Ball v. Social Security Administration, Commissioner of (TWP1)
Filing
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MEMORANDUM AND OPINION finding that Plaintiffs 16 Motion for Summary Judgment will be GRANTED IN PART, and the Commissioners 20 Motion for Summary Judgment will be DENIED. The case will be REMANDED to the ALJ for reconsideration of Plaintiffs ability to interact with the general public by re-weighing the medical opinions and other evidence of record.Signed by Magistrate Judge Debra C Poplin on 9/21/2018. (MDG)
UNITED STATES DISTRICT COURT
EASTERN DISTRICT OF TENNESSEE
AT KNOXVILLE
DONNA BALL,
)
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Plaintiff,
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v.
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No. 3:17-CV-78-DCP
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NANCY A. BERRYHILL,
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Deputy Commissioner for Operations,
)
performing the duties and functions not
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reserved to the Commissioner of Social Security, )
)
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Defendant.
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MEMORANDUM OPINION
This case is before the undersigned pursuant to 28 U.S.C. § 636(b), Rule 73 of the Federal
Rules of Civil Procedure, and the consent of the parties [Doc. 19]. Now before the Court is
Plaintiff’s Motion for Summary Judgment and Memorandum in Support [Docs. 16 & 17] and
Defendant’s Motion for Summary Judgment and Memorandum in Support [Docs. 20 & 21].
Donna Ball (“Plaintiff”) seeks judicial review of the decision of the Administrative Law Judge
(“the ALJ”), the final decision of the Defendant Nancy A. Berryhill (“the Commissioner”). For
the reasons that follow, the Court will GRANT IN PART Plaintiff’s motion and DENY the
Commissioner’s motion.
I.
PROCEDURAL HISTORY
On March 29, 2013, Plaintiff filed an application for disability insurance benefits and
supplemental security income benefits pursuant to Title II and XVI of the Social Security Act, 42
U.S.C. §§ 401 et. seq., and 1381 et. seq., claiming a period of disability that began on November
24, 2012. [Tr. 91-92]. After her application was denied initially and upon reconsideration,
Plaintiff requested a hearing. [Tr. 140]. On October 6, 2015, a hearing was held before the ALJ
to review determination of Plaintiff’s claim. [Tr. 34-58]. On November 13, 2015, the ALJ found
that Plaintiff was not disabled. [Tr. 19-29]. The Appeals Council denied Plaintiff’s request for
review [Tr.1-4], making the ALJ’s decision the final decision of the Commissioner.
Having exhausted her administrative remedies, Plaintiff filed a Complaint with this Court
on March 2, 2017, seeking judicial review of the Commissioner’s final decision under Section
405(g) of the Social Security Act. [Doc. 1]. The parties have filed competing dispositive motions,
and this matter is now ripe for adjudication.
II.
ALJ FINDINGS
The ALJ made the following findings:
1. The claimant meets the insured status requirements of the Social
Security Act through December 31, 2016.
2. The claimant has not engaged in substantial gainful activity since
November 24, 2012, the alleged onset date (20 CFR 404.15271 et
seq., and 416.971 et seq.).
3. The claimant has the following severe impairments: anxiety,
depression, post-traumatic stress disorder, and personality disorder
(20 CFR 404.1520(c) and 416.920(c)).
4. The claimant does not have an impairment or combination of
impairments that meets or medically equals the severity of one of
the listed impairments in 20 CFR Part 404, Subpart P, Appendix 1
(20 CFR 404.1520(d), 404.1525, 404.1526, 416.920(d), 416.925
and 416.926).
5. After careful consideration of the entire record, the undersigned
finds that the claimant has the residual functional capacity to
perform a range of work at all exertional levels but with the
following nonexertional limitations. She should avoid concentrated
exposure to hazards. She is able to perform simple, routine,
repetitive tasks, in that she can apply commonsense understanding
to carry out oral written and diagrammatic instructions. She should
have only occasional exposure to coworkers and the general-public.
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She is able to perform work in a low stress environment, with few
changes in the work setting and no executive level functioning.
6. The claimant is capable of performing past relevant work as a
maid. This work does not require the performance of work-related
activities precluded by the claimant’s residual functional capacity
(20 CFR 404.1565 and 416.965).
7. The claimant has not been under a disability, as defined in the
Social Security Act, from November 24, 2012, through the date of
this decision (20 CFR 404.1520(f) and 416.920(f)).
[Tr. 21-29].
III.
STANDARD OF REVIEW
When reviewing the Commissioner’s determination of whether an individual is disabled
pursuant to 42 U.S.C. § 405(g), the Court is limited to determining whether the ALJ’s decision
was reached through application of the correct legal standards and in accordance with the
procedure mandated by the regulations and rulings promulgated by the Commissioner, and
whether the ALJ’s findings are supported by substantial evidence. Wilson v. Comm’r of Soc. Sec.,
378 F.3d 541, 544 (6th Cir. 2004); Blakley v. Comm’r of Soc. Sec., 581 F.3d 399, 405 (6th Cir.
2009) (citation omitted).
Substantial evidence is “more than a scintilla of evidence but less than a preponderance; it
is such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.”
Cutlip v. Sec’y of Health & Human Servs., 25 F.3d 284, 286 (6th Cir. 1994) (citations omitted). It
is immaterial whether the record may also possess substantial evidence to support a different
conclusion from that reached by the ALJ, or whether the reviewing judge may have decided the
case differently. Crisp v. Sec’y of Health & Human Servs., 790 F.2d 450, 453 n.4 (6th Cir. 1986).
The substantial evidence standard is intended to create a “‘zone of choice’ within which the
Commissioner can act, without the fear of court interference.” Buxton v. Halter, 246 F.3d 762,
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773 (6th Cir. 2001) (quoting Mullen v. Bowen, 800 F.2d 535, 545 (6th Cir. 1986)). Therefore, the
Court will not “try the case de novo, nor resolve conflicts in the evidence, nor decide questions of
credibility.” Garner v. Heckler, 745 F.2d 383, 387 (6th Cir. 1984) (citation omitted).
On review, the plaintiff “bears the burden of proving his entitlement to benefits.” Boyes v.
Sec’y. of Health & Human Servs., 46 F.3d 510, 512 (6th Cir. 1994) (citation omitted).
IV.
DISABILITY ELIGIBILITY
“Disability” is the “inability to engage in any substantial gainful activity by reason of any
medically determinable physical or mental impairment which can be expected to result in death or
which has lasted or can be expected to last for a continuous period of not less than twelve months.”
42 U.S.C. §§ 423(d)(1)(A), 1382c(a)(3)(A). A claimant will only be considered disabled if:
his physical or mental impairment or impairments are of such
severity that he is not only unable to do his previous work but
cannot, considering his age, education, and work experience, engage
in any other kind of substantial gainful work which exists in the
national economy, regardless of whether such work exists in the
immediate area in which he lives, or whether a specific job vacancy
exists for him, or whether he would be hired if he applied for work.
§§ 423(d)(2)(A), 1382c(a)(3)(B).
Disability is evaluated pursuant to a five-step analysis summarized as follows:
1. If claimant is doing substantial gainful activity, he is not disabled.
2. If claimant is not doing substantial gainful activity, his
impairment must be severe before he can be found to be disabled.
3. If claimant is not doing substantial gainful activity and is
suffering from a severe impairment that has lasted or is expected to
last for a continuous period of at least twelve months, and his
impairment meets or equals a listed impairment, claimant is
presumed disabled without further inquiry.
4. If claimant’s impairment does not prevent him from doing his
past relevant work, he is not disabled.
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5. Even if claimant’s impairment does prevent him from doing his
past relevant work, if other work exists in the national economy that
accommodates his residual functional capacity (“RFC”) and
vocational factors (age, education, skills, etc.), he is not disabled.
Walters v. Comm’r of Soc. Sec., 127 F.3d 525, 529 (6th Cir. 1997) (citing 20 C.F.R. § 404.1520).
A claimant’s residual functional capacity (“RFC”) is assessed between steps three and four and is
“based on all the relevant medical and other evidence in your case record.” 20 C.F.R. §§
404.1520(a)(4), -(e), 416.920(a)(4), -(e). An RFC is the most a claimant can do despite his
limitations. §§ 404.1545(a)(1), 416.945(a)(1).
The claimant bears the burden of proof at the first four steps. Walters, 127 F.3d at 529.
The burden shifts to the Commissioner at step five. Id. At the fifth step, the Commissioner must
prove that there is work available in the national economy that the claimant could perform. Her
v. Comm’r of Soc. Sec., 203 F.3d 388, 391 (6th Cir. 1999) (citing Bowen v. Yuckert, 482 U.S. 137,
146 (1987)).
V.
ANALYSIS
On appeal Plaintiff contends that the ALJ’s RFC determination is not supported by
substantial evidence. First, Plaintiff maintains that the medical opinions of record, including the
opinions of treating physician Catherine Gyurik, M.D., consultative examiner Candice Blake,
Psy.D., and nonexamining state agency consultants, Robert del la Torre, Psy.D., and P. Jerry
Wright, Ph.D., support a marked limitation in the area of social functioning contrary to the ALJ’s
RFC determination. [Doc. 17 at 11-13]. Second, Plaintiff argues that the ALJ did not properly
apply the treating physician rule to the medical opinion of Dr. Gyurik. [Id. at 8-11]. Plaintiff
asserts that the ALJ failed to assess Dr. Gyurik’s opinion for controlling weight and did not provide
“good reason” for the weight assigned to the opinion. [Id. at 8-11]. The Court will address
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Plaintiff’s allegations of error in turn.
A.
Social Functioning
Plaintiff contends that substantial evidence does not support the ALJ’s finding that Plaintiff
can occasionally interact with the general public.
The opinion evidence regarding Plaintiff’s social functioning is as follows. Plaintiff was
consultatively examined by Dr. Blake on August 23, 2013, wherein Dr. Blake recounted Plaintiff’s
history of anxiety and panic attacks. [Tr. 538-41]. Dr. Blake noted that Plaintiff’s panic attacks
occurred daily if she left her house and interacted with other people. [Tr. 538]. Plaintiff reported
dropping out of school when she was in the 8th grade “because she was throwing up everyday
before she had to go to school” and was simply too nervous to attend. [Id.]. She obtained her
GED and attempted a year-and-a-half of college before dropping out. [Tr. 538-39]. Plaintiff
reported symptoms of racing heart, a smothering sensation, and a fear of passing out in front of
others. [Id.]. In November 2012, Plaintiff was laid off from her job after having panic attacks in
front of people. [Tr. 540]. Dr. Blake described Plaintiff as severely depressed, lacked motivation
or interest, and slept excessively. [Id.]. Plaintiff had noticeably slow speech and mannerisms, she
appeared overwhelmed, and she exhibited difficulty concentrating and explaining the details of
her problems. [Id.]. In pertinent part, Dr. Blake concluded that Plaintiff was markedly limited in
social interaction due to social anxiety. [Tr. 541].
Thereafter, at the initial level of the administrative proceedings, nonexamining state agency
consultant Dr. del la Torre completed a “Mental Residual Functional Capacity Assessment” on
August 30, 2013. [Tr. 72-73]. Assessing Plaintiff’s social functioning limitations, Dr. del la Torre
found that Plaintiff was markedly limited in her ability to interact appropriately with the general
public and moderately limited in her ability to get along with coworkers or peers without
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distracting them or exhibiting behavioral extremes. [Tr. 73, 88]. Dr. del la Torre concluded that
Plaintiff could not interact effectively with the general public and, instead, would work better with
things than people. [Id.]. However, Plaintiff could interact appropriately with supervisors and
peers but such interactions should be brief, superficial, task oriented, and not within a crowded
setting. [Id.]. On February 11, 2014, at the reconsideration level, a second nonexamining state
agency consultant, Dr. Wright, concurred with Dr. del la Torre, making identical findings in social
functioning. [Tr. 105, 120].
Finally, Plaintiff’s treating physician, Dr. Gyurik, completed a “Mental Medical Source
Statement” on May 19, 2015, wherein she responded to a variety of multiple-choice and short
answer questions regarding Plaintiff’s ability to perform different work-related activities. [Tr.
887-91]. In pertinent part, Dr. Gyurik opined that Plaintiff was precluded 15% or more of the time
in an eight-hour workday from interacting appropriately with the general public, asking simple
questions, accepting instructions and responding appropriately to criticism from superiors, and
getting along with coworkers and peers without distracting them or exhibiting behavioral extremes.
[Tr. 889].
In the disability determination, the ALJ summarized Plaintiff’s mental health status
examinations as having “been primarily within normal limits.” [Tr. 24-25]. The ALJ cited a
January 22, 2012 treatment note in which Plaintiff reported going out with her sister. [Tr. 25].
The ALJ then discussed several treatment notes from 2013, in which Plaintiff was noted as having
a pleasant, appropriate, or normal mood and affect, normal thought process and thought content,
cooperative attitude, and denial of homicidal and suicidal thoughts upon examination. [Id.].
Throughout 2014, Plaintiff was noted as appearing stable; her reasoning, judgment, and insight
were noted as fair; her thought process was normal; her anxiety was stable; her mood and affect
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were normal; and she was oriented to time, person, and place. [Id.]. The ALJ also highlighted
two instances in which Plaintiff’s mood was noted as depressed and anxious. [Id.].
As to the opinion evidence, the ALJ assigned “little weight” to Dr. Gyurik’s opinion
because the opinion was “inconsistent with the mental status examinations at her various office
visits,” there was no evidence of hospitalizations, and “mental status examinations were consistent
at non-mental health providers as well, on the few occasions [Plaintiff] presented for care.” [Tr.
27]. Dr. Blake received “some weight,” but the ALJ concluded that the record did not support
marked limitations in social functioning. [Tr. 27-28]. Finally, the ALJ gave “substantial weight”
to the opinions of Dr. del la Torre and Dr. Wright. [Tr. 28]. The ALJ characterized their opinions
as only assessing moderate limitations in maintaining social functioning. [Id.].
Plaintiff argues that the opinion evidence of record unanimously supports a finding that
she is markedly limited in her interactions with the general public, and the ALJ failed to cite to
any substantial evidence to the contrary. [Doc. 14 at 11-13]. The Court agrees. While the ALJ
cites to “normal” mental status examination findings such as appropriate affect and thought
content, normal mood, cooperative attitude, and fair reasoning, judgment and insight, the Court
concludes that such findings are not particularly relevant to Plaintiff’s ability to interact with the
public. To be sure, treatment notes nonetheless contemporaneously document Plaintiff’s fear of
leaving her home and interacting with the public. In fact, Plaintiff’s social phobia is well
documented throughout the record. [See e.g., Tr. 384, 389, 561, 571, 574, 577-78, 580, 587, 616,
618, 633].
For example, Plaintiff frequently reported symptoms of panic attacks in social situations,
prompting her to drop out of school and later quit her job due to severe social anxiety. [Tr. 538,
580]. Plaintiff also reported sleeping 16 hours a day in an effort to isolate herself. [Tr. 616, 618].
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Moreover, she related that she does not leave her home except for medical appointments. [Tr. 560,
580]. Medical records further demonstrate that on at least two occasions, Plaintiff planned to seek
inpatient treatment through her mental health provider’s Crisis Stabilization Unit but never
followed through due to her fear of being around others. [Tr. 558].
Further supporting marked limitations in interacting with the public are the opinions of Dr.
del la Torre and Dr. Wright, both of whom concluded that Plaintiff was markedly limited in her
ability to interact with the public and whose opinions received substantial weight from the ALJ.
Although the ALJ is not obligated to adopt all of the findings of a medical source whose opinion
receives great weight, Moore v. Comm’r of Soc. Sec., No. 1:13-CV-00395, 2013 WL 6283681, at
*7 (N.D. Ohio Dec. 4, 2013), the ALJ in the instant matter mischaracterized the opinions of Dr.
del la Torre and Dr. Wright as only assessing “moderate” limitations in social functioning. Both
doctors concluded that Plaintiff was markedly limited in that she “cannot interact effectively with
the general public.” [Tr. 73, 88, 105, 120]. Additionally, the opinions of Dr. Blake and Dr. Gyurik
echo marked limitations in Plaintiff’s ability to interact with the public. In short, the ALJ’s
decision does not provide substantial evidence for concluding that Plaintiff retained the ability to
occasionally interact with the public.
The Commissioner argues that the record undermines a marked limitation in interacting
with the public because Plaintiff attended doctor appointments and therapy sessions, she attended
college for two years before quitting, she attended church, she visited her mother-in-law in the
hospital, she spent time with her nephew and grandson, and she reported going out with her sister
in 2014. [Doc. 21 at 9] (citing Tr. 359, 538, 562, 574-75, 603, 633-34). As an initial matter, the
Court declines to penalize Plaintiff for seeking mental health treatment. Furthermore, the Court
finds no basis to conclude that Plaintiff’s decision to seek professional help to address her
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impairments is tantamount to an ability to interact with the general public on a continuous and
sustained basis for purposes of demonstrating that Plaintiff can perform substantial gainful activity.
As to the remaining activities cited by the Commissioner, the Court is unpersuaded that said
activities undermine a marked limitation. First, Plaintiff attended college in 1987, 25 years prior
to her alleged onset date. [Tr. 212]. Second, Plaintiff reported going to church one time in a six
month period. [Tr. 359, 634]. And while Plaintiff reported one instance of going out with her
sister, she also reported that she felt exhausted after being out a short while. [Tr. 620]. Treatment
notes also clarify that Plaintiff’s mother-in-law was on in-home hospice care, not in the hospital,
when Plaintiff visited her. [Tr. 572, 633].
Accordingly, the Court finds that substantial evidence does not support the ALJ’s
conclusion that Plaintiff can interact with the public on an occasional basis. Therefore, Plaintiff’s
assignment of error in this regard is well-taken.
The case will be remanded for further
consideration of Plaintiff’s social functioning abilities.
B.
Opinion of Catherine Gyurik, M.D.
In addition to Plaintiff’s contention that Dr. Gyurik’s opinion supports greater limitations
in social functioning than found by the ALJ, Plaintiff also argues that other findings made in Dr.
Gyurik’s Mental Medial Source Statement were entitled to controlling weight and the ALJ did not
give good reason for finding otherwise. Because the Court’s order of remand in this case will
necessitate, by default, reconsideration of Dr. Gyurik’s opinion, including the weight the opinion
deserves and the reasons for that weight, the Court finds that it need not address Plaintiff’s
remaining arguments concerning the treating physician rule.
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VI.
CONCLUSION
Based on the foregoing, Plaintiff’s Motion for Summary Judgment [Doc. 16] will be
GRANTED IN PART, and the Commissioner’s Motion for Summary Judgment [Doc. 20] will
be DENIED. The case will be REMANDED to the ALJ for reconsideration of Plaintiff’s ability
to interact with the general public by re-weighing the medical opinions and other evidence of
record.
IT IS SO ORDERED.
ENTER:
____________________________
Debra C. Poplin
United States Magistrate Judge
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