SAEED v. BERRYHILL
Filing
19
OPINION and ORDER denying 14 Motion for Summary Judgment; granting 16 Motion for Summary Judgment. Signed by Judge Donetta W. Ambrose on 6/25/19. (slh)
IN THE UNITED STATES DISTRICT COURT
FOR THE WESTERN DISTRICT OF PENNSYLVANIA
AFRAH AHMED SAEED,
)
)
)
)
)
)
)
)
)
)
Plaintiff,
-vsANDREW M. SAUL,1
COMMISSIONER OF SOCIAL SECURITY,
Defendant.
Civil Action No. 18-113
AMBROSE, Senior District Judge
OPINION
Pending before the Court are Cross-Motions for Summary Judgment. (ECF Nos. 14 and
16). Both parties have filed Briefs in Support of their Motions. (ECF Nos. 15 and 17). After
careful consideration of the submissions of the parties, and based on my Opinion set forth below,
I am denying Plaintiff’s Motion for Summary Judgment (ECF No. 14) and granting Defendant’s
Motion for Summary Judgment. (ECF No. 16).
I. BACKGROUND
Plaintiff brought this action for review of the final decision of the Commissioner of Social
Security denying an application for supplemental security income pursuant to the Social Security
Act. Administrative Law Judge (“ALJ”), David F. Brash, held video hearings on February 2, 2016
and again on June 1, 2017. (ECF No. 7-3). On February 13, 2017, the ALJ found that Plaintiff
was not disabled under the Social Security Act. (ECF No. 7-2, pp. 17-34).
1
Andrew M. Saul was sworn in as Commissioner of Social Security on June 18, 2019, replacing Acting
Commissioner, Nancy A. Berryhill.
1
After exhausting all administrative remedies thereafter, Plaintiff filed this action. The
parties have filed Cross-Motions for Summary Judgment. (ECF Nos. 14 and 16). The issues are
now ripe for review.
II. LEGAL ANALYSIS
A. Standard of Review
The standard of review in social security cases is whether substantial evidence exists in
the record to support the Commissioner’s decision. Allen v. Bowen, 881 F.2d 37, 39 (3d Cir.
1989). Substantial evidence has been defined as “more than a mere scintilla. It means such
relevant evidence as a reasonable mind might accept as adequate.” Ventura v. Shalala, 55 F.3d
900, 901 (3d Cir. 1995), quoting Richardson v. Perales, 402 U.S. 389, 401 (1971). Additionally,
the Commissioner’s findings of fact, if supported by substantial evidence, are conclusive. 42
U.S.C. §405(g); Dobrowolsky v. Califano, 606 F.2d 403, 406 (3d Cir. 1979). A district court
cannot conduct a de novo review of the Commissioner’s decision or re-weigh the evidence of
record. Palmer v. Apfel, 995 F.Supp. 549, 552 (E.D. Pa. 1998). Where the ALJ's findings of
fact are supported by substantial evidence, a court is bound by those findings, even if the court
would have decided the factual inquiry differently. Hartranft v. Apfel, 181 F.3d 358, 360 (3d Cir.
1999). To determine whether a finding is supported by substantial evidence, however, the district
court must review the record as a whole. See, 5 U.S.C. §706.
To be eligible for social security benefits, the plaintiff must demonstrate that he cannot
engage in substantial gainful activity because of a 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 at least 12 months. 42 U.S.C. §423(d)(1)(A); Brewster v. Heckler,
786 F.2d 581, 583 (3d Cir. 1986).
2
The Commissioner has provided the ALJ with a five-step sequential analysis to use when
evaluating the disabled status of each claimant.
20 C.F.R. §404.1520(a).
The ALJ must
determine: (1) whether the claimant is currently engaged in substantial gainful activity; (2) if not,
whether the claimant has a severe impairment; (3) if the claimant has a severe impairment,
whether it meets or equals the criteria listed in 20 C.F.R., pt. 404, subpt. P., appx. 1; (4) if the
impairment does not satisfy one of the impairment listings, whether the claimant’s impairments
prevent him from performing his past relevant work; and (5) if the claimant is incapable of
performing his past relevant work, whether he can perform any other work which exists in the
national economy, in light of his age, education, work experience and residual functional capacity
(“RFC”).2 20 C.F.R. §404.1520. The claimant carries the initial burden of demonstrating by
medical evidence that he is unable to return to his previous employment (steps 1-4).
Dobrowolsky, 606 F.2d at 406. Once the claimant meets this burden, the burden of proof shifts
to the Commissioner to show that the claimant can engage in alternative substantial gainful
activity (step 5). Id.
A district court, after reviewing the entire record may affirm, modify, or reverse the decision
with or without remand to the Commissioner for rehearing. Podedworny v. Harris, 745 F.2d 210,
221 (3d Cir. 1984).
B.
Weighing of Opinion Evidence in Determining Plaintiff’s RFC
With regard to opinion evidence, Plaintiff argues that the ALJ failed to follow the treating
physician rule when discounting the opinion of Dr. DeMatteis and further “erred by creating his
mental RFC determination out of whole cloth.” (ECF No. 15, pp. 9-15). The amount of weight
2
RFC refers to the most a claimant can still do despite his/her limitations. 20 C.F.R. §§ 404.1545(a),
416.945(a). The assessment must be based upon all of the relevant evidence, including the medical
records, medical source opinions, and the individual’s subjective allegations and description of his own
limitations. 20 C.F.R. § 416.945(a).
3
accorded to medical opinions is well-established. Generally, the ALJ will give more weight to the
opinion of a source who has examined the claimant than to a non-examining source. 20 C.F.R. §
416.927(c)(1). In addition, the ALJ generally will give more weight to opinions from a treating
physician, “since these sources are likely to be the medical professionals most able to provide a
detailed, longitudinal picture of [a claimant’s] medical impairment(s) 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, such as consultative examinations or brief
hospitalizations.” Id. §416.927(c)(2). The opinion of a treating physician need not be viewed
uncritically, however. Rather, only where an ALJ finds that “a treating source’s opinion on the
issue(s) of the nature and severity of [a claimant’s] impairment(s) is well-supported by medically
acceptable clinical and laboratory diagnostic techniques and is not inconsistent with the other
substantial evidence [of] record,” must he give that opinion controlling weight. Id. “[T]he more
consistent an opinion is with the record as a whole, the more weight [the ALJ generally] will give
to that opinion.” Id. § 416.927(c)(4).
If the ALJ finds that “a treating source’s opinion on the issue(s) of the nature and severity
of [a claimant’s] impairment(s) is well-supported by medically acceptable clinical and laboratory
diagnostic techniques and is not inconsistent with the other substantial evidence [of] record,” he
must give that opinion controlling weight. Id. Also, “the more consistent an opinion is with the
record as a whole, the more weight [the ALJ generally] will give to that opinion.” Id. §416.927(c)(4).
In the event of conflicting medical evidence, the Court of Appeals for the Third Circuit has
explained:
“A cardinal principle guiding disability determinations is that the ALJ accord treating
physicians’ reports great weight, especially ‘when their opinions reflect expert
judgment based on continuing observation of the patient’s condition over a
prolonged period of time.’” Morales v. Apfel, 225 F.3d 310, 317 (3d Cir. 2000)
(quoting Plummer v. Apfel, 186 F.3d 422, 429 (3d Cir. 1999)). However, “where . .
. the opinion of a treating physician conflicts with that of a non-treating, non-
4
examining physician, the ALJ may choose whom to credit” and may reject the
treating physician’s assessment if such rejection is based on contradictory medical
evidence. Id. Similarly, under 20 C.F.R. § 416.927(d)(2), the opinion of a treating
physician is to be given controlling weight only when it is well-supported by medical
evidence and is consistent with other evidence in the record.
Becker v. Comm’r of Social Sec. Admin., No. 10-2517, 2010 WL 5078238, at *5 (3d Cir. Dec. 14,
2010). Although the ALJ may choose whom to credit when faced with a conflict, he “cannot reject
evidence for no reason or for the wrong reason.” Diaz v. Comm’r of Soc. Security, 577 F.3d 500,
505 (3d Cir. 2009).
In this case, Plaintiff argues that the reasons the ALJ gave Dr. DeMatteis’ opinion partial
weight are not supported by substantial evidence. (ECF No. 15, pp. 9-13). The ALJ gave Dr.
DeMatteis, a treating neurologist, partial weight, because the “assessed limitations are not fully
supported by the medical evidence.” Id. After relating Dr. DeMatteis’ opinion in his medical
source statement, the ALJ weighed the same. (ECF No. 7-2, p. 31). In so doing, the ALJ set
forth examples of internal inconsistency and inconsistency with other evidence of record. Id.
I give this opinion partial weight, as Dr. DeMatteis is a specialist, who has a treating
relationship with the claimant. However, the assessed limitations are not fully
supported by the medical evidence. For example, while Dr. DeMatteis assessed
significant exertional limitations, the treatment records do not include the same.
Further, the frequency of office visits (e.g., 6 months to one year) is inconsistent
with a disabling level of functioning (Exhibit 13F/8). Dr. DeMatteis crossed out
“good” prognosis and indicated a low probability for medical control of seizures.
However, the medical evidence shows medication efficacy when properly titrated,
as evidenced by the absence of seizures for over one year (Exhibit 16F/2; see
also, Exhibit 6F/5). Further, while the claimant had varying definitions of “seizure,”
she generally described the same as 2-3 minutes of right ulnar jerking without
secondary generalization, altered mentation, or residual effects. While she
sometimes reported the same as occurring once per month in 2014 and 2015, she
also reported the same occurring less frequently (see, Exhibits 6F and 9F).
Based on the medical evidence, there is no indication her seizures occurred with
such frequency, duration or severity as to preclude all work activity on a continuing
and regular basis. The assessed postural limitations are not fully supported by
the other evidence, including physical therapy records documenting functional
objective tests within normal limitations (see, Exhibit 5F). Additionally, the
assessed lifting and manipulative limitations draw no dominant/non-dominant
distinction. DeMatteis indicated the claimant had mild right hemiparesis. This is
consistent with the above residual functional capacity.
5
(ECF No. 7-2, p. 31).
In challenging the reasons, Plaintiff first asserts that while it is true that the treatment
records do not include any exertional limitations, this is not a valid reason for discounting the
opinion because “there was no reason for Dr. DeMatteis to include any of these facts.” (ECF No.
15, p. 11). A record need not contain anything in particular, nonetheless, it is appropriate for the
ALJ to look to the treatment record for consistency. Consistency is a valid reason for crediting
or discrediting evidence. See, 20 C.F.R. §§416.927, 404.1527 (Evaluating Opinion Evidence).
Furthermore, I note that, as set forth above, this was not the only reason for discounting Dr.
DeMatteis’ opinion. See, ECF No. 7-2, p. 31.
Plaintiff also points to evidence of record to support Dr. DeMatteis’ assessed limitations.
(ECF No. 15, pp. 11-12). To be clear, the standard is not whether there is evidence to establish
Plaintiff’s position. Allen v. Bowen, 881 F.2d 37, 39 (3d Cir. 1989).
[The] question is not whether substantial evidence supports Plaintiff’s claims, or
whether there is evidence that is inconsistent with the ALJ’s finding…. Substantial
evidence could support both Plaintiff’s claims and the ALJ’s findings because
substantial evidence is less than a preponderance. Jesurum v. Sec’y of U.S.
Dep’t of Health & Human Services, 48 F.3d 114, 117 (3d Cir. 1995) (citing
Richardson v. Perales, 402 U.S. 389, 401 (1971). If substantial evidence
supports the ALJ’s finding, it does not matter if substantial evidence also supports
Plaintiff’s claims. Reefer v. Barnhart, 326 F.3d 376, 379 (3d Cir. 2003).
Weidow v. Colvin, Civ. No. 15-765, 2016 WL 5871164 at *18 (M.D. Pa. Oct. 7, 2016). Thus, the
question before me is whether substantial evidence supports the ALJ’s findings. Allen v. Bowen,
881 F.2d 37, 39 (3d Cir. 1989). Therefore, Plaintiff’s argument in this regard is misplaced.
Plaintiff next argues that “[t]he fact that an outdated State agency opinion from 2014
contradicts Dr. DeMatteis’ assessment is not indicative of substantial evidence” and a nonexamining physician’s opinion cannot serve as a sufficient reason to discount a treating
physician’s opinion. (ECF No. 15, p. 13). To begin with, a treating doctor’s opinion is not
6
automatically entitled to greater weight over that of a non-examining doctor’s opinion, as Plaintiff
suggests. In accordance with the Regulations, the ALJ is charged with the responsibility of
weighing all of the medical opinion evidence in determining whom to credit and he must explain
his rationale for doing so. See, 20 C.F.R. §§404.1527; 416.927 (Evaluating Opinion Evidence).
Additionally, an ALJ is entitled to rely upon the findings of an evaluator even if there is a lapse of
time between the report and the hearing. Chandler v. Comm'r of Soc. Sec., 667 F.3d 356, 361
(3d Cir. 2012) (“The Social Security regulations impose no limit on how much time may pass
between a report and the ALJ's decision in reliance on it.”). In this case, the ALJ did not give the
state agency medical consultant, Dr. Fox, great weight. (ECF No. 7-2, p. 30). Rather, the ALJ
gave Dr. Fox’s opinion only partial weight because Dr. Fox did not have the opportunity to review
all of the records and the treatment records indicated Plaintiff had residual pain, numbness, and
weakness.
Id.
As a result, the ALJ acknowledged subsequent medical limitations and
accommodated the same in the RFC. Id.
I am able to conduct a meaningful review and the
ALJ’s assessment is supported by substantial evidence.
(ECF No. 7-2, pp. 23-32).
Consequently, I find Plaintiff’s arguments are without merit. Therefore, remand is not warranted.
Next, Plaintiff submits that the ALJ improperly created the mental RFC assessment “out
of thin air.” (ECF No. 15, p. 5). In support of the same, Plaintiff agrees that she has mental
limitations, but simply argues that “it is unclear how the ALJ reached his mental RFC
determination.” Id. at 14. As such, Plaintiff argues that the ALJ’s decision is not supported by
substantial evidence such that remand is warranted. Id. After a review of the record, I disagree.
The ALJ determined Plaintiff has the RFC to perform light work with various physical and
mental limitations. (ECF No. 7-2, p. 23). With regard to the mental limitations, the ALJ found
numerous and specific exceptions.
[Plaintiff] is limited to understanding, remembering, and carrying out simple
instructions and performing simple, routine tasks; is limited to work that can be
7
taught by demonstration; is limited to no work related interaction with the public,
only occasional and superficial interaction with co-workers, and only occasional
supervision; and is limited to a low stress work environment, that means no
production rate pace work (e.g., assembly line work), instead, is limited to only
occasional and routine change in work setting and goal-oriented work, and any
routine change will not require alteration in work method.
(ECF No. 7-2, p. 23). “Rarely can a decision be made regarding a claimant’s [RFC] without an
assessment from a physician regarding the functional abilities of the claimant.” Gormont v.
Astrue, No. 11-2145, 2013 WL 791455 at *7 (M.D. Pa. Mar. 4, 2013), citing Doak v. Heckler, 790
F.2d 26 (3d Cir. 1986). In this case, however, the only opinion evidence related to Plaintiff’s
mental abilities is from the state agency consultant, Dr. Croyle, who determined that Plaintiff’s
mental impairment was nonsevere. (ECF No. 7-2, p. 31). The ALJ gave this opinion little weight
because “Dr. Croyle did not have an opportunity to review all of the records at the time of his
assessment. Further, he did not adequately consider the combined effect of the claimant’s
impairments.”
Id.
Thus, contrary to Plaintiff’s inferences, the ALJ is not rejecting more
restrictive opinion evidence related to her mental impairments. Rather, after rejecting the mental
opinion evidence that Plaintiff has a nonsevere mental impairment, the ALJ gave Plaintiff the
benefit of the doubt and added additional limitations based on the other evidence of record. (ECF
No. 7-2, pp. 23-32). To be clear, there is no medical opinion evidence opining that Plaintiff’s
alleged mental limitations result in limiting her abilities to function. In fact, as the ALJ pointed
out, “[t]he record indicates that the claimant did not receive ongoing mental health treatment
during the period under adjudication. Further, she often denied depression.” (ECF No. 7-2, pp.
29-30). The ALJ then went on to provide Plaintiff’s mental claims, with the benefit of the doubt,
and included numerous mental limitations in the RFC. Providing Plaintiff with limiting mental
abilities in the RFC only serves Plaintiff’s advantage. Thus, I find remand is not warranted on
this basis.
8
C.
Plaintiff’s Husband’s Statement
Plaintiff’s husband testified at the hearing. (ECF No. 7-2, p. 31; No. 7-3, pp. 60-67).
Plaintiff submits that the ALJ erred in failing to provide legitimate reasoning for discounting her
husband’s testimony. (ECF No. 7-2, pp. 15-16). Again, to be clear, the ALJ did not reject her
husband’s testimony. (ECF No. 7-2, pp. 31-32). Rather, the ALJ gave Plaintiff’s husband’s
testimony “limited weight.” (ECF No. 7-2, p. 32). As explained by the ALJ, the ALJ found
Plaintiff’s husband was not a medical professional and further that his statement was inconsistent
with the overall medical evidence. Id. That is not to say, as Plaintiff infers, that the ALJ did not
consider the evidence, just that he was not considering it as opinion evidence from a medical
professional. After a review of the record, I find there is substantial evidence to support this
finding of the ALJ. (ECF No. 7-2, pp. 23-32). Therefore, I find no error in this regard.
An appropriate order shall follow.
9
IN THE UNITED STATES DISTRICT COURT
FOR THE WESTERN DISTRICT OF PENNSYLVANIA
AFRAH AHMED SAEED,
Plaintiff,
-vsANDREW M. SAUL,3
COMMISSIONER OF SOCIAL SECURITY,
Defendant.
)
)
)
)
)
)
)
)
)
)
Civil Action No. 18-113
AMBROSE, Senior District Judge
ORDER OF COURT
THEREFORE, this 25th day of June, 2019, it is ordered that Plaintiff’s Motion for Summary
Judgment (ECF No. 14) is denied and Defendant’s Motion for Summary Judgment (ECF No. 16)
is granted.
BY THE COURT:
s/ Donetta W. Ambrose
Donetta W. Ambrose
United States Senior District Judge
3
Andrew M. Saul was sworn in as Commissioner of Social Security on June 18, 2019, replacing Acting
Commissioner, Nancy A. Berryhill.
Disclaimer: Justia Dockets & Filings provides public litigation records from the federal appellate and district courts. These filings and docket sheets should not be considered findings of fact or liability, nor do they necessarily reflect the view of Justia.
Why Is My Information Online?