ROSS v. COLVIN
Filing
13
MEMORANDUM OPINION AND ORDER denying 9 Plaintiff's Motion for Summary Judgment; and granting 11 Commissioner's Motion for Summary Judgment, as explained therein. Signed by Judge Terrence F. McVerry on 7/29/15. (mh)
IN THE UNITED STATES DISTRICT COURT
FOR THE WESTERN DISTRICT OF PENNSYLVANIA
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ROGER J. ROSS,
Plaintiff,
v.
CAROLYN W. COLVIN,
ACTING COMMISSIONER OF
SOCIAL SECURITY,
Defendant.
MEMORANDUM OPINION AND ORDER
July 29, 2015
I.
Introduction
Roger J. Ross (“Plaintiff”) brought this action for judicial review of the decision of the
Acting Commissioner of Social Security (“Commissioner”), which denied his applications for
supplemental security income (“SSI”) under Title XVI of the Act, 42 U.S.C. §§ 1381-1383(f).
Now pending before the Court are the parties’ cross-motions for summary judgment (ECF Nos.
9, 11), which have been fully briefed (ECF Nos. 10, 12) and are ripe for disposition. For the
following reasons, Plaintiff’s motion will be DENIED, and the Acting Commissioner’s motion
will be GRANTED.
II.
Background
Plaintiff was born on September 17, 1960.1 (R. 21). He was married but is currently
divorced and he has two adult sons. (R. 33, 471). He attended high school until the tenth grade
1.
As of his alleged onset date, Plaintiff was 51 years old, making him an individual closely
approaching advanced age under the Social Security Administration Regulations. 20 C.F.R. §
404.1563(d) (“If you are closely approaching advanced age (age 50–54), we will consider that
1
and obtained a GED in 1990. (R. 34). He has relevant work experience as a tree trimmer,
plumber’s helper and press operator. (R. 21). However, the record reflects that he has not
engaged in substantial gainful activity since his alleged onset date of August 11, 2011 (the date
he was released from prison). (R. 16). Plaintiff was last employed as a plumber’s helper in 2002
when he violated a parole condition. (R. 470).
A.
Medical Evidence
Although Plaintiff provided additional evidence to the Appeals Council, the Court is
limited in its review to the evidence that was provided to the ALJ and cannot consider the
supplemental information.2 Therefore, only the pertinent facts will be reviewed and discussed in
this opinion.
Plaintiff testified that he was in a car accident on July 22, 2002 in which he fractured both
feet and his right leg. (R. 34, 35). Plaintiff sustained a second fracture to his left ankle and a
compression fracture of his spine in November 2002 when he fell from a tree. (R. 35, 377, 422,
449). In August 2003, the compression fracture of the spine was treated surgically with a
thoracic fusion at T11 to L1. (R. 377, 422). Between July 2004 and August 2011, Plaintiff was
incarcerated for aggravated assault with a motor vehicle and DUI.
On September 27, 2011, Dr. Jeffrey A. Baum examined Plaintiff for a potential hernia
repair. (R. 377). Dr. Baum noted Plaintiff’s history of spinal fusion surgery. (R. 377). Back xrays taken that day showed a solid interbody fusion with a cage, normal alignment of the spine
your age along with a severe impairment(s) and limited work experience may seriously affect
your ability to adjust to other work.”).
2.
“[T]he options open to the district court, when the Appeals Council has denied review the
district court may affirm, modify, or reverse the Commissioner's decision, with or without a
remand based on the record that was made before the ALJ.” Matthews v. Apfel, 239 F. 3d 589,
593 (3d Cir. 2001).
2
and no significant kyphosis. (R. 376). Dr. Baum further noted a healed incision on Plaintiff’s left
side, but could not appreciate the presence of a hernia. (R. 377). Dr. Baum observed that Plaintiff
ambulated around the room easily and stated that Plaintiff was neurologically normal in his
lower extremities, including his reflexes and muscle strength. (R. 377).
On October 13, 2011, Dr. John McKeating evaluated Plaintiff for his hernia. (R. 380). He
concluded that Plaintiff did not have an actual hernia; rather he had some atonic musculature on
the abdominal wall most likely related to his surgery in 2003. (R. 381). Dr. McKeating observed
normal mental status, and normal reflexes, strength, sensation, gait and balance. (R. 381).
On December 19, 2011, Dr. Lisa Weidner evaluated Plaintiff for his complaints of midback and abdominal pain. (R. 421). Plaintiff complained of constant pain since his surgery. (R.
422). Plaintiff reported that he got around by walking and using public transportation. (R. 422).
Dr. Weidner observed that Plaintiff’s gait was non-antalgic. (R. 423). She noted no tenderness to
palpation in the midline of his thoracic spine and some tenderness around the incision site. (R.
423). Plaintiff had symmetric muscle tone, girth, and strength, (R. 424). His reflexes and
sensation were intact and straight leg raise was performed without reports of pain. (R. 424). Dr.
Weidner suggested possible diagnostic/therapeutic intercostal nerve injections and adjustments
to his medications. (R. 424).
On December 20, 2011, Dr. Shabana Khan, a psychiatrist, evaluated Plaintiff. (R. 437).
Plaintiff reported that he had been depressed since 2002 and that he felt increased anxiety when
he was in crowds and noisy environments. (R. 437). Dr. Khan noted that Plaintiff was dressed
neatly, was cooperative and had appropriate behavior. (R. 438). Plaintiff’s speech was logical,
relevant and coherent and he denied any paranoia, suicidal/homicidal ideation and delusions. (R.
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438). Dr. Kahn diagnosed Plaintiff with generalized anxiety disorder and depressive disorder and
assigned a GAF3 score of 55. (R. 438).
On January 19, 2012, Dr. Dane Wukich examined Plaintiff for mid-foot pain. (R. 575).
She diagnosed Plaintiff with right mid-foot arthritis and left 5th metatarsophalangeal joint pain
secondary to excessive bone formation. (R. 576). Plaintiff stated that he had not tried any type of
adaptive footwear, inserts or physical therapy. (R. 575). Dr. Wukich offered Plaintiff a cortisone
injection, which he declined. (R. 576).
On January 24, 2012, Eric Bernstein, PH.D., evaluated Plaintiff at the request of the
Social Security Commissioner. (R. 469-473). Plaintiff walked to the appointment and reported
no difficulties in doing so. (R. 469). During the evaluation, Plaintiff was serious and spoke with
organization and clarity as he related his physical complaints and medical conditions. (R. 472).
Plaintiff was oriented in all four spheres of person, place, situation and time. (R. 472). His
knowledge of general information and abstract reasoning skills appeared to be low average. (R.
472). Dr. Bernstein diagnosed Plaintiff with depressive disorder and pain disorder associated
with both psychological factors and a chronic general medical condition. (R. 473). He also
assigned a GAF score of 48.4 (R. 473).
During a follow-up examination in April 2012, Dr. Baum noted that Plaintiff’s recent
cervical MRI had shown moderate degenerative disc disease and some moderate foraminal
The GAF scale ranges from zero to 100 and “[c]onsider[s] psychological, social, and
occupational functioning on a hypothetical continuum of mental health-ilness.” Diagnostic and
Statistical Manual of Mental Disorders Fourth Edition, (“DSM-IV”), 32 (American Psychiatric
Association 1994). A GAF of 55 denotes “[m]oderate symptoms … OR moderate difficutly is
social, occupational, or school functioning …” DSM-IV at 32.
4.
A GAF of 48 indicates that the individual has “[s]erious symptoms … OR any serious
impairment in social, occupationsl, or school functioning …” DSM-IV at 32.
3.
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narrowing. (R. 517-18). Plaintiff stated that Vicodin was somewhat helpful in relieving his
symptoms. (R. 517).
B.
Procedural History
Plaintiff protectively filed an application for SSI on November 21, 2011, alleging
disability as of August 8, 2011, as a result of previous fractures of the spine and feet, abdominal
surgery, anxiety and compulsive disorder. (R. 57). After Plaintiff’s claim was denied on
February 2, 2012, at the administrative level, he requested a hearing, which was conducted on
April 4, 2013 in Pittsburgh, Pennsylvania. (R. 14). Administrative Law Judge Alma S. de Leon
(“ALJ”) presided over the hearing. Although informed of his right to representation, Plaintiff
chose to appear and testify without the assistance of an attorney or other representative. An
impartial vocational expert also appeared at the hearing. (R. 28-56).
On April 10, 2013, the ALJ issued an unfavorable decision to Plaintiff. (R. 14-23).
Carefully following the applicable five-step sequential evaluation process, the ALJ first found
that Plaintiff had not engaged in substantial gainful activity since November 21, 2011 and that he
had severe impairments including right mid-foot arthritis, left fifth metatarsophalangeal joint
pain secondary to excessive bone formation, history of vertebral fracture with thoracic fusion,
cervical degenerative disc disease, status post left ankle fracture, incisional hernia, depressive
disorder, and generalized anxiety disorder. (R. 16). However, in reviewing the medical evidence
and testimony, the ALJ concluded Plaintiff did not have an impairment or combination of
impairments that met or medically equaled the severity of one of the listed impairments in 20
C.F.R. Part 404, Subpt. P, App’x 1. (R. 16-18). Specifically, the ALJ considered the medically
determinable impairments under Listings 1.02, 1.04, 1.06, 12.04 and 12.06.
5
Regarding the Musculoskeletal System Listings 1.02, 1.04, and 1.06, the ALJ noted that
Plaintiff is able to ambulate effectively and diagnostic testing failed to document evidence
required to meet the Listings. (R. 16-17). Plaintiff’s mental impairments were considered under
the criteria of Listings 12.04 and 12.06 in which the ALJ concluded the mental impairments did
not cause at least two “marked” limitations or one “marked” limitation and “repeated” episodes
of decompensation.
In evaluating the Plaintiff’s residual functional capacity (“RFC”), the ALJ found that the
Plaintiff “has the RFC to perform light work as defined by 20 C.F.R. § 416.967(b) except that
[Plaintiff] can lift and/or carry no more than 20 pounds; cannot reach overhead; is limited in
pushing and/or pulling in his upper and lower extremities; should avoid exposure to vibration,
temperature extremes and heights; is limited in his ability to deal directly with the public; can
have only occasional contact with peers and supervisors; is limited in his ability to follow
detailed instructions such that he is relegated to simple, routine tasks. (R. 18).
To determine the extent to which Plaintiff’s limitations erode the occupation base, the
ALJ asked the vocational expert whether jobs existed in the national economy for an individual
with Plaintiff’s age, education, work experience and RFC. The vocational expert testified that
given all the factors, Plaintiff would be able to perform the requirements of occupations such as a
cleaner, packer or mail clerk. Thus, consistent with the vocational expert’s testimony, the ALJ
found that Plaintiff is not disabled within the meaning of the Act. (R. 22).
Plaintiff submitted additional medical evidence to the Appeals Council; however, on
October 28, 2014, the Appeals Council denied the request for review, making the decision of the
ALJ the final decision of the Acting Commissioner. As noted above, this Court’s review is
limited to the record before the ALJ. Mathews, 239 F. 3d at 593.
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On December 23, 2014, Plaintiff filed his Complaint in this Court, in which he seeks
judicial review of the decision of the ALJ. The parties’ cross-motions for summary judgment
then followed.
III.
Legal Analysis
A.
Standard of Review
The Act strictly limits this Court’s power to review the Commissioner's final decision.
42 U.S.C. §§ 1383(c)(3). “This Court neither undertakes a de novo review of the decision, nor
does it re-weigh the evidence of the record.” Thomas v. Massanari, 28 F.App’x 146, 147 (3d Cir.
2002). Instead, this Court’s “review of the Commissioner’s final decision is limited to
determining whether that decision is supported by substantial evidence.” Hartranft v. Apfel, 181
F.3d 358, 360 (3d Cir. 1999). If the Commissioner’s finding is supported by substantial
evidence, it is conclusive and must be affirmed by the Court. 42 U.S.C. § 405(g); Rutherford v.
Barnhart, 399 F.3d 546, 552 (3d Cir. 2005). The United States Supreme Court has defined
“substantial evidence” as “such relevant evidence as a reasonable mind might accept as adequate
to support a conclusion.” Richardson v. Perales, 402 U.S. 389 (1971). It consists of more than a
scintilla of evidence, but less than a preponderance. Thomas v. Comm’r of Soc. Sec., 625 F.3d
798 (3d Cir. 2010). Importantly, “[t]he presence of evidence in the record that support a contrary
conclusion does not undermine the Commissioner’s decision so long as the record provides
substantial support for that decision.” Malloy v. Comm’r of Soc. Sec., 306 F. App’x 761, 764 (3d
Cir. 2009).
B. Sequential Evaluation Process
When deciding whether an adult claimant is or is not disabled, the Commissioner utilizes
a five-step sequential evaluation. 20 C.F.R. §§ 404.1520 and 416.920. This process requires the
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Commissioner to consider, in sequence, whether a claimant (1) is working, (2) has a severe
impairment, (3) has an impairment that meets or equals the requirements of a listed impairment,
(4) can return to his or her past relevant work, and (5) if not, whether he or she can perform other
work. See 42 U.S.C. § 404.1520; Newell v. Comm’r of Soc. Sec., 347 F.3d 541, 545-46 (3d Cir.
2003) (quoting Burnett v. Comm’r of Soc. Sec., 220 F.3d 112, 118-19 (3d Cir. 2000)).
To qualify for disability benefits under the Act, a claimant must demonstrate that there is
some “medically determinable basis for an impairment that prevents him or her from engaging in
any substantial gainful activity for a statutory twelve-month period.” Fargnoli v. Massanari, 247
F.3d 34, 38-39 (3d Cir. 2001) (internal citation omitted); See also 42 U.S.C. § 423 (d)(1) (1982).
This may be done in two ways: (1) by introducing medical evidence that the claimant is disabled
per se because he or she suffers from one or more of a number of serious impairments delineated
in 20 C.F.R. Regulations No. 4, Subpt. P, Appendix 1, see Heckler v. Campbell, 461 U.S. 458
(1983); Newell, 347 F.3d at 545-46; Jones v. Barnhart, 364 F.3d 501, 503 (3d Cir. 2004); or,
(2) in the event that claimant suffers from a less severe impairment, by demonstrating that he or
she is nevertheless unable to engage in “any other kind of substantial gainful work which exists
in the national economy . . . .” Campbell, 461 U.S. at 461 (citing 42 U.S.C. § 423 (d)(2)(A)).
In order to prove disability under the second method, a claimant must first demonstrate
the existence of a medically determinable disability that precludes a plaintiff from returning to
his or her former job. Newell, 347 F.3d at 545-46; Jones, 364 F.3d at 503. Once it is shown that
claimant is unable to resume his or her previous employment, the burden shifts to the
Commissioner to prove that, given claimant’s mental or physical limitations, age, education and
work experience, he or she is able to perform substantial gainful activity in jobs available in the
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national economy. Rutherford, 399 F.3d at 551; Newell, 347 F.3d at 546; Jones, 364 F.3d at 503;
Burns v. Barnhart, 312 F.3d 113, 119 (3d Cir. 2002).
When a claimant has multiple impairments, which may not individually reach the level of
severity necessary to qualify any one impairment for a Listed Impairment status, the
Commissioner nevertheless must consider all of the impairments in combination to determine
whether, collectively, they meet or equal the severity of a Listed Impairment. Diaz v. Comm’r of
Soc. Sec., 577 F.3d 500, 502 (3d Cir. 2009); 42 U.S.C. § 423(d)(2)(C) (“in determining an
individual’s eligibility for benefits, the Secretary shall consider the combined effect of all of the
individual’s impairments without regard to whether any such impairment, if considered
separately, would be of such severity”).
C.
Discussion
Plaintiff raises several grounds in support of reversing the decision of the ALJ: (1) the
ALJ erred in determining that Plaintiff’s impairments did not meet or medically equal Listings
1.02, 1.04 and 12.04; (2) the ALJ ignored the opinion of a consultative examiner; and (3) the
ALJ improperly assigned an RFC of light work.
1. The ALJ Properly Determined that Plaintiff Did Not Have an
Impairment that Meets or Equals a Listed Impairment
Plaintiff argues that the ALJ erred in finding that his impairments did not meet or
medically equal Listings 1.02, 1.04 and 12.04. As the Supreme Court has explained, “For a
claimant to show that his 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.” Cathcart v. Astrue, 2010 WL 1054049, at *15 (W.D. Pa. Mar. 22, 2010) (citing
Sullivan v. Zebley, 493 U.S. 521, 530 (1990)).
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For Listings 1.02 and 1.04, one of the criteria that Plaintiff must meet is that the
impairment results in the inability to ambulate effectively as defined in 20 C.F.R. Part 404,
Subpt. P., App’x 1, § 1.00B2b. The inability to ambulate effectively means an “extreme
limitation of the ability to walk.” Id. “Examples of “ineffective ambulation” under Listing
1.00B2b include, the inability to walk without the use of a walker, two crutches or two canes; the
inability to use standard public transportation; the inability to carry out routine ambulatory
activities, such as shopping and banking; and the inability to climb a few steps at a reasonable
pace with the use of a single hand rail. Roberts v. Astrue, 2009 WL 3183084, at *7 (W.D. Pa.
Sept. 30, 2009) (citing 20 C.F.R. Part 404, Subpt. p., App’x 1, § 1.00B2b(2)).
In this case, the ALJ determined that Plaintiff’s impairments did not meet or medically
equal Listing 1.02 or 1.04 because physical examinations of Plaintiff documented normal
reflexes and strength, normal gait and balance, adequate range of motion in his hands, wrists,
elbows, shoulders, knees, ankles and spine, and negative straight leg raising tests. (R. 375, 377,
381, 399, 410, 423-24, 469, 498, 505, 517). Plaintiff argues that objective medical evidence of
record documented deformity in the left ankle with chronic pain, stiffness and limited motion.
Plaintiff also relies on his testimony at the hearing to establish that he is unable to ambulate
effectively by asserting that he can walk less than four blocks. Pl.’s Brief ECF No. 10 at 10. In
light of the the ALJ’s determination that Plaintiff was partially credible, however with the
evidence of record, Plaintiff’s argument is unpersuasive. Plaintiff’s own testimony and evidence
established that he is, in fact, able to ambulate effectively. At the hearing, Plaintiff testified that
he could walk the four blocks to the grocery store and that he takes the bus quite a bit. (R. 43,
45). In fact, he walked fifteen minutes to a consultative appointment and the physician noted that
Plaintiff had no difficulties in walking to the office. (R. 469). Moreover, there is no evidence of
10
record that Plaintiff requires the use of assistive devices to ambulate. Thus, there is substantial
evidence to support the ALJ’s determination that Plaintiff does not meet or medically equal
Listings 1.02 and 1.04.
Plaintiff supplemented his argument by stating that the ALJ erred when she discounted
scans which indicated moderate degenerative disc disease and foraminal narrowing. Pl.’s Brief,
ECF No. 10, at 9. Even assuming that this scan result established spinal stenosis resulting in
narrowing between the vertebrae, Plaintiff cannot meet the Listing requirements because he is
able to ambulate effectively, as discussed above. Thus, there is no need to further discuss the
evidence at Step two.
Listing 12.04 relates to major depressive disorders and requires an applicant to meet
either paragraphs A and B or paragraph C of the Listing. Listing 12.04 impairments are such that
they prevent all gainful activity. 20 C.F.R. § 404.1525. In this case, the ALJ started her analysis
with paragraph B. (ECF No. 7–2, at 17–18). Therein, the ALJ found that because Plaintiff's
“mental impairments do not cause at least two ‘marked’ limitations or one ‘marked limitation’
and ‘repeated’ episodes of decompensation, each of extended duration,” paragraph B criteria are
not satisfied. (ECF No. 7–2, p. 18). Plaintiff has only mild restrictions in activities of daily
living. He maintains personal needs and grooming, prepares his own meals, and completes
chores such as laundry, cleaning and making the bed. (R. 41, 42, 44, 190, 191). Additionally, the
State agency consultants determined that Plaintiff had no more than mild difficulties with
activities in daily living. (R. 65). Plaintiff’s social functioning was determined to be no more
than moderately difficult (R. 67), and he has only moderate difficulty with regard to
concentration, persistence or pace. (R. 66). Although Plaintiff experienced one to two episodes
of decompensation, in order to meet the criteria, the repeated espisodes of decompensation must
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have been “three within one year or an average of once every four months.” 20 C.F.R. pt. 404,
subpt. P, app. I, § 12.00(C)(4). Thus, the paragraph B criteria are not satisfied.
Plaintiff, however, asserted that the ALJ improperly discounted his GAF score of 48,
which is indicative of serious impairments in social, occupational and social function. Notably, a
GAF score is only a snapshot opinion about the level of functioning. Black v. Colvin, 2015 WL
1746121, at *2 (W.D. Pa. Apr. 16, 2015). “Unless the clinician clearly explains the reasons
behind his or her GAF rating, and the period to which the rating applies, it does not provide a
reliable longitudinal picture of the claimant's mental functioning for a disability analysis.” Id.
More importantly, a failure to discuss GAF scores does not necessarily constitute error when the
ALJ had conducted a thorough analysis of the medical evidence regarding plaintiff's mental
impairments. See Coy v. Astrue, 2009 WL 2043491, at *13–14 (W.D. Pa. July 8, 2009). “This is
particularly true if the mental health provider's report does not relate the score to specific
limitations, or explain the basis for the GAF rating, or if the ALJ discussed the records where the
GAF scores were provided.” Black, 2015 WL 1746121, at *2; see also Gilroy v. Astrue, 351 F.
App’x 714, 715–16 (3d Cir. 2009); Shamonsky v. Comm'r of Soc. Sec., 2011 WL 3101800, at *6
(W.D. Pa. July 25, 2011). Like other evidence, a GAF score may be accorded little or no weight
depending upon its consistency with the other relevant evidence in the record. Torres v.
Barnhart, 139 Fed. App’x 411, 415 (3d Cir. 2005).
In this case, the ALJ expressly considered all of the GAF scores in the record, including
the consultative exam, and determined that they were of limited evidentiary value as they were
subjectively addressed. (R. 20). Moreover, the physicians did not tie the GAF scores to any
specific limitation relevant to Plaintiff’s residual functional capacity. Accordingly, the ALJ did
consider the pertinent records and properly explained her approach to those records.
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Plaintiff also contends that his records while incarcerated reflect that he was anti-social,
had poor judgment, poor insight and psychotic thought content which were indicative of a
serious affective disorder. In fact, the records indicate Plaintiff showed no paranoia or psychosis
(R. 261-263), his judgment was documented as intact or fair on multiple occasions (R. 253, 255,
260, 262), it was only documented on two occasions that Plaintiff had poor insight (R. 258, 263)
while his insight was intact to limited on five occasions (R. 253, 255, 260-262). Thus, this
argument is without merit regarding Plaintiff’s ability to meet Listing 12.04 criteria.
Lastly, Plaintiff argues that his functioning is in a highly supportive environment which
supports a finding that he meets Listing 12.04. Listing 12.04 paragraph C criteria is only met by
showing a “[c]urrent history of 1 or more years’ inability to function outside a highly supportive
living arrangement, with an indication of continued need for such an arrangement.” Pt. 404,
Subpt. P, App’x 1, § 12.04(C)(3). Here, however, there is no indication of a continued need for
such an arrangement. The Department of Corrections noted that Plaintiff would reside on his
own after his stay at a halfway house. (R. 271). Furthermore, Plaintiff testified that he is trying
to come back to Pittsburgh and the only reason he was sent to the halfway house after his
incarceration was “because they didn’t have a home plan.” (R. 31). Therefore, this argument is
also without merit.
2. The ALJ Properly Weighed the Opinion of the Consultative Examiner
Plaintiff asserts that the ALJ did not give sufficient weight to the opinion of the
consultative examiner, Dr. Eric Bernstein, regarding Plaintiff’s inability to perform work that
required standing and/or walking for long periods. The Social Security Regulations set out
factors to consider in weighing medical opinions from treating sources, non-treating sources, and
non-examining sources. See 20 C.F.R. §§ 404.1527(d), 416.927(d). As such, “[t]he
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Administration generally gives ‘more weight to opinions from [an applicant’s] treating sources,
since these sources are likely to be the medical professionals most able to provide a detailed,
longitudinal picture of [the applicant’s] medical impairments and may bring a unique perspective
to the medical evidence that cannot be obtained from the objective medical findings alone or
from reports of individual examinations.” Soto v. Astrue, 2009 WL 2327402, at *5-6 (E.D. Pa.
July 28, 2009) (citing 20 C.F.R. §§ 404.1527(d)(2), 416.927(d)(2)).
In this case, Plaintiff saw Dr. Bernstein on only one occasion at the request of the Bureau
of Disability Determination. (R. 469). Dr. Bernstein noted that Plaintiff walked to the
appointment and experienced no difficulties. Id. Dr. Bernstein then noted that “by Mr. Ross’
report, he is unable to stand or walk for long periods of time without pain and thus at least by his
report, he would not be able to perform work.”5 (R. 473) (emphasis added). Based on the
standards described above, the ALJ properly weighed all the evidence and concluded that the
evidence did not support the limitations noted by Dr. Bernstein that were merely based on the
subjective statements/reports of Plaintiff himself.
3. Substantial Evidence Supports the ALJ’s Finding that Plaintiff has the
Residual Functional Capacity to Perform Light Work
Plaintiff argues that the ALJ improperly concluded that he could perform light work.
“Residual functional capacity is defined as that which an individual is still able to do despite the
limitations caused by his or her impairment(s).” Burnett v. Comm'r of Soc. Sec. Admin., 220 F.3d
112, 121 (3d Cir. 2000) (quoting Hartranft, 181 F.3d at 359 n. 1); see also 20 C.F.R. §
404.1545(a). The ALJ must consider all relevant evidence when determining an individual's
5.
Plaintiff stated that Dr. Bernstein opined that he was unable to work, however, this was a
misstatement of the record. Dr. Bernstein merely noted what Plaintiff had stated. In fact, in
answer to question 4 of the medical source statement (whether the “above are assumed to be your
opinion …” SSA Form HA-1152-U3), Dr. Bernstein answered N/A. (R. 473).
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residual functional capacity. See 20 C.F.R. §§ 404.1527(e)(2), 404.1545(a), 404.1546. That
evidence includes medical records, observations made during formal medical examinations,
descriptions of limitations by the claimant and others, and observations of the claimant's
limitations by others. See 20 C.F.R. § 404.1545(a). Moreover, the ALJ's finding of residual
functional capacity must “be accompanied by a clear and satisfactory explication of the basis on
which it rests.” Cotter v. Harris, 642 F.2d 700, 704 (3d Cir. 1981).
In this case, the ALJ determined that Plaintiff had the residual functional capacity to
perform light work. The SSA defines work as “light” when it
involves lifting no more than 20 pounds at a time with frequent lifting or carrying
of objects weighing up to 10 pounds. Even though the weight lifted may be very
little, a job is in this category when it requires a good deal of walking or standing,
or when it involves sitting most of the time with some pushing and pulling of arm
or leg controls. To be considered capable of performing a full or wide range of
light work, you must have the ability to do substantially all of these activities.
20 C.F.R. § 404.1567(b). Plaintiff contends, however, that he should have been assessed a
sedentary RFC. Pls. Br. ECF No. 10 at 13. In support of this claim, he relies solely upon his own
testimony that he can walk no more than four blocks and can lift only ten to fifteen pounds when
grocery shopping. Id. at 12-13. Yet, there is no objective medical evidence in the record which
limits Plaintiff to sedentary work. After careful consideration of all the evidence, the ALJ
concluded that Plaintiff’s contentions were out of proportion to and inconsistent with the medical
evidence of record. (R. 19). Credibility determinations made by the ALJ is entitled to great
deference by the district court. Reefer v. Barnhart, 326 F.3d 376, 380 (3d Cir. 2003). This
determination must “contain specific reasons for the finding on credibility, supported by the
evidence in the case record, and must be sufficiently specific to make clear to the individual and
to any subsequent reviewers the weight the adjudicator gave to the individual's statements and
15
the reasons for that weight.” SSR 96-7; see also Lang v. Barnhart, 2006 WL 3858579, at *10
(W.D. Pa. Dec.6, 2006). The ALJ complied with SSR 96-7.
Under the applicable regulations, a plaintiff's daily activities are a valid factor to be
considered by the ALJ when conducting an inquiry as to the reliability of the claimant's
subjective complaints. 20 C.F.R. §§ 404.1529(c)(3), 416.929(c)(3). Inconsistencies in a
claimant's testimony or daily activities permit an ALJ to conclude that some or all of the
claimant's testimony about his limitations or symptoms is not fully credible. See Burns v.
Barnhart, 312 F.3d 113, 129-130 (3d Cir. 2002). Here, Plaintiff’s reported daily activities
suggest that he is not limited, as one would expect, given his reported symptoms and limitations.
Plaintiff maintains personal needs and grooming, prepares his own meals, cleans, makes his bed
and does laundry. (R. 41, 42, 44, 190, 191). He spends time with others, uses public
transportation often, shops in stores and attends church. (R. 43, 45, 192, 193). He testified he is
able to lift and/or carry ten to fifteen pounds, which is clearly within the definition of light work.
Moreover, no treating or examining medical source reported any limitations as to Plaintiff's
activities of daily living.
Furthermore, the ALJ extensively discussed the medical evidence including physical
examinations that documented that Plaintiff has normal reflexes and strength, normal gait and
balance, and adequate range of motion. (R. 375, 377, 381, 399, 410, 423-24, 469, 498, 505, 517).
In fact, there was no apparent distress when Plaintiff was examined and he ambulated about the
room very easily. (R. 377, 381, 423, 469).
Lastly, the ALJ noted that the State agency medical consultants found that Plaintiff could
perform light work. Substantial weight was given to the State agency consultants as they are
deemed to possess specific understanding of the disability program and the evidentiary
16
requirements. SSR 96-6p. Furthermore, the assessments were consistent with and supported by
the record evidence. Accordingly, the ALJ extensively reviewed the record and the finding of
light work capability was appropriate.
IV.
Conclusion
It is undeniable that Plaintiff has a number of impairments, and this Court is sympathetic
and aware of the challenges of which Plaintiff faces in seeking gainful employment. Under the
applicable standards of review and the current state of the record, however, the Court must defer
to the reasonable findings of the ALJ and her conclusion that Plaintiff is not disabled within the
meaning of the Social Security Act, and that he is able to perform a limited range of work at the
light exertional level.
For the reasons hereinabove set forth, the Court will GRANT the Motion for Summary
Judgment filed by the Commissioner and DENY the Motion for Summary Judgment filed by
Plaintiff. An appropriate Order follows.
McVerry, S.J.
17
IN THE UNITED STATES DISTRICT COURT
FOR THE WESTERN DISTRICT OF PENNSYLVANIA
)
)
)
) 1:14-cv-318-TFM
)
)
)
)
)
ROGER J. ROSS,
Plaintiff,
v.
CAROLYN W. COLVIN,
ACTING COMMISSIONER OF
SOCIAL SECURITY,
Defendant.
ORDER
AND NOW, this 29th day of July, 2015, in accordance with the foregoing Memorandum
Opinion, it is hereby ORDERED, ADJUDGED, and DECREED that Plaintiff’s MOTION
FOR SUMMARY JUDGMENT (ECF No. 9) is DENIED, and Defendant’s MOTION FOR
SUMMARY JUDGMENT (ECF No. 11) is GRANTED. The clerk shall docket this case as
CLOSED.
BY THE COURT:
s/ Terrence F. McVerry
United States District Judge
cc:
Michael J. Koehler
Email: mkoehler@npslaws.com
Christian A. Trabold
Email: christian.a.trabold@usdoj.gov
(via CM/ECF)
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