Ford v. Berryhill
| Decision Date | 16 August 2017 |
| Docket Number | No. 4:16 CV 1527 JMB,4:16 CV 1527 JMB |
| Parties | CHANTAL FORD, Plaintiff, v. NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant. |
| Court | U.S. District Court — Eastern District of Missouri |
This action is before the Court pursuant to the Social Security Act, 42 U.S.C. §§ 401, et seq. ("the Act"). The Act authorizes judicial review of the final decision of the Commissioner of Social Security (the "Commissioner") denying Plaintiff Chantal Ford's application for Disability Insurance Benefits and Supplemental Security Income. All matters are pending before the undersigned United States Magistrate Judge with consent of the parties, pursuant to 28 U.S.C. § 636(c). The matter is fully briefed, and for the reasons discussed below, the Commissioner's decision is affirmed.
On August 26, 2013, Plaintiff filed applications for Disability Insurance Benefits ("DIB") and Supplemental Security Income ("SSI") under the Act. Plaintiff alleged a disability onset date of September 17, 2012. (Tr. 12)2 Plaintiff's claims were denied initially on October 4,2013. (Id.) Thereafter, Plaintiff requested a hearing before an Administrative Law Judge ("ALJ"), which was held on June 3, 2015. Plaintiff and Darrell Taylor, Ph.D., an independent Vocational Expert ("VE"), testified at the hearing. (Tr. 29) In a decision dated September 4, 2015, the ALJ denied benefits, concluding that Plaintiff was not disabled under the Act. (Tr. 12-22) The Social Security Administration Appeals Council denied Plaintiff's request for review, leaving the ALJ's decision as the final decision of the Commissioner in this matter. Plaintiff filed the instant action on September 27, 2016. (ECF No. 1) Accordingly, Plaintiff has exhausted her administrative remedies and the matter is properly before this Court. Plaintiff has been represented throughout all relevant proceedings.
Although the ultimate issue before the Court is whether substantial evidence supports the Commissioner's decision, Plaintiff's request for judicial review asks the Court to consider two inter-related issues, namely:
Both of these issues require the Court to address other related issues, including the ALJ's consideration of Plaintiff's credibility and the medical opinion evidence in the administrative record.
After a thorough review of the record, the Court concludes that the Commissioner's decision is supported by substantial evidence. The ALJ gave good reasons for discounting Plaintiff's credibility. Although the ALJ did not give significant weight to any of the medical opinions in the record, contrary to Plaintiff's contention, there is medical evidence in the record,including medical source opinion evidence, to support a conclusion that Plaintiff is capable of sedentary work with the additional limitations noted. Such evidence includes aspects of the opinion provided by Plaintiff's treating physician, Dr. Gayla Jackson, M.D.
Plaintiff was 31 years old at the time of her administrative hearing. Prior to her alleged disability onset, Plaintiff worked in a variety of positions, including as a customer services representative, cashier, and casino security services. (Tr. 20) In her Disability Report - Adult, Plaintiff listed the following mental and physical conditions as limiting her ability to work: mental health; bipolar disorder; depression; anxiety; PTSD; obesity; high blood pressure; migraine headaches; sleep apnea; and asthma. (Tr. 184) In her Function Report - Adult, Plaintiff listed the following limitations to her ability to work: lifting, squatting, bending, standing, walking, sitting, kneeling, talking, stair climbing, seeing, memory, completing tasks, concentration, understanding, following instructions, and getting along with others.3 (Tr. 223)
There is a great deal of medical evidence in the record. The Court has considered the entire record and summarizes specific aspects herein to provide context for this memorandum and order.
There are a few treatment records that predate Plaintiff's alleged disability onset date. Dr. Melissa Hollie apparently treated Plaintiff's hypertension, but noted that she was unsure whether Plaintiff had been compliant with her medications. (Tr. 269-71)
Plaintiff received treatment on numerous occasions, for a variety of reasons, from providers at SSM DePaul Health Center, including at the emergency room ("ER"). (See, e.g., Tr. 273-345, 678-90) For example, in 2012, Plaintiff received treatment for migraine headaches, ear pain, a sore finger, a broken tooth, chest pain, abdominal pain, and coughing. The medical records indicate that she typically received routine and conservative treatment for her conditions. For example, in February 2013, Plaintiff was treated at the ER for chest pain. The treatment notes indicate, among other things, that Plaintiff had a normal EKG. She was given a prescription for pain and referred to her primary care provider. (Tr. 311-16) Similarly, on June 23, 2013, Plaintiff again appeared at the ER with chest pain, and again she had a normal EKG and was found to have no acute disease of the chest. (Tr. 324-34) In July 2, 2013, Plaintiff was treated at the ER for abdominal pain with vomiting. The treatment notes reflect that all laboratory tests were "unremarkable." (Tr. 335, 341) Furthermore, the treatment notes for many if not most of her ER visits indicate that she had 100% oxygen saturation.
Additionally, a review of all of the treatment records from SSM DePaul Health Center show that the providers regularly found Plaintiff to be oriented, have a normal mood and affect, and intact memory and judgment.
Between 2012 and 2015, Plaintiff received treatment numerous times at Christian Hospital Northwest, including at the ER. Plaintiff was treated for a variety of complaints, including chest pain, ear pain, dizziness, knee pain, a finger burn from Clorox, women's health issues, a hand injury due to punching a person, breathing issues related to asthma, nausea and stomach symptoms. Despite her many trips to this facility, the record shows that Plaintiff typically received routine and conservative treatment and was not in acute distress, eitherphysically or mentally. For example, in December 2012, Plaintiff appeared at the ER complaining of chest pain. Plaintiff was oriented and did not appear to be in distress and did not meet the criteria for critical care. Rather, she was advised to follow up with her primary care physician. As another example, in August 2014, Plaintiff was treated at this facility after complaining of difficulty breathing. She was diagnosed with asthma and tobacco abuse. In April 2015, Plaintiff returned to this facility, complaining of chest pain, shortness of breath, numbness, and a headache. Testing revealed no acute cardiopulmonary abnormalities.
The administrative record includes a large number of treatment notes from the Mercy Clinic and Dr. Gayla Jackson, M.D., from 2013 into 2015. The records suggest that Dr. Jackson treated Plaintiff for a number of different conditions, including but not limited to, asthma, obstructive sleep apnea, morbid obesity, and women's health issues. Plaintiff also reported to Dr. Jackson that she was attempting to conceive and have a child and received treatment from another provider, Dr. Marsha Fisher, related to fertility issues. Plaintiff also received periodic treatment at the Mercy Hospital ER.
Dr. Jackson's treatment notes reflect problems controlling Plaintiff's various symptoms. For example, notes from May 2013 represent that Plaintiff's asthma was not well controlled and that she continued to suffer from morbid obesity. The notes further indicate that Plaintiff suffered from occasional anxiety and was receiving multiple psychiatric-related medications. Dr. Jackson's notes regularly indicate that Plaintiff exhibited a normal mood and affect, and was well-oriented.
Dr. Jackson's notes, which span about two years, indicate that one of the substantial issues with Plaintiff's health care was controlling her asthma and hypertension. This issue is generally consistent with Plaintiff's frequent visits to the ER. Dr. Jackson's notes indicate,however, that Plaintiff was non-compliant with her treatment and/or medications. Dr. Jackson regularly noted that Plaintiff continued to smoke cigarettes despite her conditions. Similarly, Plaintiff was not using her CPAP machine to assist with her obstructive sleep apnea, and was not compliant with other medications, including medications for blood pressure, migraines, and psychiatric issues. Dr. Jackson's notes also indicate that Plaintiff consumed a poor diet, at one time reporting that she subsisted largely on fast food. Dr. Jackson's notes often indicate that she spent more than 50% of her time with Plaintiff on counselling, including encouraging Plaintiff to modify her lifestyle.
On the whole, the treatment notes from Dr. Jackson and Mercy Clinic indicate that Plaintiff typically received routine and conservative treatment for her various ailments, and that Plaintiff was non-compliant with the course of treatment provided and recommended.
Dr. Jackson completed an Arthritis Residual Functional Capacity Questionnaire, dated May 14, 2015, which is one of the important pieces of opinion evidence in the record. (Tr. 987) Dr. Jackson...
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