Opinion
Civil No. 05cv1322 W (AJB).
April 14, 2006
Plaintiff, Minh Le, proceeding by and through counsel, seeks judicial review of the final decision by the Commissioner of Social Security denying his claim for Supplemental Social Security Benefits under Title VXI of the Social Security Act. Plaintiff moves for summary judgment reversing the Commissioner's decision or, in the alternative, remand to the Social Security Administration for further proceedings. Defendants oppose Plaintiff's motion and filed a Cross-Motion for Summary Judgment seeking dismissal of this action. Plaintiff filed a Reply. These motions are appropriate for submission on the papers and without oral argument pursuant to Local Rule 7.1(d)(1). For the reasons set forth herein, it is recommended that Plaintiff's motion be GRANTED, Defendant's motion be DENIED, and that the case be REMANDED to the Social Security Administration (SSA) to determine the appropriate award of disability income benefits.
PROCEDURAL HISTORY
On September 12, 1994, Plaintiff filed an application for Supplemental Security Income (SSI) benefits. (Administrative Record `A.R.' at 80.) Plaintiff's application was initially denied on November 23, 1994, and again on reconsideration on August 15, 2005. (A.R. at 103, 107.) On September 8, 1995, Plaintiff requested a hearing before the SSA, which was subsequently granted. (A.R. at 115,181.)On October 10, 1997, an administrative hearing was held before ALJ Albert Tom. (A.R. at 435.) In a decision dated October 27, 1997 (hereinafter `1997 decision'), ALJ Tom denied Plaintiff's request for SSI benefits. (A.R. at 220.) Plaintiff requested review of the ALJ's decision on January 6, 1998. On August 28, 1998, the SSA Appeals Council dismissed the request as untimely. (A.R. at 238.)
On October 22, 1998, Plaintiff filed a second application for SSI benefits. Plaintiff's second SSI application was initially denied on March 23, 1999, and again on reconsideration on July 29, 1999. (A.R. at 242, 247.) Plaintiff then requested an administrative hearing, which was subsequently held on February 23, 2000, before ALJ Jerry Muskrat. (A.R. at 251, 255, 471.) On March 10, 2000, ALJ Muskrat issued an unfavorable decision (hereinafter `2000 decision') in which he found Plaintiff was not disabled and denied SSI benefits. (A.R. at 46.) Plaintiff sought review of this decision before the SSA Appeals Council. On September 28, 2000, the Appeals Council denied Plaintiff's request, concluding that there was no basis upon which to grant review. (A.R. at 15.) Plaintiff did not file a civil action in federal district court with respect to this decision.
On November 15, 2000, Plaintiff filed a third application for SSI benefits, which the Commissioner granted with an onset date of March 11, 2000, the day following ALJ Muskrat's decision. (A.R. at 7.)
In 2002, Plaintiff joined a class action filed in this Court alleging with regard to his first denial of application that ALJ Tom was biased. Dut Le et al. v. Apfel, 98cv1896-J(JFS) ( Dut Le class action). On November 18, 2002, the Court issued an order approving settlement of the Dut Le class action pursuant to Fed.R.Civ.P. 23(e), and remanded the class action to the Commissioner pursuant to 42 U.S.C. § 405(g), sentence four, for further administrative proceedings as set forth in the Settlement Agreement. Dut Le, et al. v. Apfel, 98cv1896-J (JFS) (Defendant's Exhibit C). The Court then dismissed the action with prejudice, but retained jurisdiction over the case to enforce the terms of the Settlement Agreement. Id.
The Settlement Agreement granted eligibility for consideration and review of denied and dismissed SSI claims for class plaintiffs who met certain criteria. Per the terms of the Settlement Agreement, Plaintiff was sent a notice from the SSA indicating that he was a member of the category II class of people and could therefore request review of the prior administrative decision by ALJ Tom denying benefits in Plaintiff's first application. Plaintiff submitted the request for review form, and on November 28, 2004, Plaintiff received a notice from the SSA stating that it "found no reason under [SSA] rules to review the Administrative Law Judge's decision." (A.R. at 6.) Pursuant to 42 U.S.C. § 405(g), Plaintiff now seeks judicial review of the Commissioner's final decision.
The settlement agreement defined category II as "class members who requested Appeals Council review and whose requests for review were denied by the Appeal Council."
FACTUAL BACKGROUND
Plaintiff is a 56-year old male who was born in Vietnam and immigrated to the United States in 1994. He presently resides with his wife and two step-daughters. Plaintiff does not speak English and can only communicate with non-Vietnamese-speaking persons through an interpreter. (A.R. 191-192.)
Plaintiff completed high school in Vietnam and later served as a military intelligence officer in the South Vietnamese army during the Vietnam War. In this capacity, Plaintiff worked to infiltrate and expose Communist spy networks. Plaintiff also married his first wife during this period and had his first child. (A.R. 191-192.)
In 1975, South Vietnam fell to the Communist regime. Shortly thereafter, Plaintiff was captured by the opposing Viet Cong forces and imprisoned in a POW camp where he was held for approximately nine years. There, Plaintiff was beaten, tortured, forced into hard labor, and subjected to unsanitary living conditions. As a result, Plaintiff developed a range of ailments, including degenerative disc disease of the lumbar spine, arthritis, chronic fatigue, Hepatitis B, and tuberculosis. (A.R. 130, 148, 162.)
In 1984, Plaintiff was released from the POW camp. Upon his release, he learned from friends that his wife and child attempted to flee Vietnam, presumably by boat to Australia as had many other South Vietnamese after the Communist takeover. Plaintiff, nor his friends and family, have heard from his wife or child and they are presumed lost at sea. (A.R. 193.)
During the years following his release, Plaintiff worked as a bicycle repair person in a small village. He later married his present wife, who already had two children from a previous marriage. Plaintiff subsequently changed professions and began raising small chickens and several pigs to support his new family. By 1993, however, Plaintiff's strength and health began to rapidly deteriorate, limiting his ability to work or care for the family's animals. Plaintiff's wife and step-daughters increasingly assumed his various responsibilities and eventually became responsible for running and operating the entire farm and household. (A.R. 193.)
Plaintiff and his family immigrated to the United States in 1994. Plaintiff has not worked or held any employment since his arrival. His most basic needs, such as cooking, cleaning, and shopping, are all performed by his wife and step-daughters. Outside of his immediate family, Plaintiff has no friends or acquaintances, and in fact has little contact with the outside world. (A.R. 193.)
Additionally, in 1994 Plaintiff was diagnosed with tuberculosis and hepatitis. (A.R. 146, 148.) Plaintiff also suffers from headaches, back aches, stomach aches, and fatigue, which he claims are the result of physical abuse he suffered while imprisoned in Vietnam. Plaintiff also claims to suffer from depression, anxiety, and posttraumatic stress disorder (PTSD), which he similarly attributes to his experiences as a prisoner of war. (A.R. 193-194.)
Prior to ALJ Tom's 1997 decision, Plaintiff received treatment and/or examination from three sources: Dr. Don. E. Miller, Ph.D., Dr. Stephen M. Greenleaf, M.D., and Dr. Ajit Raisinghani, D.O. Additionally, prior to the administrative hearing, Plaintiff's medical file was reviewed by Dr. Ansar Haroun, M.D. These medical findings and opinions are set forth below.
A. Relevant Medical History 1. Dr. Raisinghani
On or about July 29, 1995, Plaintiff received a consultative internal medicine examination from Dr. Ajit Raisinghani, D.O. (A.R. 208.) Plaintiff reported experiencing headaches, which he attributed to beatings he suffered while imprisoned in Vietnam, and shortness of breath, which he attributed to a prior bout with tuberculosis. (A.R. 208.) Dr. Raisinghani examined Plaintiff's body, muscle tone, and range of motion, and found Plaintiff to be generally healthy. Dr. Raisinghani also examined Plaintiff's neurological functions and reported Plaintiff's memory and senses to be "grossly intact." (A.R. 209-211.)
In his final assessment, Dr. Raisinghani concluded that Plaintiff's headaches were tension-related, as opposed to stress related. With respect to Plaintiff's breathing difficulties, Dr. Raisinghani reported that Plaintiff possessed good air movement in his lungs and found no evidence of obstructive lung disease. (A.R. 211.)
2. Dr. Greenleaf
Dr. Stephen M. Greenleaf, M.D., performed a consultative psychiatric examination of Plaintiff on or about August 7, 1995, roughly two years before the administrative hearing. During the examination, Plaintiff communicated through a non-professional interpreter. (A.R. 214.)
Initially, Dr. Greenleaf noted that Plaintiff had no hobbies, did little more than bathe and dress himself, was irritable and isolated, and demonstrated trouble with relationships. Dr. Greenleaf also administered a Mental Status Exam (MSE) and determined that Plaintiff possessed moderate psychomotor retardation, demonstrated no evidence of hyper vigilance or exaggeration of the startle response, exhibited speech and thought flow which were moderately under-productive, but logical and coherent, and did not demonstrate suicidal or homicidal ideations. (A.R. 216.)
Dr. Greenleaf ultimately concluded that Plaintiff suffered from moderate depression. He diagnosed Plaintiff with PTSD as well, but only "strictly by history," meaning strictly by Plaintiff's own account. Dr. Greenleaf characterized Plaintiff's PTSD as existing only strictly by history because Plaintiff did not exhibit signs of hyper vigilance or startle-response, which are symptoms commonly associated with PTSD. Finally, Dr. Greenleaf assessed Plaintiff's functional ability and concluded that Plaintiff could likely perform work in a low-stress environment with little peer contact. He further reported that Plaintiff could understand complex instructions and could tolerate reasonable constructive criticism. (A.R. 218.)
3. Dr. Miller — 1994 and 1997 Evaluation
In 1994, Plaintiff was examined by Dr. Don E. Miller, Ph.D., a state licensed psychologist. Plaintiff visited Dr. Miller four times over a three month period, with each visit lasting two hours. During the visits, Plaintiff communicated with Dr. Miller through a friend who served as a translator. (A.R. 190.)
During the four sessions, Dr. Miller monitored Plaintiff's mood and behavior and administered a battery of psychological tests, including the Rorschach test, the Wechsler Adult Intelligence Scale (WAIS) test, and the Global Assessment Functioning (GAF) test. (A.R. 195-196.) Plaintiff's Rorschach test results indicated that he "sees great danger" and views life as "a dog-eat-dog situation." The results further indicated that Plaintiff displays "a vigilant attitude," "startle response," and is upset by loud noises. (A.R. 195.) Plaintiff scored a 78 on the WAIS test, placing him in the lowest 7th percentile of test-takers, a range typically reserved for `borderline mentally retarded' persons. (A.R. 190, 196.)
Based on his observations and medical findings, Dr. Miller concluded that Plaintiff suffers from "severe depression, anxiety, and post traumatic stress disorder," which limits his ability to focus and concentrate. (A.R. 195-196.) Dr. Miller suggested that these psychological conditions, coupled with Plaintiff's deficits in focus and concentration, rendered Plaintiff disabled and incapable of performing work. Additionally, Dr. Miller reported that Plaintiff appeared fatigued and short of breath during the evaluation sessions, and speculated that these conditions might be related to Plaintiff's previously diagnosed tuberculosis. Dr. Miller further suggested that these physical conditions impede Plaintiff's ability to focus and concentrate, making work difficult if not impossible. Dr. Miller conceded, however, that the extent and severity of Plaintiff's tuberculosis were matters outside of his expertise. (A.R. 195-196.)
Dr. Miller examined Plaintiff again in 1997, just three months before the administrative hearing. (A.R. 164.) Although Dr. Miller's depression, anxiety, and PTSD diagnoses remained unchanged, Dr. Miller reported that Plaintiff's psychological impairments had worsened significantly since 1994. (A.R. 171-172.)
Dr. Miller reported that Plaintiff's anxiety and fears, and their resulting manifestations, had become significantly more severe and intense. For instance, besides nightmares and flashbacks, Plaintiff also suffered from constant delusions that Communist soldiers were looming nearby, waiting to recapture and imprison him. Plaintiff was so frightened by these delusions that he concocted odd and unusual plans to defend himself should the Communists arrive. Under one such plan, Plaintiff stated he would build a slingshot to shoot Communist soldiers with rocks before allowing himself to be recaptured. Plaintiff even described how he had collected stones for the slingshot in case of an attack. (A.R. 167-168.)
Dr. Miller also reported that Plaintiff had become more isolated and uncommunicative. Plaintiff had no friends and little if any contact with the outside world. Plaintiff rarely spoke to his family, and when he did, he would explode in fits of yelling and anger. For the most part, Plaintiff spent his days sitting on the couch, occasionally watching television. (A.R. 168-170.)
Dr. Miller further reported that Plaintiff exhibited fatigue, a lack of energy, and severe head and stomach aches. (A.R. 170-171.) In his 1994 evaluations, Dr. Miller speculated that Plaintiff's pain and fatigue were related to lung damage caused by tuberculosis. (A.R. 196-197.) However, in his 1997 report, Dr. Miller modified his diagnosis and opined that Plaintiff's pain and chronic lack of energy were instead somatic manifestations resulting from anxiety and PTSD. In other words, Plaintiff's internal stress and tension would result in headaches and body pain, which in turn resulted in low energy and fatigue. Dr. Miller stated that he could not envision a work site which could accommodate Plaintiff's psychological impairments. (A.R. 171-172.)
Before concluding his report, Dr. Miller also addressed Dr. Greenleaf's 1995 psychiatric findings. (A.R. 168.) Dr. Miller acknowledged that Dr. Greenleaf found PTSD only by history, and noted that this finding was based on the absence of observed hyper vigilance and startle response. Dr. Miller attempted to reconcile the disparity between his opinion and Dr. Greenleaf's by explaining that, in his experience, many patient suffering from PTSD may never demonstrate hyper vigilance or startle response in clinical settings. In other words, the absence of hyper vigilance and startle response is not determinative on the issue of PTSD. Dr. Miller also explained that, since both he and Dr. Greenleaf had last seen Plaintiff in 1994, Plaintiff's condition had deteriorated considerably, and therefore, the disparity between their opinions was somewhat irrelevant. (A.R. 168-169.) B. The Administrative Hearing and Decision
The ALJ held an administrative hearing on October 10, 1997. At the hearing, Dr. Ansar Haroun, M.D., testified as a medical expert. (A.R. 435.) Dr. Haroun's opinions and testimony were based solely on a review of Plaintiff's medical files, as he neither treated nor examined Plaintiff. Dr. Haroun concluded that Plaintiff was not disabled and could perform gainful activity. (A.R. 461, 462.)
As a threshold matter, Dr. Haroun testified that he did not consider Dr. Miller to be a treating doctor. Rather, Dr. Haroun classified Dr. Miller as an examining doctor because he did not provide Plaintiff with medical treatment. (A.R. 22.) Dr. Haroun then provided nine reasons for disregarding Dr. Miller's opinions and findings. (A.R. 456-459.) After rejecting Dr. Miller's opinions, Dr. Haroun concluded that Plaintiff was not disabled, and in doing so, he relied heavily on the opinions of Drs. Greenleaf and Raisinghani. (A.R. 459-462.) The ALJ largely adopted Dr. Haroun's testimony, reasons, and rationale in rendering the final disability determination.
Dr. Haroun's reasoning can be summarized as follows: (1) there was no evidence to suggest neurological disease; (2) Dr. Miller's conclusions lack credibility because they are based on improper testing; (3) Dr. Miller's conclusions regarding Plaintiff's behavior were contradicted by Plaintiff's conduct during the hearing; (4) Dr. Miller rendered a legal conclusion regarding disability which is reserved for the ALJ; (5) Dr. Miller rendered findings on Plaintiff's physical condition (tuberculosis) which were outside of Plaintiff's expertise; (6) although Dr. Miller recommended prescribing anti-depressants to Plaintiff, he never prescribed such medication; (7) Dr. Miller did not fully elaborate on his various diagnoses; (8) Dr. Miller's PTSD diagnosis is internally inconsistent with his finding that Plaintiff enjoys watching war movies; and (9) Dr. Miller was not knowledgeable about local community counseling programs available to Plaintiff.
On October 27, 1997, the ALJ issued an unfavorable decision and concluded that Plaintiff was not disabled. (A.R. 223.) The ALJ determined that Plaintiff's impairments, alone or in combination, did not meet or equal the Listing of Impairments criteria set forth in 20 CFR Pt. 404, Subpt. P, App. 1. He then concluded that Plaintiff possessed the residual functional capacity to perform medium work and that such work existed in significant numbers in both the regional and national economies. (A.R. 225.)
The ALJ determined that Plaintiff possessed slight difficulties in daily living activities, slight difficulties in social functioning, seldom experienced difficulty with concentration, persistence and pace, and exhibited no episodes of decompensation.
The ALJ's decision was largely based on Dr. Haroun's position that Dr. Miller was not a treating doctor. Like Dr. Haroun, the ALJ concluded that Dr. Miller did not provide Plaintiff with counseling or medication, and therefore did not provide "treatment." (A.R. 227.) The ALJ then provided six reasons for rejecting Dr. Miller's findings and opinions in their entirety. (A.R. 227-228.) Finally, the ALJ adopted the opinions of Drs. Greenleaf and Raisinghani in concluding that Plaintiff was not disabled. (A.R. 229.)
The ALJ provided six reasons for rejecting and disregarding Dr. Miller's medical testimony: (1) Dr. Miller's opinions were based on medical findings outside his scope of expertise; (2) Dr. Miller concluded that Plaintiff was disabled (an issue reserved for the ALJ) without providing Plaintiff's functional limitations; (3) Dr. Miller's findings were internally contradicting and unsupported by the medical record as a whole; (4) Dr. Miller's findings were based on Plaintiff's subjective complaints rather than on objective clinical results; (5) Dr. Greenleaf's findings were more reliable because they were based on objective medical findings; and (6) Dr. Haroun's reasoning and testimony.
DISCUSSION
The present matter comes before the Court pursuant to the class-action settlement in Dut Ban Le v. Commissioner, No. 98-cv-1896L (JFS) (S.D. Cal. Nov. 9, 2002). Under the settlement terms in Le, qualifying class-members became eligible to appeal unfavorable final disability decisions rendered by the Commissioner. Plaintiff appealed ALJ Tom's 1997 decision pursuant to Le, however, the SSA Appeals Council upheld its earlier decision. Plaintiff now seeks reversal of the Appeals Council decision.
The Court notes that review of this case is limited strictly to ALJ Tom's 1997 decision and evidence available to the ALJ at the time that decision was rendered. As such, arguments that are based on medical opinions rendered after the 1997 decision or that challenge findings and conclusions rendered in the 2000 decision, are not relevant to the instant case.
The parties dispute two issues; first, whether Dr. Miller is a treating doctor, and second, whether the ALJ's decision is supported by substantial evidence. Plaintiff argues that, in 1997, his impairments satisfied the Listing of Impairments criteria and that he is therefore conclusively presumed disabled under the regulations. Plaintiff further argues that the ALJ's disability determination was based on the legally erroneous premise that Dr. Miller was a non-treating doctor, and as such, must be reversed. In response, Defendants assert that the ALJ's disability determination is supported by substantial evidence. Defendants argue further that the ALJ correctly characterized Dr. Miller as an examining physician and provided clear and convincing reasons for rejecting Dr. Miller's opinions. The Court disagrees.
The Court concludes that Dr. Miller was a treating doctor and that his treating opinions are presumptively entitled to controlling weight, unless contradicted by clear and convincing evidence. Andrews v. Shalala, 53 F.3d 1035, 1041 (9th Cir. 1995). Although the ALJ offered several reasons for disregarding Dr. Miller's opinions, the Court finds these reasons unpersuasive. See, Supra note 3. Therefore, because the ALJ erroneously rejected Dr. Miller's controlling, treating opinions, the Court finds the ALJ's disability determination unsupported by substantial evidence and subject to reversal for the reasons set forth below.
See supra note 4.
A. Dr. Miller Was a Treating Doctor
The ALJ determined that Dr. Miller was not a treating doctor because he did not provide Plaintiff with counseling or medication. The Court finds no legal or factual support for this conclusion in the administrative record.
The Code of Federal Regulations defines a treating doctor as a physician or psychologist who provides a person with medical treatment or evaluation in the scope of an on-going treatment relationship. 20 C.F.R. § 404.1502. An on-going treatment relationship exists where a medical source treats or evaluates a claimant with a frequency consistent with accepted medical practice. Id. Notwithstanding this rather vague regulatory guidance, the Ninth Circuit has suggested that there is no hard and fast rule for determining the existence of a treating relationship. Benton, 331 F.3d at 1038 (citing Ratto v. Sec'y, Dep't of Health Human Serv., 839 F. Supp. 1415, 1425 (D. Or. 1993)). Instead, a treating relationship is best viewed as "a continuum reflecting the duration of the treatment relationship and the frequency and nature of contact," the central issue being whether the medical relationship was prompted by the claimant's need for treatment. Id.; see Bowman v. Comm'r, Soc. Sec. Admin., 2001 WL 215790 (Feb. 23, 2001) 2001 U.S. Dist. LEXIS 4391. As such, a medical source who treats or evaluates a claimant "only a few times or after longer intervals (e.g., twice a year)" may nonetheless constitute a treating doctor. 20 C.F.R. § 404.1502.
Applying the standard set forth in Benton, the Court has no trouble characterizing Dr. Miller as a treating doctor. Benton, 331 F.3d at 1038. The length, nature, and circumstances of Dr. Miller's medical relationship with Plaintiff demonstrate all the hallmarks of a typical treating relationship. Plaintiff initially sought help from Dr. Miller because he was suffering from anxiety, nightmares, and flashbacks stemming from his experiences as a prisoner of war. He and Dr. Miller subsequently established an on-going treating relationship through a series of five 2-hour sessions spanning a three year period. The existence of this treating relationship is further supported by Plaintiff's testimony at the administrative hearing, in which he stated he regularly contacted Dr. Miller when he needed advice and guidance concerning his psychological problems. (A.R. at 452.) Indeed, Dr. Miller is the only medical source who possesses any long term knowledge of Plaintiff's condition. In light of these facts, the Court concludes that Dr. Miller was a treating doctor.
The ALJ, however, reasoned that Dr. Miller was an examining physician because he did not provide Plaintiff with counseling or medication. The Court disagrees. Although Dr. Miller's reports do not provide great detail regarding the treatment Plaintiff received, the administrative record shows that Dr. Miller attempted "several interventions" during his relationship with Plaintiff. (A.R. 346.) Based on this fact and Dr. Miller's on-going relationship with Plaintiff, the Court is satisfied that Dr. Miller provided Plaintiff with treatment within the meaning of 20 C.F.R. § 404.1527.
Additionally, the Court finds the ALJ's reference to prescription medication irrelevant to Dr. Miller's status as a treating doctor. The Court can find no support for the proposition that a medical doctor must prescribe medication to be characterized as a treating doctor, or conversely, that failure to prescribe medication precludes status as a treating doctor. Such a rule would effectively bar all psychologists from serving as treating doctors, as psychologists are not licensed to prescribe medication. Consequently, the Court rejects the ALJ's characterization of Dr. Miller as a non-treating doctor to the extent it relies on this line of reasoning. B. Dr. Miller's Opinions and Findings are Entitled to Controlling Weight
Dr. Miller's status as a treating doctor does not automatically compel the conclusion that his opinions are entitled to controlling weight. Although treating doctors' opinions are generally entitled to greater weight than non-treating doctors' opinions, an ALJ may, within his discretion, disregard or reject a treating doctor's opinion when it is contradicted by other medical evidence. Shalala, 53 F.3d at 1041. Where a treating doctor's opinion is contradicted by a non-treating doctor's opinion that is based on independent clinical findings, an ALJ may reject the treating doctor's opinion in favor of the non-treating doctor's opinion, provided the decision is supported by substantial evidence. Id. However, where the treating doctor's opinion is uncontroverted, an ALJ must provide clear and convincing reasons before rejecting such an opinion. Id.
The ALJ determined that Dr. Miller's opinions and findings were contradicted by the medical record as a whole and disregarded them completely. The Court notes as a threshold matter, that the opinions of Drs. Miller and Greenleaf constitute the entire body of relevant medical evidence concerning Plaintiff's mental impairments. For this reason, the Court finds the six reasons provided by the ALJ's decision rejecting Dr. Miller's findings to be without merit and unsupported by substantial evidence.
Although Dr. Raisinghani performed an internal medicine examination on Plaintiff, his findings and conclusions primarily speak to Plaintiff's physical functional capacity and offer little insight into Plaintiff's mental health. As such, these opinions are entitled to lesser weight with respect to the nature and extent of Plaintiff's mental impairments.
Dr. Haroun's opinions and findings are similarly entitled to less weight. First, Dr. Haroun was a non-treating, non-examining doctor who had no contact with Plaintiff and whose opinions and findings were based entirely on Plaintiff's medical records. As such, Dr. Haroun's opinions are presumptively entitled to less weight than any of the other treating or examining doctors.
Second, the Court finds Dr. Haroun's testimony and medical opinions lack credibility. The Court notes numerous instances in which Dr. Haroun misstated facts and evidence in the record and mischaracterized Dr. Miller's findings and diagnoses. For instance, Dr. Haroun stated that Dr. Miller diagnosed Plaintiff as mentally retarded, when in fact, Dr. Miller only reported that Plaintiff's WAIS test score fell within a range of scores typically associated with "borderline mentally retarded" persons. (A.R. at 195, 456.) See, seq. note 8. Similarly, Dr. Haroun stated that Dr. Miller improperly conducted clinical psychological testing, when in fact there is no mention anywhere in the record concerning the methods employed by Dr. Miller in administering various psychological tests. (A.R. at 457.) The Court notes that its review was unnecessarily complicated by Dr. Haroun's questionable interpretation of the medical record and the ALJ's subsequent adoption of Dr. Haroun's testimony.
The ALJ found that Dr. Miller concluded Plaintiff was disabled (an issued reserved for the ALJ) without providing specific functional limitations resulting from Plaintiff's condition. Contrary to this assertion, the Court found numerous references to Plaintiff's inability to concentrate, focus, work, and socialize with others, all of which were supported by objective, clinical findings. (A.R. 169-172, 194-197)
Relatedly, the ALJ found that Dr. Miller's opinions were unsupported by objective clinical findings. However, after reviewing the record, the Court finds ample objective evidence to support Dr. Miller's opinions, including results from Plaintiff's Rorschach, WAIS, and GAF tests, and over 10 hours of observation covering a three year time period.
Last, the ALJ relied heavily on Dr. Haroun's testimony and medical opinions. However, as set forth in footnote 6 above, the Court found numerous instances in which Dr. Haroun misstated or misrepresented the record. As such, the Court finds Dr. Haroun's opinions to be unreliable.
The ALJ initially rejected Dr. Miller's opinions as unqualified because they were largely based on Plaintiff's previously diagnosed tuberculosis, an area outside Dr. Miller's expertise. However, after thoroughly reviewing Dr. Miller's reports, the Court is unable to agree with the ALJ's conclusion.
In 1994, Dr. Miller diagnosed Plaintiff with depression, anxiety, and PTSD, which in combination affected Plaintiff's ability to focus and concentrate, and therefore, his ability to perform and sustain work. (A.R. 167-168.) Separately, Dr. Miller observed that Plaintiff appeared chronically fatigued and speculated that this constant tiredness might be related to tuberculosis, which Plaintiff had been previously diagnosed. Dr. Miller opined that Plaintiff's fatigue might further impair his ability to concentrate and his capacity to perform work. (A.R. 168.) Though speaking to the same psychological impairment (Plaintiff's inability to concentrate), Dr. Miller's medical findings reflect two completely separate diagnoses. One attributes Plaintiff's concentration deficits to depression, anxiety, and PTSD, while the other suggests that Plaintiff's tuberculosis and fatigue affect his ability to think. The ALJ, however, misconstrued Dr. Miller's findings as a single diagnosis based entirely on Plaintiff's tuberculosis. By interpreting Dr. Miller's findings in this manner, the ALJ completely ignored the various objective, psychological and clinical findings supporting his conclusions. As such, to the extent the ALJ's decision relies on this line of reasoning, the Court finds the decision to be unsupported by the administrative record.
Second, the ALJ rejected Dr. Miller's opinions as internally inconsistent. The ALJ found that Dr. Miller's PTSD diagnosis was directly contradicted by his finding that Plaintiff enjoyed watching war movies. The ALJ noted that, by definition, those suffering from PTSD seek to avoid things which reference traumatizing events, rather than relive them as Plaintiff did by watching such movies. The Court, however, finds this interpretation of Dr. Miller's findings to be misleading.
In 1997, Dr. Miller noted that Plaintiff enjoyed watching scenes from war movies in which Communist soldiers were killed. While the ALJ found this statement to be self-contradicting with respect to Dr. Miller's PTSD diagnoses, when read in the context of Dr. Miller's entire report and diagnoses, this statement demonstrates Plaintiff's fear of Communist soldiers and his deep-seeded resentment toward them. Viewed in this light, Dr. Miller's statements do not support the ALJ's interpretation of the facts.
The ALJ also found as internally inconsistent Dr. Miller's report that Plaintiff could manage money and his finding that Plaintiff was "mentally retarded." Again, however, the ALJ misstates the record. Dr. Miller never reported Plaintiff as being "mentally retarded." Rather, Dr. Miller reported that Plaintiff's WAIS test score fell within the range of scores normally associated with mental retardation. (A.R. at 195.) As such, the Court finds the ALJ's rationale is unpersuasive and wholly without merit and is rejected.
Third, the ALJ noted that Dr. Miller's opinions were in conflict with those of Dr. Greenleaf. In 1994, Dr. Miller concluded that Plaintiff suffered from severe depression, anxiety, and PTSD, which in combination, rendered Plaintiff disabled and unemployable. (A.R. 196-197.) In contrast, in 1995, Dr. Greenleaf diagnosed Plaintiff as being only moderately depressed, and found PTSD strictly by history. While acknowledging Plaintiff's difficulties in social functioning, Dr. Greenleaf ultimately concluded that Plaintiff could work in low-stress environments will little peer contact. (A.R. 217-218.)
However, in 1997, Dr. Miller examined Plaintiff and concluded that Plaintiff's condition was far worse than either he or Dr. Greenleaf had previous diagnosed in 1994 or 1995. (A.R. 168.) Dr. Miller reported that Plaintiff's PTSD and anxiety had become more pronounced, that he had greater difficulty socializing and had become withdrawn and isolated, and that he was experiencing somatic manifestations from his fears and anxiety. (A.R. 167-168.)
While Drs. Miller and Greenleaf vary in the severity of Plaintiff's diagnosis in 1994 and 1995, the ALJ concluded that Dr. Greenleaf's findings were supported by objective medical findings, whereas Dr. Miller's were only supported by Plaintiff's subjective complaints, and consequently rejected Dr. Miller's opinions in their entirety. The Court finds that Dr. Miller's 1997 findings provide a more accurate picture of Plaintiff's psychological condition at or about the time of the hearing. The Court finds the changes in Plaintiff's condition during the period between 1994 and 1997 to be significant.
In sum, the Court is unpersuaded by the ALJ's stated reasons for rejecting Dr. Miller's findings and opinions. The Court finds Dr. Miller's opinions as a treating doctor to be controlling with respect to the nature and extent of Plaintiff's mental impairments, as Dr. Miller treated Plaintiff during the entire 1994-1997 period, whereas Dr. Greenleaf merely examined Plaintiff once in 1995.
C. The ALJ's Disability Determination is Unsupported by Substantial Evidence.
A District Court "shall have power to enter . . . a judgment affirming, modifying, or reversing the decision of the Commissioner, with or without remanding the case for a rehearing." 42 U.S.C. § 405(g). Notwithstanding this authority, an ALJ's findings of fact shall be deemed conclusive unless unsupported by substantial evidence. Andrews v. Shalala, 53 F.3d 1035, 1039, (9th Cir. 1995); Magallanes v. Bowen, 881 F.3d 747, 750 (9th Cir. 1989). "Substantial evidence means more than a mere scintilla but less than a preponderance; it is such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Id. In determining whether an ALJ's decision is supported by substantial evidence, a court of review must consider the entire administrative record, weighing both evidence which supports and detracts from the ALJ's conclusion. Id. Where the evidence is susceptible to more than one rational interpretation, the ALJ's decision must be upheld. Id.
The ALJ determined that Plaintiff's impairments failed to meet the Listing of Impairments criteria set forth under Listings 12.04 and 12.06. (A.R. 225.) However, as set forth above, the ALJ's disability determination was based on the legally erroneous premise that Dr. Miller was a non-treating doctor. Plaintiff argues that the ALJ's failure to properly consider Dr. Miller's treating opinions renders the ALJ's disability determination unsupported by substantial evidence, and therefore, subject to reversal. The Court agrees.
The Social Security Administration has established a five-step sequential evaluation process for determining whether a person is disabled. Andrews, 53 F.3d at 1040 ( citing Bowen v. Yuckert, 482 U.S. 137, 140 (1987)); 20 CFR §§ 404.1520, 416.920 (2003). Under this evaluation process, the claimant must initially establish that he possesses a medically determinable impairment which precludes substantial gainful activity. Id. Once this threshold burden is satisfied, the ALJ must then determine whether the claimant's impairments satisfy the Listing of Impairments criteria set forth in 20 CFR Pt. 404, Subpt. P, App. 1. If the claimant's impairments meet or equal the Listing of Impairments criteria, the claimant is conclusively presumed disabled. Id.
The Listing of Impairments criteria measure the severity of a claimant's alleged impairments and are structured into two categories, A and B. Id. Category A criteria help the ALJ determine whether a claimant possesses a recognized, medically determinable impairment. Id. Category B criteria assist the ALJ in measuring the severity of a determinable impairment, or conversely, the claimant's residual functional capacity notwithstanding his impairments. Id.
The ALJ determined that Plaintiff exhibited only slight deficits in the areas of daily activities and social functioning, seldom demonstrated difficulties with concentration, persistence and pace, and exhibited no episodes of decompensation. (A.R. 229.) However, as set forth above, the Court found the ALJ's determination that Dr. Miller's opinions were unsupported and entitled to less weight to be without merit and unsupported by substantial evidence, as the ALJ's determination conflicts with Dr. Miller's treating opinions. Furthermore, Plaintiff asserts that he possesses mental impairments which satisfy Listings 12.04 for Affective Disorders and 12.06 for Anxiety Related Disorders. Defendant, however, argues that even if Plaintiff's impairments satisfy the category A criteria under Listings 12.04 and 12.06, Plaintiff's impairments fail to meet or equal the category B criteria. The issue of disability, therefore, turns on whether Dr. Miller's medical findings demonstrate that Plaintiff's impairments satisfy the category B criteria.
The criteria in category B "describe impairment-related functional limitations that are incompatible with the ability to do any gainful activity." 20 CFR Pt. 404, Subpt. P, App. 1. Category B criteria measure an impairment in four specific subcategories: (1) activities of daily living, (2) social functioning, (3) concentration, persistence, or pace, and (4) the presence or absence of episodes of decompensation. Id. To satisfy the category "B" criteria, the claimant must demonstrate "marked" restrictions or difficulties in at least two of the four subcategories. Id. Marked "means more than moderate but less than extreme" in severity. Id. "A marked limitation may arise when several activities or functions are impaired, or even when only one is impaired, as long as the degree of limitation is such as to interfere seriously with [a claimant's] ability to function independently, appropriately, effectively, and on a sustained basis." Id. 1. Activities of Daily Living
The "activities of daily living" subcategory considers the claimant's ability to perform typical daily activities such as "cleaning, shopping, cooking, taking public transportation, paying bills, [and] maintaining a residence." 20 CFR Pt. 404, Subpt. P, App. 1, Listing 12.00. In assessing the claimant's ability to perform daily living activities, the decision maker must determine "the extent to which [the claimant is] capable of initiating and participating in [these] activities independent of supervision and direction." Id. A "marked" condition is not defined by the number of activities that a claimant is capable of performing but rather by the degree of interference the impairment causes in the performance of a given activity. Id.
The Court finds that Plaintiff possesses marked deficits in the area of daily living. Both Drs. Miller and Greenleaf reported that Plaintiff does little more than bathe and groom himself. (A.R. 166-167, 216) Plaintiff's basic needs, such as cooking, cleaning, shopping, and house work, are all performed by his family. Indeed, when Plaintiff attempts to perform chores by himself, for instance washing dishes, he is unable muster enough energy and concentration to properly complete and finish the task and his wife or step-daughters must typically redo or complete Plaintiff's work for him. (A.R. 166-167.) Dr. Miller concluded that these functional deficits result from Plaintiff's stress-related concentration difficulties and anxiety-induced fatigue. Even if Plaintiff were placed in a low-stress work environment, as suggested by the ALJ, Plaintiff's mental impairments would likely interfere with his ability to complete basic tasks, and therefore, preclude him from sustaining employment. (A.R. 168-170.)
2. Social Functioning
The "social functioning" subcategory considers the claimant's "capacity to interact independently, appropriately, effectively, and on a sustained basis with other individuals." 20 CFR Pt. 404, Subpt. P, App. 1, Listing 12.00. Evidence of impaired or marked social functioning may consist of, "a history of altercations . . ., firings, fear of strangers, avoidance of interpersonal relationships, or social isolation." Id. In contrast, evidence of "ability to initiate social contacts with others, communicate clearly with others, or interact and actively participate in group activities" may demonstrate normal social functioning. Id.
There is ample evidence in the record demonstrating that Plaintiff possesses marked difficulties in the area of social functioning. Both Drs. Miller and Greenleaf observed Plaintiff to be isolated and highly irritable. (A.R. 166-167, 216) Plaintiff has no friends and no contact with the outside world other than through his immediate family. Yet, as noted by Dr. Miller, Plaintiff even experiences difficulty interacting with his family. Plaintiff has a strained relationship with his wife and step-daughters, and is often uncommunicative with them. On rare occasions when Plaintiff does speak, the dialogue is generally harsh and abrasive. (A.R. 166-167.) These social functioning deficits, coupled with Plaintiff's other peculiar behaviors, delusions, and fears, render Plaintiff incapable of functioning in a typical work environment. As such, the Court finds there is ample support in the record demonstrating that Plaintiff experiences marked deficits in social functioning.
The ALJ, however, concluded that Plaintiff was capable of socializing and functioning within a normal work environment. The ALJ based this conclusion on Dr. Greenleaf's 1995 opinion that Plaintiff could work in low-stress environments and could tolerate moderate criticism. However, as previously discussed, Dr. Greenleaf's opinions were based on outdated findings and observations made roughly two years before the administrative hearing. A more accurate picture of Plaintiff's condition can be gleaned from Dr. Miller's 1997 evaluation, which offers the most recent assessment of Plaintiff's condition. Thus, neither the ALJ's decision nor Dr. Greenleaf's findings alter the Court's conclusion.
3. Concentration, Persistence, and Pace
The "concentration, persistence, and pace" subcategory considers the claimant's ability "to sustain focused attention and concentration sufficiently long to permit the timely completion of tasks commonly found in work settings." 20 CFR Pt. 404, Subpt. P, App. 1, Listing 12.00. A "marked" condition may exist when a claimant "cannot complete . . . tasks without extra supervision or assistance, or in accordance with quality and accuracy standards, or at a consistent pace without unreasonable number and length of rest periods, or without undue interruptions or distractions." Id.
The Court concludes that Plaintiff possesses marked difficulties in the area of concentration, persistence, and pace. Dr. Miller reported that Plaintiff's anxiety and PTSD interfere with his ability to focus and concentrate. (A.R. at 168-169.) Dr. Miller noted further that Plaintiff's anxiety generates stress, which in turn can lead to somatic manifestations like headaches, stomach aches, and fatigue. (A.R. at 171-172.) These somatic manifestations further interfere with Plaintiff's ability to concentrate for long periods of time. (A.R. 169-170.) Dr. Miller concluded that, in combination, these conditions would likely prevent Plaintiff from maintaining employment. (A.R. 170-172.)
Despite Dr. Miller's findings, the ALJ concluded that Plaintiff only seldomly experienced deficits in concentration, persistence, and pace. In support of this conclusion, the ALJ cited Dr. Greenleaf's opinion that Plaintiff could understand complex instructions and could perform three-step instructions. However, as set forth above, Dr. Greenleaf was merely an examining doctor who saw Plaintiff once in 1995, and in light of the on-going treatment provided by Dr. Miller from 1994-1997, the Court finds Dr. Miller's opinion to ultimately be the most relevant and persuasive opinion within the record. As such, the Court is unpersuaded by the ALJ's argument.
After reviewing Dr. Miller's and Dr. Greenleaf's findings in conjunction with the category B criteria for Listings 12.04 and 12.06, the Court finds that Plaintiff's impairments satisfy the category B criteria.
The Court finds that Plaintiff's medical records demonstrate marked restrictions in the categories of daily living, social functioning, and concentration, persistence, and pace. As such, Plaintiff's mental impairments satisfy the category A and B criteria under Listings 12.04 and 12.06. Plaintiff is therefore, conclusively presumed disabled.
CONCLUSION
For the reasons discussed herein, the Court finds the ALJ's decision disregarded Dr. Miller's opinion as a treating doctor, and in doing so, rendered a disability determination that is not supported by substantial evidence or the record as a whole. As such, this Court recommends that Plaintiff's Motion for Summary Judgment be GRANTED, that Defendant's Cross-Motion for Summary Judgment be DENIED, and that the matter be REMANDED to the Social Security Administration only insofar as necessary to determine the appropriate award of disability income benefits.
This report and recommendation will be submitted to the United States District Judge assigned to this case, pursuant to 28 U.S.C. s 636(b)(1) and Rule 72(b) of the Federal Rules of Civil Procedure. Written objections and any response to those objections shall be filed pursuant to the provisions of the Federal Rules. The parties are advised that failure to file objections within the proper time periods may waive the right to appeal the District Court's order. Martinez v. Ylst, 951 F.2d 113 (9th Cir. 1991).
IT IS SO ORDERED.