CLAPPER v. ASTRUE
Filing
16
OPINION. Signed by Judge Mark R. Hornak on 11/26/13. (jad) Modified on 11/26/13 to indicate related document. (bdb)
IN THE UNITED STATES DISTRICT COURT
FOR THE WESTERN DISTRICT OF PENNSYLVANIA
ERICA LYNN CLAPPER,
Plaintiff,
v.
CAROL YN W. COLVIN,! Acting as
Commissioner of Social Security,
Defendant.
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Civil Action No. 12-1688
Judge Mark R. Hornak
OPINION
Mark R. Hornak, United States District Judge
I. INTRODUCTION
Erica Clapper ("Plaintiff') brings this action pursuant to 42 U.S.C. § 405(g), seeking
review of the final determination of the Commissioner of Social Security ("Defendant" or
"Commissioner") denying her application for supplemental security income ("SSI") under Title
XVI of the Social Security Act, 42 U.S.c. §§ 401-433, 1381-1383f ("Act"). This matter comes
before the Court on cross motions for summary judgment (ECF Nos. 8, 10). The record has been
developed at the administrative level, and for the reasons which follow, Plaintiffs Motion for
Summary Judgment will be denied and Defendant's Motion for Summary Judgment will be
granted.
II. PROCEDURAL HISTORY
Plaintiff applied for SSI on June 24, 2009, claiming a disability onset of January 1,2009.
CR. at 103-107).2 Plaintiff was initially denied benefits on November 4, 2009. (R. at 66-70). A
I Carolyn W. Colvin became the Acting Commissioner of Social Security on February 14,2013. Pursuant to Rule
25(d) of the Federal Rules of Civil Procedure, Carolyn W. Colvin should be substituted for Michael J. Astrue as the
Defendant in this suit. No further action needs to be taken to continue this suit by reason of the last sentence of §
205(g) of the Social Security Act, 42 U.S.c. § 405(g).
hearing before an Administrative Law Judge ("ALJ"), Brian W. Wood, was held on February 10,
2011, and Plaintiff testified, represented at her request by non-attorney Stephanie Tecza. (R. at
28-59). A vocational expert was also present to testify. (R. at 28-59). The ALl issued his
decision denying benefits to Plaintiff on March 25, 201 L (R. at 8-25). Plaintiff filed a Request
for Review of Hearing Decision with the Appeals Council, which was denied on September 15,
2011, thereby making the ALl decision the final decision of the Commissioner. (R. at 1-6).
Plaintiff filed her Complaint in this Court on November 29, 2012. (ECF No.3).
Defendant filed an Answer on February 4, 2013. (ECF No.5). Cross motions for summary
judgment followed. (ECF Nos. 8, 10). The matter has been fuBy briefed. (ECF Nos. 9, 11, 12,
15).
III. STATEMENT OF FACTS
A. General Background
Plaintiff was born on March 22, 1991, was eighteen years of age at the time of her
application for benefits, and was twenty years of age at the time of the ALl's decision. (R. at 33).
Plaintiff graduated from Butler Area Senior High School, however, was identified to have a
specific learning disability and emotional disturbance and was enrolled in an Individualized
Educational Program. (R. at 35-36, 166, 170). Plaintiff began working part-time for Goodwill in
October of 2010 and was still working there at the time of the administrative hearing. (R. at 38,
47, 152,398). Plaintifflived with her family at all relevant times (R. at 34).
B. Physical Health History
On April 7, 2008, Plaintiff saw her family doctor, Michael J. Wahl, M.D., for a physical
examination. (R. at 305). At this visit, Dr. Wahl concluded that Plaintiff was doing well and did
Citations to ECF Nos. 6-2-10, the Record, hereinafter, "R. at __ ."
2
not diagnose her with any impainnents. (R. at 305). On February 9, 2009, Dr. Wahl diagnosed
Plaintiff with headaches, recommended blood work, and prescribed Topamax. (R. at 303).
On February 22, 2009, Plaintiff went to the Emergency Room because she was
experiencing blurred vision, nausea, and headaches. (R. at 244). Plaintiff was diagnosed with
headaches and abdominal pain. (R. at 258, 260). Plaintiff had also recently been diagnosed with
Lyme disease and was taking amoxicillin. (R. at 244, 252, 286). A CT scan from this visit found
no intracranial hemorrhage or mass effect and Plaintiff was discharged. (R. at 252, 254, 324). Dr.
Wahl's notes provide that on February 24, 2009, he advised Plaintiff's mother that complying
with this medication was of the "utmost importance." (R. at 300).
On March 16, 2009, Dr. Wahl examined Plaintiff and diagnosed her with headaches and
Lyme disease. (R. at 299). During this session, Plaintiff reported that she was feeling much better
overall and that her headaches were "getting better." (R. at 299). Dr. Wahl noted that "[Plaintiff]
actually looks and is acting much better." (R. at 299). On April 21, 2009, Dr. Wahl examined
Plaintiff regarding a stomachache and prescribed Nexium. (R. at 298). Dr. Wahl's notes from
this session provide that Plaintiff had been non-compliant with her medications. (R. at 298). On
April 22, 2009, Plaintiff returned to the Emergency Room and was diagnosed with visual
disturbance, abdominal pain, and urinary tract infection. (R. at 225). Plaintiff was prescribed
medication, her condition was stabilized, and she was discharged to go home. (R. at 221, 225).
An MRI of Plaintiff's brain conducted on April 27, 2009 displayed prominence of the pituitary
gland and right sphenoid sinus disease. CR. at 284,323).
On April 29, 2009, Thomas McGill, M.D., examined Plaintiff on referral from Dr. Wahl.
(R. at 210). Plaintiff complained of headaches, nausea, vomiting, and problems with her vision.
(R. at 210). Dr. McGill observed that Plaintiff was nonnally developed and contemplated that
3
she could have a "false positive Lyme test with no IgC conversion." CR. at 210). On May 4,
2009, Constantine A. Balouris, M.D., conducted an eye examination of Plaintiff, and her vision
was determined to be within the normal limits. CR. at 346-349).
During an annual physical examination on May 22, 2009, Plaintiff informed Dr. Wahl
that she was still experiencing headaches. CR. at 296). Dr. Wahl noted that Plaintiff was "hit and
miss with her meds still" and was "doing okay." (R. at 296). A follow-up MRI of Plaintiff's
brain on May 13, 2009 showed "borderline size of the pituitary gland which is a nonspecific
finding without any signs of any adenoma" and that "[t]he remainder of the MRI of the brain
[was] unremarkable." (R. at 282, 322).
On June 25, 2009, Munir Y. Elawar, M.D., examined Plaintiff on referral from Dr. Wahl
and diagnosed her with headaches and the possibility of seizures. (R. at 290-294). Dr. Elawar
opined that Plaintiff would benefit from further testing, including an EEG and MRI. (R. at 292).
Dr. Elawar believed Plaintiff would benefit from medication, however, "her mother said she is
not good with taking medications and the patient does not want medications." (R. at 292).
On November 4, 2009, Juan B. Mari-Mayans, M.D., conducted a Physical Residual
Functional Capacity of Plaintiff. (R. at 377-383). Dr. Mari-Mayans did not physically examine
Plaintiff but reviewed her medical records and diagnosed her with headaches and a history of
Lyme disease. (R.at 377,382). Dr. Mari-Mayans opined that Plaintiff can occasionally lift and/or
carry 50 pounds, can frequently lift and/or carry 25 pounds, can stand and/or walk for a total of
about 6 hours in an 8 hour day, and can sit for a total of about 6 hours in an 8 hour day. (R. at
378). Dr. Mari-Mayans also found Plaintiffs statements to be "partially credible" and noted that
"[Plaintiff] has described daily activities that are not significantly limited in relation to her
4
alleged symptoms" and "treatment has generally been successful in controBing her symptoms."
(R. at 382).
C. Mental Health History
On September 25, 2006, when Plaintiff was fifteen years old, Patricia M. McGuire, M.D.,
perfonned a psychiatric evaluation of Plaintiff "due to poor academic perfonnance, problems
with attention and organization and difficulty handling anger and frustration." (R. at 384). Dr.
McGuire observed that Plaintiff had nonnal speech, had an irritable and bored affect, and her
cognition was grossly intact. (R. at 386). Further, Plaintiff exhibited no motor abnonnalities, no
suicidal ideation, and no evidence of looseness of associations, thought blocking or flight of
ideas. (R. at 386). Dr. McGuire diagnosed Plaintiff with attention deficit hyperactivity disorder,
oppositional defiant disorder, and learning disorder. (R. at 386). Plaintiff had a Global
Assessment of Functioning ("GAF") score of 45 at this session? (R. at 386).
In February 2009, Plaintiff was enroBed in an Individualized Educational Program at
Butler Area Senior High School, which consisted of basic, regular, and learning support classes.
(R. at 170, 182). Plaintiff was identified with a specific learning disability in basic reading skills
and mathematic problem solving as weB as severe emotional disturbance. (R. at 166, 174).
Plaintiff had a verbal IQ score of 83 and a full scale IQ score of 78. (R. at 181). The report noted
that "[Plaintiff] worked successfully academically at the senior high this year" and was proficient
in English. (R. at 170, 175).
The Global Assessment of Functioning Scale ("GAF") assesses an individual's psychological, social and
occupational functioning with a score of I being the lowest and a score of I 00 being the highest. The GAF score
considers "psychological, social, and occupational functioning on a hypothetical continuum of mental health
illness." American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (DSM-lV-TR)
34 (4th ed.2000). An individual with a GAF score of 41-50 may have "(s]erious symptoms (e.g., suicidal
ideation ...)" or "impairment in social. occupational, or school functioning (e.g., no friends, unable to keep a job)."
3
Id.
5
On October 23,2009, state consultative examiner T. David Newman, Ph.D., conducted a
clinical psychological disability evaluation and intellectual evaluation regarding Plaintiffs claim
for SSI. (R. at 353-358). Dr. Newman diagnosed Plaintiff with borderline intellectual functioning
("BIF"). (R. at 356). Plaintiff reported that she did laundry, went on the computer, liked to "hang
out with friends," and had a boyfriend. (R.at 354). Dr. Newman noted that Plaintiff "whine[d]"
during the examination and was "was lethargic and reluctant to make an effort throughout the
interview and testing." (R. at 353-354, 356). Nevertheless, Dr. Newman observed that Plaintiffs
"speech content was consistently relevant, rational, and coherent," she exhibited a euthymic
mood, her concept formation was intact, and had a weak fund of general information. (R. at 354).
Further, Plaintiff was oriented, her memory functioning was reasonably intact, her social
judgment and test judgment were sufficient, she had good insight, and she had not indicated a
disturbance of impulse control and related hostility, aggressiveness, or sexuality. (R. at 354-355).
Dr. Newman assessed Plaintiff with a verbal IQ score of 74, a performance IQ score of 79, and a
full scale IQ score of 75. (R. at 355).
Dr. Newman's report contained a pre-printed form and he made check marks under the
column on that form titled "marked limitations" regarding Plaintiffs ability to interact
appropriately with supervisors, respond appropriately to work pressures, and respond
appropriately to changes in the work routine. (R. at 357). In an explanatory summary, Dr.
Newman opined that Plaintiff was capable of receiving and carrying out instructions for simple
and repetitive tasks, however, cautioned that Plaintiffs attitude could pose a problem regarding
more detailed tasks. (R. at 356). Dr. Newman believed that Plaintiff lacked the necessary
experience and intellectual functioning to personally manage her funds. (R. at 356).
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On October 28, 2009, non-exammmg state agency psychologist John Rohar, Ph.D.,
issued a mental residual functional capacity assessment and psychiatric review technique of
Plaintiff. (R. at 359-376). Dr. Rohar concluded that Plaintiff had medically detenninable
impainnents of BIF and specific learning disability. (R. at 361, 364, 367). According to Dr.
Rohar, Plaintiff could perfonn simple, routine, repetitive work in a stable environment; could
understand, retain, and follow simple job instructions; could make simple decisions; was capable
of asking simple questions and accepting instructions; and could function in production oriented
jobs requiring independent decision making. (R. at 361). Dr. Rohar filled out a fonn where he
found Plaintiff was either "not significantly limited" or "moderately limited" for all of the
questions. (R. at 359-360). Based on the totality of the medical evidence that Dr. Rohar relied
upon, he decided that Plaintiffs sUbjective complaints were not reliable. (R. at 361).
On October 14, 2010, Randon Simmons, M.D., conducted a psychiatric evaluation on
Plaintiff. (R. at 388-391). Dr. Simmons diagnosed Plaintiff with mood disorder NOS and
personality disorder NOS with dependent and obsessive compulsive traits. (R. at 391). Plaintiff
received a GAF score of 35 at this session. 4 (R. at 391). Dr. Simmons observed that Plaintiff s
speech was nonnal in tempo and volume, her motor activity was not abnonnal, her mood was
dysphoric, her affect was inappropriate at times, her thoughts were organized, and she had
below-average intelligence, good memory, poor insight, and poor judgment. (R. at 390). Plaintiff
denied suicidal ideation and hallucinations. (R. at 390). Dr. Simmons noted in his report that
Plaintiff refused to take medication as advised, and her mother said that Plaintiff "needs more
mental health history and a diagnosis in order to get [SSI] benefits." (R. at 388).
4 An individual with a GAF score of 31-40 may have "[s]ome impairment in reality testing or communication" or
"major impairment in several areas, such as work or school, family relations, judgment, thinking or mood."
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorder~ (DSM-IV- TR) 34 (4th
ed.2000).
7
Plaintiff saw Dr. Simmons again on November 29,2010. (R. at 394-401). Dr. Simmons
noted that Plaintiff was "slightly more comfortable, interactive, and engaging" during this
session. (R. at 398). Plaintiff reported that she had been taking her medication and drove to the
appointment. (R. at 398). Plaintiff also informed Dr. Simmons that she began working at
Goodwill sometime in October and stated that "it's really easy." (R. at 398).
D. Administrative Hearing
Plaintiff appointed non-attorney Stephanie Tecza to represent her at the administrative
hearing. (R. at 28-59, 102). Ms. Tecza told the ALJ that she had known Plaintiff through her
work in the PEAL Center, S where she was as a parent advisor involved in education advocacy.
(R. at 32). Ms. Tecza informed the ALJ that she had never represented anyone in a hearing
before. (R. at 55). Ms. Tecza had an opportunity to examine the file prior to the hearing and
prepared a summary of the evidence, which she submitted to the ALJ during the hearing. (R. at
31-32,153-164).
Plaintiff testified that she lived at home with her parents. (R. at 34). At the time of the
hearing, Plaintiff was working four days a week at Goodwill, which allowed her to pay her
phone bill and buy food. (R. at 34-35, 38). At work, Plaintiff operated a cash register, put clothes
away, and assisted her mentally challenged co-workers. (R. at 37-38). She was paid every two
weeks and her most recent pay check at the time of the hearing was for approximately $230. (R.
at 38). Plaintiff had a driver's license and said that she only drove alone when she traveled to
work. (R. at 35).
"The PEAL Center is an organization of parents of children with special health care needs and disabilities reaching
out to assist other parents and professionals." The PEAL Center, http://www.pealcenter.org/aboutus/aboutpeaLphp
(last visited Nov. 19, 2013). "The Mission of the PEAL Center is to ensure that children, youth, and adults with
disabilities and special health care needs lead rich, active lives and participate as full members of their schools and
communities by providing training, information, and technical assistance based on best practices to individuals,
families and all people who support them." Id.
5
8
Plaintiff graduated from high school but was enrolled in an Individualized Educational
Program, which included special education courses. (R.at 35-36). She testified that she could
write, count money, and read, but had difficulty doing so. (R. at 36-37). Plaintiff also stated that
she went to the mall and grocery store with her mother and went out to eat with friends. (R. at
35,48). She testified that she used a computer and sent friends text messages, including her ex
boyfriend. (R. at 48). Regarding household chores, Plaintiff said that she would run the sweeper,
however, refused to clean dishes, which she considered disgusting. (R. at 47). Ms. Tecza asked
Plaintiff if her "cleanliness issue" affected her work and she replied that if there was a spill in the
store, she would not clean it up and instead would notify a utility man to do so. (R. at 50-51).
The ALl asked Plaintiff about her treatment with Dr. Elawar and Plaintiff said she never
got the EEG done because it required putting glue in her hair. (R. at 40-41). Plaintiff testified that
Dr. Wahl was her family doctor and that she was still seeing him. (R. at 41). Plaintiff also stated
that she was prescribed medication by "some guy at Irene Stacy's" but could not remember his
name. (R. at 41-42). She stopped taking this medication because she did not think it would work.
(R. at 44). Plaintiff testified that she had headaches three days per week and that 500 milligram
Tylenol helped, but she tried to avoid using it. (R. at 45-46). Plaintiff was asked about her history
of Lyme disease and she said it had gotten better and that her eye problem was better as well. (R.
at 46).
Following Plaintiffs testimony, the ALl questioned the vocational expert. (R. at 51-56).
The ALl first stated that
Plaintiff had no past relevant work and then asked whether a
hypothetical person of Plaintiffs age, education, and work experience would be eligible for a
significant number ofjobs in existence in the national economy if limited to: lifting and carrying
fifty pounds occasionally, lifting and carrying twenty-five pounds frequently, standing or
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walking for six hours of an eight-hour work day, sitting for six hours of an eight-hour work day,
performing simple, routine, repetitive tasks, requiring low-stress work (defined as occasional,
simple, decision making and occasional changes in the work setting), cannot perform work in a
fast-paced production environment, can have occasional interaction with co-workers,
supervisors, and the public, and limited to only basic reading, writing, and math skills. (R. at 52).
The vocational expert responded that such a person would be capable of working as a
dishwasher, with 209,000 such jobs available nationally, as a janitor, with over 1,000,000 such
jobs available, and as a grounds worker, with about 100,000 such jobs available. (R. at 52-53).
The ALl went on to ask whether jobs would be available to a person with the additional
limitation of working in relatively clean environments. (R. at 53). The vocational expert replied
that such a person would be capable of working as a stock clerk, with 118,000 such jobs
available, as a packer at the light level, with 206,000 such jobs available, and as a bagger, with
100,000 such jobs available. (R. at 54). Then the ALl asked whether there would be any work
available if someone was off-task twenty percent of the work day and the vocational expert
responded in the negative. (R. at 54). The ALl asked the vocational expert whether his testimony
was consistent with the information in the Dictionary of Occupational Titles, to which the
vocational expert answered in the affirmative. (R. at 54).
Ms. Tecza next had the opportunity to examine the vocational expert. (R. at 54-56).
However, she struggled in framing proper questions. (R. at 54-56). The ALJ assisted Ms. Tecza
by explaining how to appropriately ask questions but she continued to have difficulty. (R. at 54
56). The ALJ ultimately asked the vocational expert whether an individual that had three
outbursts with supervisors or co-workers per month would be able to retain employment, and the
vocational expert answered in the negative. (R. at 56).
10
Several times throughout the hearing the ALl advised both Plaintiff and Ms. Tecza of the
importance of attaining a complete medical record. (R. at 39-40, 42, 56-58). The ALl requested
that Ms. Tecza get additional medical records from Irene Stacy, Dr. Wahl, and Dr. Elawar and
said he would hold the record open for twenty days in case she had difficulty gathering these
records. (R. at 56-57). Then the ALl mentioned it might be easier on Ms. Tecza if his office
obtained the records, asked Plaintiff if she wished to sign three (3) release fonns, and announced
he would make his decision after he considered the new medical evidence. (R. at 58).
IV. STANDARD OF REVIEW
To be eligible for Social Security benefits under the Act, a claimant must demonstrate to
the Commissioner that he or she cannot engage in substantial gainful activity because of a
medically detenninable physical or mental impainnent 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 twelve months.
42 U.S.C. § 423(d)(1)(A); Brewster v. Heckler, 786 F.2d 581, 583 (3d Cir.1986). When
reviewing a claim, the Commissioner must utilize a five-step sequential analysis to evaluate
whether a claimant has met the requirements for disability. 20 C.F.R. §§ 404.1520, 416.920.
The Commissioner must detennine: (1) whether the claimant is currently engaged in
substantial gainful activity; (2) if not, whether the claimant has a severe impainnent or a
combination of impainnents that is severe; (3) whether the medical evidence of the claimant's
impainnent or combination of impainnents meets or equals the criteria listed in 20 C.F .R., Pt.
404, Subpt. P, App'x 1; (4) whether the claimant's impainnents prevent him from perfonning his
past relevant work; and (5) if the claimant is incapable of perfonning his past relevant work,
whether he can perfonn any other work which exists in the national economy. 20 C.F .R. §§
404.1520(a)(4), 416.920(a)(4); see Barnhart v. Thomas, 540 U.S. 20, 24-25, 124 S.Ct. 376, 157
11
L.Ed.2d 333 (2003). If the claimant is detennined to be unable to resume previous employment,
the burden shifts to the Commissioner (Step 5) to prove that, given claimant's mental or physical
limitations, age, education, and work experience, he or she is able to perfonn substantial gainful
activity injobs in the national economy. Doak v. Heckler, 790 F.2d 26,28 (3d Cir.1986).
Judicial review of the Commissioner's final decisions on disability claims is provided by
statute, and is plenary as to all legal issues. 42 U.S.C. §§ 405(g)6, 1383(c)(3)7; Schaudeck v.
Comm'r of Soc. Sec., 181 F .3d 429, 431 (3d Cir.1999). Section 405(g) pennits a district court to
review the transcripts and records upon which a detennination of the Commissioner is based; the
court will review the record as a whole. See 5 U.S.C. § 706. The District Court must then
detennine whether substantial evidence exists in the record to support the Commissioner's
findings offact. Burns v. Barnhart, 312 F.3d 113, 118 (3d Cir.2002).
Substantial evidence is defined as "more than a mere scintilla. It means such relevant
evidence as a reasonable mind might accept as adequate" to support a conclusion. Ventura v.
Shalala, 55 F.3d 900, 901 (3d Cir.1995) (quoting Richardson v. Perales, 402 U.S. 389, 401, 91
S.Ct. 1420, 28 L.Ed.2d 842 (1971)). If the Commissioner's findings of fact are supported by
substantial evidence, they are conclusive. 42 U.S.C. § 405(g); Richardson, 402 U.S. at 390. A
6
Section 405(g) provides in pertinent part:
Any individual, after any final decision of the [Commissioner] made after a hearing to
which he was a party, irrespective of the amount in controversy, may obtain a review of
such decision by a civil action ... brought in the district court of the Vnited States for the
judicial district in which the plaintiffresides, or has his principal place of business.
42 V.S.c. § 405(g).
7
Section 1383(c)(3) provides in pertinent part:
The final determination of the Commissioner of Social Security after a hearing under
paragraph (1) shall be subject to judicial review as provided in section 405(g) of this title
to the same extent as the Commissioner's final determinations under section 405 of this
title.
42 V.S.c. § 1383(c)(3).
12
District Court cannot conduct a de novo review of the Commissioner's decision nor re-weigh the
evidence of record; the court can only judge the propriety of the decision in reference to the
grounds invoked by the Commissioner when the decision was rendered. Palmer v. Apfel, 995
F.Supp. 549, 552 (E.D.Pa.1998); S.E.C. v. Chenery Corp., 332 U.S. 194, 196-97 (1947). The
court will not affirm a determination by substituting what it considers to be a proper basis,
Chenery, 332 U.S. at 196-97. Further, "even where this court acting de novo might have reached
a different conclusion ... so long as the agency's fact finding is supported by substantial evidence,
reviewing courts lack power to reverse either those findings or the reasonable regulatory
interpretations that an agency manifests in the course of making such findings." Monsour
Medical Center v. Heckler, 806 F .2d 1185, 1190-91 (3d. Cir.1986).
V. DISCUSSION
In his decision, the ALl concluded that Plaintiff's work at Goodwill did not rise to the
level of substantial gainful activity. (R. at 13). The ALl found that Plaintiff had the following
severe impairments: Lyme disease, learning disorder, mood disorder, BIF, and personality
disorder. (R. at 13). As a result of said impairments, the ALl found that
[Plaintiff] has the residual functional capacity to perform medium
work as defined in 20 CFR 416.967(c). [Plaintiff] has the RFC to
lift and carry 50 pounds occasionally and 25 pounds frequently,
she can stand or walk for 6 hours of an eight hour workday. She
can sit for 6 hours of an eight-hour workday. She is able to perform
simple, routine, repetitive tasks. She requires low-stress work
defined as occasional simple decision-making and occasional
changes in the work setting. She cannot perform work in a fast
paced production environment She can have occasional interaction
with coworkers and supervisors and the pUblic. She is limited to
only basic reading, writing and math skills.
13
(R. at 16). Based upon the testimony of the vocational expert, the ALJ detennined that Plaintiff
was capable of engaging in a significant number of jobs in existence in national economy. (R. at
22-23). Plaintiff was not, therefore, awarded SSI. (R. at 23).
Plaintiff objects to the decision of the ALl, arguing that he erred by failing to secure a
waiver of counsel from Plaintiff, improperly disregarding the medical opinion of Plaintiffs
treating physicians, improperly detennining Plaintiffs residual functional capacity ("RFC"), and
improperly disregarding the testimony of the vocational expert and relying on an incomplete
hypothetical question. (ECF No. 11 at 7-15). Defendant counters that waiver of counsel is not an
issue because Plaintiff did not appear pro se and was represented a non-attorney at the hearing,
and argues in the alternative, that if Plaintiff proceeded pro se, she knowingly and intelligently
waived her right to counsel and the ALJ adequately developed the record. (ECF No. 12 at 2-8).
Defendant also contends that the ALl reasonably assessed the evidence of record, reasonably
assessed Plaintiffs RFC, posed a reasonable hypothetical to the vocational expert, and provided
substantial evidence to support his decision, so his decision should be affinned. (ECF Nos. 9,
12). The Court agrees with Defendant.
Plaintiff first argues that the ALJ failed to secure an adequate waiver of counsel. (ECF
No. 11 at 7-9). Within this argument, Plaintiff seems to contend that Ms. Tecza's representation
of Plaintiff amounted to ineffective assistance and that Plaintiff was without notice of her right to
be represented by legal counsel. (ECF No. 11 at 8-9). With respect to whether Plaintiff had
notice of her right to counsel, the Third Circuit has held that two letters sent on the same day
from the SSA advising the claimant of his right to be represented by an attorney or other
representative constituted sufficient notice. Phifer v. Comm'r of Soc. Sec., 84 F. App'x 189, 191
14
(3d Cir. 2003). In this case, Plaintiff received at least four such notices from the SSA. (R. at 69,
71, 75-83, 91). She had sufficient notice of her right to be represented by an attorney.
Plaintiff asserts that the ALJ failed to advise her on the record of "the manner in which an
attorney would aid in the proceedings, the possibility of free counselor a contingency
arrangement, or limitations on attorney's fees to 25 percent of past due benefits with Court
approval of fees," which is required in the Seventh Circuit to ensure valid waivers of
representation. (ECF No. 15 at 4); see Skinner v. Astrue, 478 F.3d 836, 841 (7th Cir. 2007).
However, the Third Circuit does not require that "ALJs explain each of these listed items that the
Court of Appeals for the Seventh Circuit case law requires" in order to obtain an effective waiver
of representation. Vivaritas v. Comm'r of Soc. Sec., 246 Fed. App'x 155, at n. 1 (3d Cir.
2008)(citing Skinner, 478 F.3d at 841). The Third Circuit "has declined to adopt a rigid protocol
for an ALJ to follow when obtaining a waiver of representation." McGrew v. Colvin, 13CVOI44,
2013 WL 2948448, *5 (W.D. Pa 20 13)(citing Vivaritas, 478 Fed. App'x at 158 n. 1).
Moreover, Plaintiff did not waive her right to have a representative at the hearing because
she was represented by Ms. Tecza. A claimant may have a representative, see 20 C.F.R. §
416.1500, and may appoint a person who is not an attorney to be her representative. 42 U.S.C. §
406(a)(l); 20 C.F.R. §§ 404.1705, 416.1505. Plaintiff appointed Ms. Tecza to be her
representative and Ms. Tecza appeared on behalf of Plaintiff at the hearing. (R. 28-59, 102).8 In
Carmichael v. Barnhart, lO4 F. App'x 803, 805 (3d Cir. 2004), the claimant argued that he
received ineffective assistance of counsel because he was represented by a non-attorney,
Plaintiff asserts in her Reply Brief that Plaintiff did not knowingly and intelligently waive her right to counsel
because on the Appointment of Representative fonn, the box stating that Ms. Tecza would be representing her in
connection with her SSI claim was not checked. (ECF No. 15 at 5). Plaintiff filled in Ms. Tecza's name on the fonn
under the Appointment of Representative section and provided her signature; and Ms. Tecza filled in her own name
under the Acceptance of Appointment section, marked that she anon-attorney, and provided her signature. (R. at
102). This fonn was completed on the day of the All hearing and Ms. Tecza did, in fact, appear on behalf of
Plaintiff at the hearing.
8
15
however, the Third Circuit held that the ALI fulfilled his duty to fully develop the record so it
affirmed the judgment of the District Court. "Because of the inquisitorial nature of Social
Security proceedings, it is the ALl's duty to investigate the facts and develop the arguments both
for and against granting benefits." Carmichael, 104 F. App'x at 805 (citing Sims v. Apfel, 530
U.S. 103, III (2000» (internal quotations omitted). "Such reasoning is further supported by the
fact that a large portion of Social Security disability benefits claimants either have no
representation at all or are represented by non-attorneys." Carmichael, 104 F. App'x at 805
(citing Sims, 530 U.S.at III (2000» (internal quotations omitted). In this case, the ALI
appropriately developed the record. He elicited testimony from Plaintiff regarding her subjective
complaints, daily activities, and treatment with her doctors. The ALl's examination of the
vocational expert developed favorable evidence both for and against granting benefits.
Additionally, the ALI kept the record open so that Plaintiff could submit additional medical
records and offered to obtain those records to make it easier on Plaintiffs representative. The
ALI fulfilled his duty to fully develop the record.
Plaintiff next argues that the ALI improperly disregarded the medical opinion evidence of
Plaintiffs treating physicians. (ECF No. 11 at 9-12). Specifically, Plaintiff asserts that the ALI
erred by giving Dr. Newman's opinion little weight regarding Plaintiffs "marked limitations" in
the report, but giving "significant weight" to the rest of the report. (ECF No. 11 at 9-10; R. at
20). The "opinion of a treating physician does not bind the ALI on the issue of functional
capacity." Chandler v. Commlr of Soc. Sec., 667 F.3d 356, 361 (3d Cir. 2011 )(quoting Brown v.
Astrue, 649 F.3d 193, 197 n. 2 (3d Cir.2011 ». A showing of contradictory evidence and an
accompanying explanation will allow an ALI to reject a treating physician's opinion outright, or
accord it less weight. Brownawell v. Comm'r of Soc. Sec., 554 F.3d 352, 355 (3d Cir. 2008).
16
Moreover, a medical opinion is not entitled to any weight if unsupported by objective evidence
in the medical record. Plummer v. Apfel, 186 F.3d 422, 430 (3d Cir. 1999)(citing Jones v.
Sullivan, 954 F.2d 125, 129 (3d Cir.l991». "Fonn reports in which a physician's obligation is
only to check a box or fill in a blank are weak evidence at best" and if "unaccompanied by
thorough written reports, their reliability is suspect." Mason v. Shala1a, 994 F.2d 1058, 1065 (3d
Cir. 1993) (internal quotations omitted).
Here, Dr. Newman's report contained several pages of written notes and explanations of
his treatment of Plaintiff as well as a pre-printed fonn at the end where he checked boxes,
including three that said that Plaintiff had "marked limitations." (R. at 355-358). The ALJ
afforded these marked limitations little weight, stating that they were not supported by Dr.
Newman's examination of Plaintiff or Dr. Newman's written notes in the report. (R. at 20)
Further, the ALJ found the marked limitations were not consistent with Plaintiffs part-time work
at Goodwill. (R. at 20). See Russo v. Astrue, 421 F. App'x. 184, 189 (3d Cir. 2011)(finding it
notable that the claimant continued to work after her alleged onset of disability even though that
work did not reach the level of substantial gainful activity); 20 C.F.R. § 404.1571 (work done
during alleged disability period may show that claimant can work at substantial gainful activity).
As such, the ALl's granting the weight he did to the marked limitations in Dr. Newman's report
was not error.
Plaintiff also asserts that the ALJ erred by giving "great weight" to the opinion of non
treating psychologist Dr. Rohar. (ECF No. 11 at 11-1
R. at 21). Plaintiff argues that Dr.
Rohar's opinion should not be given significant weight because Dr. Rohar did not have an
opportunity to review the reports and consider the additional diagnoses of Dr. McGuire and Dr.
Simmons, which were not in the record at the time Dr. Rohar issued his opinion. (ECF No. 11
17
at
11-12). There will always be time lapse between the state agency report and the ALJ review
because the state agency report occurs first. Chandler, 667 F.3d at 361. An update to the state
agency report will only be required when "additional medical evidence is received that in the
opinion of the [AU)... may change the State agency medicaL.consultant's finding that the
impairment(s) is not equivalent in severity to any impairment in the Listing." Id. (quoting and
adding emphasis to SSR 96-6p (July 2, 1996». The ALJ did not conclude an update to the report
was necessary. It was also not error that the ALJ relied on a state agency opinion. Such opinions
deserve significant consideration. Chandler, 667 F.3d at 361. In this case, the ALJ did not simply
"rubber stamp" Dr. Rohar's RFC conclusion, but rather considered and discussed all of
Plaintiff's medical treatment and daily activities, and incorporated Dr. Mari-Mayans physical
RFC assessment into his RFC. See Id. More importantly, despite Dr. Rohar opining that
Claimant is capable of performing "production oriented jobs requiring independent decision
making," the ALJ made clear in his RFC that Plaintiff cannot work in a fast-paced production
environment. (R. at 16,361).
Plaintiff next argues that the ALJ erred by giving little weight to her GAF scores as
assessed by Dr. McGuire and Dr. Simmons. (ECF No. 11 at 10; R. at 18-19). Without citing any
case law, Plaintiff asserts that "[a] GAF score of 50 or lower is typically considered disabling as
an individual has severe impairments with a score of 50 or lower." (ECF No. 11 at 10). Such an
argument is without merit. A GAF score does not establish disability unless it was meant to
indicate an impairment of the ability to work. Bracciodieta-Nelson v. Comm'r of Soc. Sec., 782
F.Supp.2d 152, 165 (W.D.Pa. 2011). GAF scores "are only medical evidence that informs the
Commissioner's judgment of whether an individual is disabled." Rios v. Comm'r of Soc. Sec.,
444 F. App'x 532, 535 (3d Cir. 2011). The ALJ determined that the GAF score of 45 contained
18
in Dr. McGuire's psychiatric evaluation was to be given the weight that it was because it was
inconsistent with Plaintiffs numerous activities, performance in school, and treatment history.
(R. at 18). Further, this score occurred almost three years prior to Plaintiffs alleged onset of
disability at a point when she does not contend she was disabled. The ALJ also considered a
GAF score of 35 contained in Dr. Simmons' psychiatric evaluation and accorded it little weight,
finding that it was "inconsistent with [Dr. Simmons'] own examination of [Plaintiff]" and was
inconsistent with Plaintiffs ability to work part-time at Goodwill. CR. at 19). Such explanations
provided by the ALJ are reasonable and it was not an error to accord these GAF scores the
weight given.
Plaintiff also asserts that the ALJ's RFC is not supported by substantial evidence. (ECF
No. 11 at 12-14). This Court disagrees. Determining whether Plaintiff is disabled is a decision
that is to be made solely by the ALl 20 C.F.R. § 404.1 527(d)(l). An ALJ weighing the
credibility of evidence "must give some indication of the evidence which he rejects and his
reason(s) for discounting such evidence." Burnett v. Comm'r of Soc. Sec., 220 F.3d 112, 121 (3d
Cir. 2000). The ALJ must also consider Plaintiffs subjective symptoms and explain his reason(s)
for rejecting such testimony. Id. In this case, the ALJ provided a thorough discussion regarding
his assessment of Plaintiff s RFC, which totaled six pages. (R. at 16-21). The ALJ discussed
Plaintiffs testimony at the hearing, Plaintiffs physical and mental medical evidence, and how
Plaintiffs SUbjective complaints compared to her objective medical evidence and daily living
activities. (R. at 16-21). The ALJ gave specific reasons and explanations for the weight he
accorded to each medical opinion contained in the record as well as his credibility
determinations. The ALJ's RFC was supported by substantial evidence.
19
Finally, Plaintiff asserts that the ALl improperly disregarded the testimony of the
vocational expert. (ECF No. 11 at 14-15). Plaintiff argues that the ALl "chose to ignore" the
vocational expert's answers that would have resulted in Plaintiff being unable to work in the
national economy. (ECF No. 11 at 15). The ALl, however, did not ignore these responses by the
vocational expert and actually addressed them, explaining that "these limitations were not
consistent with the evidence of the record, and did not accurately reflect [Plaintiffs RFC]." (R.
at 23). Plaintiff further argues that the ALl erred by failing to ask the vocational expert questions
regarding the limitations as noted in Dr. Newman's report. "[T]he ALl must accurately convey
to the vocational expert all of claimant's credibly established limitations." Rutheford v. Barnhart,
399 F .3d 546, 554 (3d Cir. 2005)(citing and adding emphasis to Plummer, 186 F.3d at 431). As
discussed above, the ALl reasonably gave little weight to those limitations, so failure to ask
about them was not error. Therefore, because the ALl's RFC assessment of Plaintiff was
supported by substantial evidence and the ALl relied on the testimony of the vocational expert,
who found that jobs in the national economy existed based on Plaintiff s limitations, there is no
error here.
V. CONCLUSION
Based on the foregoing, the Plaintiffs Motion for Summary ludgment is denied, and
Defendant's Motion for Summary Judgment is gr~ws.
Mark R. Hornak
United States District Judge
Novernbe~
Dated:
2013
cc: All counsel of record
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