Opinion
Civil No. 19-00082 (RMB)
01-29-2020
CARMEN MEJIAS, Plaintiff, v. COMMISSIONER, SOCIAL SECURITY ADMINISTRATION, Defendant.
MEMORANDUM OPINION & ORDER
BUMB, United States District Judge:
This matter comes before the Court upon an appeal by Plaintiff Carmen Mejias from a denial of social security disability benefits.
For the reasons set forth below, the Court vacates the decision of the Administrative Law Judge ("ALJ") and remands for proceedings consistent with this Memorandum Opinion and Order's reasoning.
I. STANDARD OF REVIEW
When reviewing a final decision of an ALJ with regard to disability benefits, a court must uphold the ALJ's factual decisions if they are supported by "substantial evidence." Knepp v. Apfel, 204 F.3d 78, 83 (3d Cir. 2000); 42 U.S.C. §§ 405(g), 1383(c)(3). "Substantial evidence" means "'more than a mere scintilla. It means such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.'" Richardson v. Perales, 402 U.S. 389, 401 (1971) (quoting Cons. Edison Co. v. NLRB, 305 U.S. 197, 229 (1938)); Plummer v. Apfel, 186 F.3d 422, 427 (3d Cir. 1999).
In addition to the "substantial evidence" inquiry, the court must also determine whether the ALJ applied the correct legal standards. See Friedberg v. Schweiker, 721 F.2d 445, 447 (3d Cir. 1983); Sykes v. Apfel, 228 F.3d 259, 262 (3d Cir. 2000). The Court's review of legal issues is plenary. Sykes, 228 F.3d at 262 (citing Schaudeck v. Comm'r of Soc. Sec., 181 F.3d 429, 431 (3d Cir. 1999)).
The Social Security Act defines "disability" as 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. § 1382c(a)(3)(A). The Act further states,
[A]n individual shall be determined to be under a disability only 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.42 U.S.C. § 1382c(a)(3)(B).
The Commissioner has promulgated a five-step, sequential analysis for evaluating a claimant's disability, as outlined in 20 C.F.R. § 404.1520(a)(4)(i-v). The analysis proceeds as follows:
At step one, the ALJ determines whether the claimant is performing "substantial gainful activity[.]" 20 C.F.R. §§ 404.1520(a)(4)(i), 416.920(a)(4)(i). If he is, he is not disabled. Id. Otherwise, the ALJ moves on to step two.
At step two, the ALJ considers whether the claimant has any "severe medically determinable physical or mental impairment" that meets certain regulatory requirements. Id. §§ 404.1520(a)(4)(ii), 416.920(a)(4)(ii). A "severe impairment" is one that "significantly limits [the claimant's] physical or mental ability to do basic work activities[.]" Id. §§ 404.1520(c), 416.920(c). If the claimant lacks such an impairment, he is not disabled. Id. §§ 404.1520(a)(4)(ii), 416.920(a)(4)(ii). If he has such an impairment, the ALJ moves on to step three.
At step three, the ALJ decides "whether the claimant's impairments meet or equal the requirements of an impairment listed in the regulations[.]" Smith, 631 F.3d at 634. If the claimant's impairments do, he is disabled. 20 C.F.R. §§ 404.1520(a)(4)(iii), 416.920(a)(4)(iii). If they do not, the ALJ moves on to step four.
At step four, the ALJ assesses the claimant's "residual functional capacity" ("RFC") and whether he can perform his "past relevant work."2 *202 Id. §§ 404.1520(a)(4)(iv), 416.920(a)(4)(iv). A claimant's "[RFC] is the most [he] can still do despite [his] limitations." Id. §§ 404.1545(a)(1), 416.945(a)(1). If the claimant can perform his past relevant work despite his limitations, he is not disabled. Id. §§ 404.1520(a)(4)(iv), 416.920(a)(4)(iv). If he cannot,
the ALJ moves on to step five.Hess v. Comm'r Soc. Sec., 931 F.3d 198, 201-02 (3d Cir. 2019).
At step five, the ALJ examines whether the claimant "can make an adjustment to other work[,]" considering his "[RFC,] ... age, education, and work experience[.]" Id. §§ 404.1520(a)(4)(v), 416.920(a)(4)(v). That examination typically involves "one or more hypothetical questions posed by the ALJ to [a] vocational expert." Podedworny v. Harris, 745 F.2d 210, 218 (3d Cir. 1984). If the claimant can make an adjustment to other work, he is not disabled. 20 C.F.R. §§ 404.1520(a)(4)(v), 416.920(a)(4)(v). If he cannot, he is disabled.
II. FACTS
The Court recites only the facts that are necessary to its determination on appeal, which is narrow.
Plaintiff, who was under 50 years old at the alleged onset date, claims disability, in part, based on diagnoses of mental disabilities including depression, schizoaffective disorder, and post-traumatic stress disorder.
In support of her claim, Plaintiff provided voluminous treatment records from Nueva Vida of New Jersey Behavioral Health Center, including both an April 2017 "Adult Psychiatric Evaluation" (A.R. at 705-707) and a July 2017 "Medical Source Statement of Ability to Do Work-Related Activities (Mental)" (A.R. at 813-815) from her treating psychiatrist, Lydia C. Monte, M.D. Dr. Monte diagnosed Plaintiff with schizoaffective disorder, post-traumatic stress disorder ("PTSD"), and borderline personality features, and noted "marked" limitations in Plaintiff's ability to, inter alia, "make judgments on complex work-related decisions", "interact appropriately with the public . . . supervisor)s . . . [and] co-workers, and "moderate" limitations in her ability to "understand and remember . . . [and] carry out simple instructions", "make judgments on simple work-related decisions", and "respond appropriately to usual work situations and to changes in a routine work setting". (A.R. at 813-814)
III. ALJ'S DETERMINATION
The ALJ found Plaintiff not disabled. At Step Four of the five-step sequential analysis, the ALJ concluded that Plaintiff had "the residual function capacity to perform light work as defined in 20 CFR 416.967(b). (A.R. at 25) The ALJ did make certain accommodations for Plaintiff's asserted impairments, including that she "can have no more than occasional interaction with the public". (A.R. at 25) The ALJ gave "little weight" to Dr. Monte's assessment that Plaintiff had "marked limitations in her ability . . . to make judgments on complex work-related decisions and interact appropriately with the public, supervisors and co-workers", explaining, that "the treating notes do not document or support such severe limitation". (A.R. at 28)
At step five of the analysis, the ALJ determined that Plaintiff was not disabled and could perform the occupations of linen grader, housekeeper (night shift), or food maker (Mexican), based on her residual functional capacity
IV. ANALYSIS
Among other arguments, Plaintiff asserts that the ALJ erred in concluding that Plaintiff's mental impairments did not constitute a severe impairment because the ALJ discounted Plaintiff's treating psychiatrist's assessment for erroneous reasons. The Court finds that the ALJ's reasons for affording little weight to the treating psychiatrist's assessment are not supported by substantial evidence, and therefore the Court will remand for further proceedings consistent with this Memorandum Opinion and Order.
"An impairment, once established, must be considered severe unless the evidence demonstrates that it is merely a slight abnormality, having no more than a minimal effect on an individual's ability to work. Reasonable doubts on severity are to be resolved in favor of the claimant." Sincavage v. Barnhart, 171 F. App'x 924, 926 (3d Cir. 2006) (citing and quoting Newell v. Comm'r of Soc. Sec., 347 F.3d 541, 546-47 (3d Cir. 2003)).
The Third Circuit "ha[s] consistently held that the ALJ must give 'controlling weight' to the opinion of a treating physician unless that opinion is not supported by 'medically acceptable clinical and laboratory diagnostic techniques [or] is . . . inconsistent with the other substantial evidence in . . . [the] record.'" Masher v. Astrue, 354 F. App'x 623, 628 (3d Cir. 2009) (quoting Fargnoli v. Massanari, 247 F.3d 34, 43 (3d Cir. 2001)); 20 C.F.R. § 404.1527(d)(2). In this case, the ALJ gave less than controlling weight to Dr. Monte's July 2017 assessment because the ALJ found that "the treating notes do not document or support such severe limitation". (A.R. at 28)
The ALJ made no reference to Dr. Monte's April 2017 assessment and notes.
In his brief, the Commissioner supports the ALJ's rationale, asserting that Dr. Monte's notes elsewhere had "normal mental findings". (Def. Br. at 13 (citing A.R. 692, 700)) The Commissioner also makes the additional argument that the ALJ correctly gave little weight to Dr. Monte's July 2017 assessment because a checkbox evaluation constitutes "weak evidence at best" and that Dr. Monte's notes elsewhere had "normal mental findings". (Def. Br. at 12) Neither (a) the ALJ's finding, nor (b) the Commissioner's post hoc rationalization, however, is supported by the record.
With regards to (a), contrary to the ALJ's finding, Dr. Monte's April 2017 psychiatric evaluation of Plaintiff, conducted three months prior to the completion of the Medical Source Statement, documents and supports severe limitations on mental activity. According to Dr. Monte's assessment, Plaintiff presented as "severe" for the following behaviors: "depressed mood"; "crying"; "low energy"; "self isolation"; "anxiety"; "excessive worries"; "shakiness"; "nervousness" (with Dr. Monte's handwritten note "racing thoughts"); "violent urges" (with Dr. Monte's handwritten note "mood swing"). (A.R. at 705) Plaintiff is also noted as having "explosive behavior" 3-4 times per week, "panic attacks" twice a week, sleeping only 1-2 hours per night, having occasional flashbacks, and demonstrating paranoia. (A.R. at 705) In this same written evaluation, Dr. Monte diagnosed Plaintiff with schizoaffective disorder, PTSD, and borderline personality features. (A.R. at 707) The ALJ's opinion fails to explain how this evaluation insufficiently "documents or supports" the limitations advised by Dr. Monte in the July 2017 evaluation. Thus, the Court cannot determine whether the ALJ properly discounted Dr. Monte's opinion in this regard.
With regard to (b), the Court holds that it would be error to discount Dr. Monte's assessment based on the form used to provide the assessment. As the document itself plainly indicates, the Social Security Administration's Office of Disability Adjudication and Review approved the form for use in cases seeking disability benefits. (A.R. at 813) The Commissioner cannot provide claimants with a specific form, only later to discount the information provided therein based on nothing other than the format of that very form. To hold otherwise would be illogical and fundamentally unfair to disability claimants. The three-page form is a vehicle for presenting potentially voluminous amounts of information in a concise and easily accessible manner. Therefore, even in the absence of the OAR's express approval of the form, the Court would not find that the "check-box" nature of the form, in and of itself, is sufficient justification to support departure from the general rule that treating physicians' opinions are typically given controlling weight. Moreover, this rationale was not provided in the ALJ's opinion, and the Court cannot determine whether it reflects the ALJ's process in weighing Dr. Monte's opinion.
Notably, the form does not consist of simple "yes" or "no" questions. With regard to various mental activities and associated limitations, the form provides a continuum of several possible answers, including "none", "mild", "moderate", "marked", and "extreme." Additionally, the form provides multiple spaces for the assessor to "[i]dentify the factors . . . that support your assessment", each of which Dr. Monte completed. (A.R. at 813-814).
This case is distinguishable from cases in which non-treating, state agency physicians' reports have been discounted for using brief, check-box forms that were not specifically approved by the Social Security Administration. See, e.g., Morales v. Apfel, 225 F.3d 310, 320 (3d Cir. 2000) (discounting a "check-list-style report" because it "was prepared without the benefit of an examination of [Plaintiff]."); Mason v. Shalala, 994 F.2d 1058, 1065 (3d Cir. 1993) ("the report from the New Jersey Division of Vocational Rehabilitation is but a two-page form, entitled "General Basic Medical Examination," that requires the physician only to check boxes and briefly to fill in blanks. The report does not call for explanations of the examining physician's medical conclusions-- and no such explanations appear.").
Thus, the reasons provided in the ALJ's opinion and Commissioner's brief for discounting Dr. Monte's assessment of Plaintiff's mental impairment are not supported by the record. However, the Court concludes that remand, as opposed to reversal, is appropriate. As the ALJ's decision discusses, other medical evidence in the record potentially conflicts with Dr. Monte's assessment. On remand, the ALJ may revisit her evaluation of Dr. Monte's assessment in light of all of the record evidence, weigh it against all other relevant record evidence, and perhaps arrive at the same decision. At this juncture, however, the ALJ must revisit her analysis consistent with the law and record facts discussed herein. As such, the Court vacates the decision of the ALJ and remands for proceedings consistent with the above analysis. ACCORDINGLY, it is on this 29th day of January, 2020,
See, e.g., A.R. at 118-120 -- Ex. 1A; A.R. at 132-134 -- Ex. 3A.
It is not for this Court to determine, in the first instance, whether other potentially-- but not necessarily-- inconsistent record evidence constitutes substantial evidence which would support affording Dr. Monte's assessment less than controlling weight. See Masher, 354 F. App'x at 628 (stating that a treating physician's assessment must be given controlling weight unless it is "inconsistent with the other substantial evidence in the record."). Upon remand of this case, the ALJ should conduct this inquiry. --------
ORDERED that the decision of the Administrative Law Judge is VACATED and the case is REMANDED for further proceedings consistent with this Memorandum Opinion; and it is further
ORDERED that the Clerk of Court shall CLOSE THIS CASE.
s/ Renée Marie Bumb
RENÉE MARIE BUMB, U.S.D.J.