Opinion
For Jonathan Jeter, Plaintiff: Monica Perales, LEAD ATTORNEY, Law Offices of Lawrence D Rohlfing, Santa Fe Springs, CA.
For Carolyn W. Colvin, Acting Commissioner of Social Security, Defendant: Assistant U.S. Attorney LA-CV, LEAD ATTORNEY, AUSA - Office of U.S. Attorney, Civil Division, Los Angeles, CA; Assistant U.S. Attorney LA-SSA, LEAD ATTORNEY, Office of the General Counsel for Social Security Adm., San Francisco, CA; Sundeep R Patel, LEAD ATTORNEY, SAUSA - Office of the United States Attorney, Social Security Administration, San Francisco, CA.
DECISION AND ORDER
CARLA M. WOEHRLE, United States Magistrate Judge.
PROCEEDINGS
On January 17, 2014, Jonathan Jeter (" Plaintiff") filed a Complaint seeking review of the Commissioner's denial of his applications for supplemental security income and disability insurance benefits. Thereafter, the parties filed a Consent to Proceed Before United States Magistrate Judge Carla Woehrle. On August 1, 2014, Defendant filed an Answer to the Complaint. On October 5, 2014, the parties filed their Joint Stipulation.
As discussed below, the Court finds that the Commissioner's decision should be reversed and this matter remanded for further proceedings.
BACKGROUND
On November 30, 2010, Plaintiff filed applications for supplemental security income and disability insurance benefits. (Administrative Record [" AR" ] at 95-107.) Plaintiff alleged that, beginning on December 21, 2009, he was unable to work due to schizophrenia. (AR at 81, 95.) The Commissioner denied Plaintiff's applications initially on June 20, 2011. (AR at 81-85.)
On or about July 27, 2011, Plaintiff requested a hearing before an Administrative Law Judge (" ALJ"). (AR at 86-87.) The ALJ conducted a hearing on March 28, 2012. (AR at 52-74.) Plaintiff appeared at the hearing with his counsel and testified. (AR at 56-70.) A vocational expert also testified. (AR at 70-74.)
On July 25, 2012, the ALJ issued his decision denying benefits. (AR at 17-33.) In his decision, the ALJ found that Plaintiff suffers from the following " severe" impairment: " substance-induced psychotic disorder in alleged remission and rule out schizophrenia." (AR at 22.) Nevertheless, the ALJ concluded that Plaintiff has the residual functional capacity to " perform a full range of work at all exertional levels but with the following nonexertional limitations: [Plaintiff] is limited to simple repetitive work with no more than occasional exposure to others." (AR at 26.) The ALJ determined that Plaintiff could not perform his past relevant work as a home attendant. (AR at 28-29.) Nonetheless, considering Plaintiff's age, education, work experience, and residual functional capacity, the ALJ concluded that there are significant numbers of jobs that he can perform. Specifically, the ALJ found that Plaintiff can perform the jobs of industrial cleaner and hand packager. (AR at 29-30.) Ultimately, the ALJ concluded that Plaintiff is not disabled pursuant to the Social Security Act. (AR at 30.)
On September 24, 2012, Plaintiff filed a timely request with the Appeals Council for a review of the ALJ's decision. (AR at 14-16.) The Appeals Council subsequently affirmed the ALJ's decision. (AR at 7-12.)
PLAINTIFF'S CONTENTION
The parties' Joint Stipulation sets out the following disputed issue:
1. Whether the ALJ properly considered the opinion of Plaintiff's treating psychiatrist, James Jung, M.D.
STANDARD OF REVIEW
Under 42 U.S.C. § 405(g), this Court reviews the ALJ's decision to determine whether the ALJ's findings are supported by substantial evidence and whether the proper legal standards were applied. DeLorme v. Sullivan, 924 F.2d 841, 846 (9th Cir. 1991). Substantial evidence means " more than a mere scintilla" but less than a preponderance. Richardson v. Perales, 402 U.S. 389, 401, 91 S.Ct. 1420, 28 L.Ed.2d 842 (1971); Desrosiers v. Secretary of Health & Human Servs., 846 F.2d 573, 575-76 (9th Cir. 1988). In other words, it is " such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Richardson, 402 U.S. at 401.
In determining whether substantial evidence supports the ALJ's findings, the Court must review the record as a whole and consider " both the evidence that supports and the evidence that detracts from the Commissioner's conclusion[s]." Reddick v. Chater, 157 F.3d 715, 720 (9th Cir. 1998). " If the evidence can reasonably support either affirming or reversing, " the Court " may not substitute its judgment" for that of the ALJ, and the ALJ's decision must be upheld. Id. at 720-21; see also Gallant v. Heckler, 753 F.2d 1450, 1452 (9th Cir. 1984).
DISCUSSION
A. The Sequential Evaluation
To be eligible for disability benefits a claimant must demonstrate a medically determinable impairment which prevents the claimant from engaging in substantial gainful activity and which is expected to result in death or to last for a continuous period of at least twelve months. Tackett v. Apfel, 180 F.3d 1094, 1098 (9th Cir. 1999); Reddick, 157 F.3d at 721; 42 U.S.C. § 423(d)(1)(A).
Disability claims are evaluated using a five-step test. See 20 C.F.R. § § 404.1520, 416.920. At step one, the ALJ determines if the claimant is engaging in " substantial gainful activity." 20 C.F.R. § § 404.1520(a)(4)(i), 416.920(a)(4)(i). If he is, the claimant is found not disabled. If he is not, the ALJ proceeds to step two.
At step two, the ALJ determines whether the claimant has a " severe" impairment or combination of impairments. 20 C.F.R. § § 404.1520(a)(4)(ii), 416.920(a)(4)(ii). An impairment is " severe" if it significantly limits the claimant's ability to perform basic work activities and is expected to persist for a period of twelve months or longer. See Bowen v. Yuckert, 482 U.S. 137, 141, 107 S.Ct. 2287, 96 L.Ed.2d 119 (1987). If the claimant does not have a " severe" impairment or combination of impairments, disability benefits are denied. 20 C.F.R. § § 404.1520(a)(4)(ii), 416.920(a)(4)(ii). If the impairment or combination of impairments is " severe, " the ALJ proceeds to step three.
At step three, the ALJ determines whether the claimant's impairment or combination of impairments meets or equals an impairment listed in 20 C.F.R., Part 404, Subpart P, Appendix 1. 20 C.F.R. § § 404.1520(a)(4)(iii), 416.920(a)(4)(iii). If so, the claimant is automatically determined disabled. See 20 C.F.R. § § 404.1520(d), 416.920(d). If not, the ALJ proceeds to step four.
At step four, the ALJ must assess the claimant's residual functional capacity (" RFC"). The RFC is the " most [one] can still do despite [his or her] limitations" and represents an assessment " based on all the relevant evidence." 20 C.F.R. § § 404.1545(a)(1), 416.945(a)(1). The ALJ then must determine whether the claimant's RFC is sufficient for the claimant to perform past relevant work. 20 C.F.R. § § 404.1520(a)(4)(iv), 416.920(a)(4)(iv). If the claimant is capable of performing past relevant work, the claimant is not disabled. If the claimant is no longer capable of past relevant work, the ALJ proceeds to step five. See 20 C.F.R. § § 404.1520(f), 416.920(f).
At the fifth and final step, the ALJ determines whether, considering claimant's RFC, age, education, and work experience, the claimant is able to perform other work that is available in significant numbers in the national economy. 20 C.F.R. § § 404.1520(a)(4)(v), 416.920(a)(4)(v). If he is, the claimant is not disabled. If he is not, the claimant is disabled and entitled to benefits. Id.
Claimants have the burden of proof at steps one through four, subject to the presumption that Social Security hearings are nonadversarial and to the Commissioner's affirmative duty to assist claimants in fully developing the record even if they are represented by counsel. Tackett, 180 F.3d at 1098 and n. 3; Smolen v. Chater, 80 F.3d 1273, 1288 (9th Cir. 1996). If this burden is met, a prima facie case of disability is made, and the burden shifts to the Commissioner at step five. Tackett, 180 F.3d at 1098, 1100; Reddick, 157 F.3d at 721; 20 C.F.R. § § 404.1520, 416.920.
B. Treating Physician
In his sole claim, Plaintiff alleges that the ALJ failed to set forth legally sufficient reasons for rejecting the opinion of his treating psychiatrist, Dr. Jung. (Joint Stip. at 4-11.) As discussed below, the Court agrees.
In general, a treating physician's opinion is entitled to special consideration because a treating physician is employed to cure and has a greater opportunity to know and observe the patient as an individual. McAllister v. Sullivan, 888 F.2d 599, 602 (9th Cir. 1989). While a treating doctor's opinion regarding a claimant's condition is not necessarily conclusive as to either a medical condition or the ultimate issue of disability, it must be given substantial weight. Embrey v. Bowen, 849 F.2d 418, 422 (9th Cir. 1988); see also Magallanes v. Bowen, 881 F.2d 747, 751 (9th Cir. 1989) (stating that opinions of treating physicians are entitled to great deference). Accordingly, an ALJ " may reject the uncontradicted medical opinion of a treating physician only for 'clear and convincing' reasons supported by substantial evidence in the record." Holohan v. Massanari, 246 F.3d 1195, 1202 (9th Cir. 2001)(quoting Reddick, 157 F.3d at 725). Even when there is a medical opinion contrary to that of the treating physician, an ALJ may rely on the contrary opinion only if there are " specific and legitimate" reasons supported by substantial evidence in the record. Holohan, 246 F.3d at 1202 (quoting Lester v. Chater, 81 F.3d 821, 830 (9th Cir. 1995)). " 'The ALJ can meet this burden by setting out a detailed and thorough summary of the facts and conflicting clinical evidence, stating [his] interpretation thereof, and making findings.'" Tommasetti v. Astrue, 533 F.3d 1035, 1041 (9th Cir. 2008)(quoting Magallanes, 881 F.2d at 751).
Dr. Jung, Plaintiff's treating psychiatrist at South Bay Mental Health Center, saw Petitioner approximately once per month beginning on January 11, 2010. (AR at 346.) On March 7, 2012, Dr. Jung filled out a mental disorder questionnaire form in which he listed Plaintiff's diagnosis as " schizophrenia paranoid type." He described Plaintiff's mannerisms as guarded and vigilant, and his affect as blunted. He opined that Plaintiff has problems sustaining concentration and focused attention, cannot cope with the stress associated with normal social interaction, needs assistance to carry out normal activities of daily living, and is unable to manage his own funds. (AR at 345-46.)
Dr. Jung's opinion was contrary to the opinion of the nonexamining medical consultant, Dr. Charles Bridges. (See AR at 324.) Although the opinion of a nonexamining physician cannot " constitute substantial evidence sufficient for rejecting [a treating physician's] opinion, " it is sufficient to " establish a conflict among the medical opinions." Widmark v. Barnhart, 454 F.3d 1063, 1066-67 n.2 (9th Cir. 2006)(citing Lester, 81 F.3d at 831). Accordingly, the ALJ needed to give only specific and legitimate reasons for rejecting Dr. Jung's opinion.
In his decision, the ALJ rejected Dr. Jung's opinion because it was inconsistent with the doctor's own treatment notes. (See AR at 27.) In general, an ALJ may properly discount a treating physician's opinion if it is inconsistent with the doctor's own treatment notes. See, e.g., Tommasetti v. Astrue, 533 F.3d 1035, 1041 (9th Cir. 2008)(ALJ properly discredited doctor's opinion where responses to questionnaire were inconsistent with doctor's medical records); Connett v. Barnhart, 340 F.3d 871, 875 (9th Cir. 2003)(holding that a treating doctor's opinion can be discounted if it is unsupported by doctor's own treatment notes).
Here, however, substantial evidence does not support the ALJ's conclusion that Dr. Jung's opinion was inconsistent with the treatment notes. Unlike Dr. Jung's opinion, his treatment notes do not set forth the degree of Plaintiff's functional limitations. (See AR at 309.) Rather, they merely state that Plaintiff's condition was " stable, " " improved, " and that Plaintiff was " doing well." (See AR at 286-96, 354-59.) The fact that a person suffering from severe psychiatric symptoms makes some improvement " does not mean that the person's impairment[] no longer seriously affect[s] [his] ability to function in a workplace." Holohan v. Massanari, 246 F.3d 1195, 1205 (9th Cir. 2001)(" [The treating physician's] statements must be read in context of the overall diagnostic picture he draws."); see also Ryan v. Comm'r of Social Sec., 528 F.3d 1194, 1200-01 (9th Cir. 2008)(" Nor are the references in Dr. Monigatti-Lake's notes that [plaintiff's] anxiety and depression were 'improving' sufficient to undermine the repeated diagnosis of those conditions, or Dr. Randhawa's more detailed report.").
Indeed, the State Agency medical consultant, Dr. Bridges, noted that " Dr. Jung's notes indicate improvement, but the notes do not indicate the degree of functional limitations in sufficient detail to assess." Accordingly, Dr. Bridges requested further evidence in order to " clarify [Plaintiff's] mental limitations." (AR at 309.) It appears that this additional evidence was never obtained. (See AR at 325.)
Moreover, to the extent that the ALJ rejected Dr. Jung's opinion because it was not supported by the objective medical evidence, this reason also is not valid. The record shows that Plaintiff suffers from a serious psychiatric disorder. For example, in December 2009, the month prior to beginning treatment with Dr. Jung, he was hospitalized twice, each time for a duration of several days. On both of those occasions, Plaintiff suffered from audio hallucinations, delusions and paranoia. (See, e.g., AR at 233-54.) He was assessed with Global Assessment of Functioning scores of 20 and 25, which indicate the presence of delusions or hallucinations, serious impairment in communication or judgment, or an inability to function in almost all areas. (AR at 237, 248.)
Accordingly, because the ALJ failed to give sufficient reasons for rejecting Dr. Jung's opinion regarding Plaintiff's functional limitations, remand is warranted on this issue.
In the Joint Stipulation, Respondent argues that the ALJ also cited Plaintiff's activities of daily living in rejecting Dr. Jung's opinion. In fact, the ALJ did not do so (see AR at 27), and the Court is constrained to reviewing only the reasons the ALJ asserts. Orn v. Astrue, 495 F.3d 625, 630 (9th Cir. 2007)(" We review only the reasons provided by the ALJ in the disability determination and may not affirm the ALJ on a ground upon which he did not rely."); see also Connett v. Barnhart, 340 F.3d 871, 874 (9th Cir. 2003)(" We are constrained to review the reasons the ALJ asserts.") Moreover, Plaintiff testified to only limited daily activities, stating that he prefers to isolate himself at home. (See, e.g., AR at 67-68.) Such limited daily activities are not inconsistent with the functional limitations set forth in Dr. Jung's report.
C. Remand is Required to Remedy the Defects in the ALJ's Decision
The decision whether to remand for further proceedings is within the discretion of the district court. Treichler v. Comm'r of Soc. Sec. Admin., 775 F.3d 1090 (9th Cir. 2014)(citing Harman v. Apfel, 211 F.3d 1172, 1175-1178 (9th Cir. 2000)). Where there are outstanding issues that must be resolved before a determination can be made, and it is not clear from the record that the ALJ would be required to find the claimant disabled if all the evidence were properly evaluated, remand is appropriate. Harman, 211 F.3d at 1179. However, where no useful purpose would be served by further proceedings, or where the record has been fully developed, it is appropriate to exercise this discretion to direct an immediate award of benefits. Id. (decision whether to remand for further proceedings turns upon their likely utility).
In this case, even crediting Dr. Jung's opinion as true, outstanding issues remain. For example, there is evidence in the record suggesting that Plaintiff has a substance use disorder. (See, e.g., AR at 63-64, 173, 175, 233.) If, on remand, the ALJ finds Plaintiff disabled but that his substance use is a contributing factor material to her disabling condition, he would be disqualified from receiving benefits. 42 U.S.C. § § 423(d)(2)(C); 20 C.F.R. § § 404.1535(a), 416.935(a). Accordingly, remand for further proceedings is appropriate.
ORDER
Accordingly, IT IS ORDERED that:
1. The decision of the Commissioner is REVERSED.
2. This action is REMANDED to Defendant, pursuant to Sentence Four of 42 U.S.C. § 405(g), for further proceedings as discussed above.
3. The Clerk of the Court shall serve this Decision and Order and the Judgment herein on all parties or counsel.
JUDGMENT
IT IS ADJUDGED that this action is remanded to defendant for further proceedings pursuant to Sentence Four of 42 U.S.C. § 405(g) and consistent with the accompanying Decision and Order.