiety
was not credible. (See Doc. 8-2, p. 29 of 106.) Pursuant to regulations promulgated
by the Commissioner,“[a]llegations of . . . subjective symptoms must be supported
by objective medical evidence.” Hartranft, 181 F.3d at 362 (citing 20 C.F.R. §
404.1529). If the ALJ concludes a medical impairment that could reasonably cause
the alleged symptoms exists, the ALJ must then attempt to ascertain and evaluate the
severity of the claimant’s subjective symptoms as well as the degree to which it may
limit the claimant’s ability to perform various types of work. Id.; Scatorchia v.
Commissioner of Soc. Sec., 137 F. App’x 468, 471 (3d Cir. 2005). This inquiry
“requires the ALJ to determine the extent to which a claimant is accurately stating
the degree of [symptoms] or the extent to which he or she is disabled by it.”
Hartranft, 181 F.3d at 362 (citing 20 C.F.R. § 404.1529(c)). When the ALJ
evaluates the claimant’s credibility, he may consider the individual’s daily activities
and the consistency of the individual’s own statements. Scatorchia, 137 F. App’x at
471. An ALJ is not required to accept a plaintiff’s claims regarding his limitations.
See Van Horn v. Schweiker, 717 F.2d 871, 873 (3d Cir. 1983) (providing that
credibility determinations as to a claimant’s testimony regarding the claimant’s
limitations are for the ALJ to make). It is well-established that an ALJ’s findings
based on the credibility of the claimant are to be accorded great weight and
deference, particularly since the ALJ is charged with the duty of observing the
witness’ demeanor. Chromey v. Astrue, Civ. No. 4:11-cv-0103, 2012 WL 123548,
*6 (M.D. Pa. Jan. 17, 2012) (citing Walters v. Commissioner of Soc. Sec., 127 F.3d
525, 531 (6th Cir. 1997); Casias v. Secretary of Health & Human Servs., 933 F.2d
799, 801 (10th Cir. 1991)).
Instantly, in evaluating Plaintiff’s claims, the ALJ appropriately
considered Plaintiff’s psychological impairments, the resultant symptoms, and their
limiting effect on Plaintiff. Although the ALJ found Plaintiff’s medically
determinable impairments could reasonably be expected to produce the alleged
symptoms, he concluded that Plaintiff’s self-reported claims of debilitating
depression and anxiety were inconsistent both internally and with the balance of the
record. In support of this conclusion, the record contains evidence that: (1)
Plaintiff’s psycho-pharmaceutical treatment was generally effective and improved
Plaintiff’s psychological and emotional states; (2) Plaintiff was frequently
noncompliant with taking recommended medications; (3) Plaintiff frequently
cancelled therapy appointments; (4) Plaintiff’s annual psychiatric evaluations were
generally within normal limits; (5) Plaintiff cared for five children, prepared meals,
grocery shopped, and did housework; and (6) Plaintiff’s reports of aggravating
factors were inconsistent, inasmuch as she indicated her panic attacks are
exacerbated while she is both in crowds and in her house. Thus, substantial
evidence supports the ALJ’s conclusion that Plaintiff’s claims of essentially totally
disabling depression and anxiety were not entirely credible. Therefore, the court
will uphold the ALJ’s decision in this respect.
Plaintiff next argues that the ALJ improperly weighed her treating
psychiatrist’s opinion. Specifically, Plaintiff contends that ALJ Yatron improperly
rejected the opinion of Dr. Dedania, contained in a medical source statement. (Doc.
8-7, pp. 130-35 of 177.) Dr. Dedania treated Plaintiff since 2005 (see Doc. 8-7, p.
118 of 177), and provided a Medical Source Statement on February 27, 2007,
regarding the nature and severity of Plaintiff’s impairments and the limiting effects
thereof (see Doc. 8-7, pp. 130-35 of 177). Dr. Dedania opined that Plaintiff’s
psychological conditions extremely limited Plaintiff in terms of occupational
abilities, such as impacting her ability to maintain attention, maintain regular
attendance, be punctual, sustain an ordinary routine without special supervision,
work near others without being distracted, complete a normal workweek without
interruptions, perform at a consistent pace, and deal with normal work stress. (Id. at
p. 133 of 177.) Dr. Dedania evaluated that Plaintiff’s abilities in the foregoing areas
would be seriously limited, but not precluded. (See id. at pp. 132-33 of 177.) Dr.
Dedania only listed “depression” as her explanation of the limitations, despite the
form’s instructing the physician to identify the particular medical findings that
supported his assessment. (Id. at p. 133 of 177.)
The Third Circuit has explained, “the opinions of treating physicians
should be given great weight[.]” Johnson v. Commissioner of Soc. Sec., 398 F.
App’x 727, 735 (3d Cir. 2010) (citing Rocco v. Heckler, 826 F.2d 1348, 1350 (3d
Cir. 1987)). However, an ALJ “may reject a treating physician’s opinion outright . .
. on the basis of contradictory medical evidence.” Johnson, 398 F. App’x at 735
(citing Plummer v. Apfel, 186 F.3d 422, 429 (3d Cir. 1999)); see also 20 C.F.R. §
416.927(d)(2). Furthermore, a physician’s opinion as to whether a claimant is
capable of working or should receive disability benefits is not entitled to controlling
weight because that determination is reserved for the Commissioner. Russo v.
Astrue, 421 F. App’x 184, 191 n.5 (3d Cir. 2011) (citing Adorno v. Shalala, 40 F.3d
43, 47-48 (3d Cir. 1994) (“We recognize, of course that a statement by a plaintiff’s
treating physician supporting an assertion that she is ‘disabled’ or ‘unable to work’
is not dispositive of the issue.”)); see also 20 C.F.R. § 416.927(e).
Here, Plaintiff contends that ALJ Yatron did not properly credit her
treating psychiatrist’s opinion regarding her ability to work and psychological
abilities. The treating psychiatrist’s opinion as to this ultimate issue, i.e., Plaintiff’s
ability to work, however, is not controlling because such conclusions are expressly
reserved for the Commissioner. Russo, 421 F. App’x at 191. Moreover, the ALJ
properly found that the treating psychiatrist’s opinion was contradicted by objective
medical evidence of record. (Doc. 8-2, p. 30 of 106; see also Becker v.
Commissioner of Soc. Sec. Admin., 403 F. App’x 679, 686 (3d Cir. 2010) (citing
Plummer, 186 F.3d at 429, for the proposition that an ALJ “may reject the treating
physician’s assessment if such rejection is based on contradictory medical
evidence”). In rejecting Dr. Dedania’s opinion, ALJ Yatron reasoned as follows:
The opinion itself is not internally consistent. It defies
logic to believe that the claimant could have marked
limitations in 3 functional limitations despite not being
precluded from functioning in a single one of the 25
abilities listed. There is also no evidence in the record of
any episodes of deterioration or decompensation. Dr.
Dedania did not give any examples of such episodes, so it
is not clear how she arrives at the number of 3. . . .
Moreover, Dr. Dedania’s own treatment notes show that
the claimant’s affect, appearance, memory, orientation,
thought content, thought process, perceptions, motor
activity, interview behavior, speech and language were all
within normal limits. She found only moderately
depressed and anxious mood, mildly impaired insight and
judgment, and distractibility. These findings fall well
short of anything that would support the extreme
limitations found by Dr. Dedania [in the medical source
(Doc. 8-2, pp. 30-31 of 106 (citations omitted).)
The court agrees that Dr. Dedania’s assessment is inconsistent both
internally as well as with the medical records, and that the marked limitations set
forth therein are at odds with the balance of the psychiatrist’s own medical notes
created during the course of treatment. A simple review of Plaintiff’s medical
records demonstrate that Dr. Dedania’s opinion contained in the medical source
statement paints an entirely different picture of Plaintiff as the picture reflected in
the treatment records.
In response to ALJ Yatron’s reasoning, Plaintiff argues that Dr.
Dedania’s opinion that Plaintiff had experienced three episodes of decompensation
and deterioration is supported by evidence in the form of Plaintiff’s multiple missed
appointments with her psychiatrist and therapists. (See Doc. 13, p. 9 of 14.)
Plaintiff apparently requests the court to assume Plaintiff’s failure to keep her
appointments was a result of her suffering episodes of decompensation. (See id.)
The record does not demonstrate that Plaintiff failed to keep her appointments
because of such episodes; rather, the record simply provides that Plaintiff failed to
attend her scheduled appointments. The court will not engage in speculation to
attribute a reason to Plaintiff’s failures. Indeed, Plaintiff’s argument that her
absences were due to her suffering such episodes is unsupported. Accordingly, the
court agrees with ALJ Yatron that Dr. Dedania’s indicating Plaintiff had three
episodes of deterioration or decompensation is unsupported by the medical record
and was justifiably discredited.
Furthermore, with respect to Plaintiff’s ability to engage in competitive
employment, Dr. Segal found that Plaintiff had only mild restrictions of activities of
daily living and difficulties in maintaining social functioning, moderate difficulties
in maintaining concentration, persistence, or pace, and no repeated episodes of
decompensation. With respect to Plaintiff’s work-related psychological activities,
Dr. Segal opined that Plaintiff had no significant limitations in social interactions,
and only a few moderate limitations to her understanding and memory, sustained
concentration and persistence, and adaptation abilities. Dr. Segal opined that
Plaintiff was capable of meeting the basic demands of competitive work on a
sustained basis despite the limitations resulting from her having a depressive
disorder. The court finds that the ALJ’s crediting Dr. Segal’s opinion was supported
by substantial evidence.
The objective medical evidence does not support, and indeed
contradicts, Dr. Dedania’s assessments. Because Plaintiff’s treating physician’s
opinions contained in the medical source statement were based, at most, on
Plaintiff’s subjective claims of debilitating depression and anxiety, the ALJ was
justified in discrediting Dr. Dedania’s opinions based upon Plaintiff’s claims that the
ALJ found to be exaggerated, see supra Part III.C.1, and was further justified in
crediting the opinion of Dr. Segal, which was more consistent with the medical
record. Accordingly, the ALJ appropriately considered the treating physician’s
opinion, and the court will uphold the ALJ’s decision in this respect because it is
supported by substantial evidence.
The ALJ’s not crediting Plaintiff’s testimony was not improper because
the objective evidence of record did not support Plaintiff’s claims of her
experiencing totally debilitating depression and anxiety rising to the level of
disability. The ALJ did not improperly discredit the treating psychiatrist’s opinion
because the limitations set forth in Dr. Dedania’s medical source statement was
unsupported by empirical information and was not consistent with other evidence of
record. Based upon the forgoing, and following a thorough review of the
administrative record, the court concludes that the Commissioner’s decision denying
Plaintiff’s application for DIB benefits is supported by substantial evidence, and will
affirm the decision of the Commissioner.
An appropriate order will issue.
S/SYLVIA H. RAMBO
United States District Judge
Dated: January 10, 2014.
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