Gonzales v. Colvin

• Decision Date: 17 February 2015
• Docket Number: 3:13–cv–2620
• Citation: 191 F.Supp.3d 401
• Parties: Laura Mary GONZALES, Plaintiff, v. Carolyn W. COLVIN, Acting Commissioner of Social Security, Defendant.
• Court: U.S. District Court — Middle District of Pennsylvania

191 F.Supp.3d 401

Laura Mary GONZALES, Plaintiff,

v.Carolyn W. COLVIN, Acting Commissioner of Social Security, Defendant.

3:13–cv–2620

United States District Court, M.D. Pennsylvania.

Signed February 17, 2015

Thomas D. Sutton, Levanthal, Sutton & Gornstein, Trevose, PA, for Plaintiff.

G. Michael Thiel, U.S. Attorney's Office, Scranton, PA, for Defendant.

ORDER

John E. Jones III, United States District Judge

AND NOW , upon consideration of the Report and Recommendation of United States Magistrate Judge Gerald B. Cohn (Doc. 24), recommending that the decision of the Commissioner of Social Security denying Plaintiff's social security disability insurance be vacated and the case be remanded to the Commissioner of Social Security to develop the record fully, conduct a new administrative hearing, and appropriately evaluate the evidence, and noting that the Commissioner filed a letter (Doc. 25) with the Court advising that she does not object to the Magistrate Judge's recommendation,¹ and after an independent review of the record and the Court finding Judge Cohn's analysis to be thorough, well-reasoned, and fully supported by the record IT IS HEREBY ORDERED THAT:

1. The Report and Recommendation of Magistrate Judge Cohn (Doc. 25) is ADOPTED in its entirety.

2. The decision of the Commissioner of Social Security denying Plaintiff's social security disability insurance and supplemental security income is VACATED .

3. This matter is REMANDED to the Commissioner of Social Security to develop the record fully, conduct a new administrative hearing, and appropriately evaluate the evidence.

4. The Clerk of Court is directed to CLOSE the file on this case.

REPORT AND RECOMMENDATION TO VACATE THE DECISION OF THE COMMISSIONER AND REMAND FOR FURTHER PROCEEDINGS

GERALD B. COHN, UNITED STATES MAGISTRATE JUDGE

REPORT AND RECOMMENDATION

I. Introduction

The above-captioned action is one seeking review of a decision of the Commissioner of Social Security ("Commissioner") denying the application of Plaintiff Laura M. Gonzales for disability insurance benefits ("DIB") and supplemental security income ("SSI") under the Social Security Act, 42 U.S.C. §§ 401 –433, 1382 –1383 (the "Act"). Here, the decision of the Commissioner lacks substantial evidence because, although the administrative law judge ("ALJ") found that Plaintiff had limitations in concentration, persistence, and pace, he did not include any related limitations in Plaintiff's residual functional capacity ("RFC"). The ALJ also erred in discounting multiple medical opinions without providing any reason. Moreover, the ALJ discounted another medical opinion solely because of an alleged lack of objective evidence, but the medical record is replete with objective findings. As a result, the Court recommends that Plaintiff's appeal be granted, the decision of the Commissioner be vacated, and the matter be remanded for further proceedings.

II. Procedural Background

On December 22, 2006, Plaintiff filed an application for SSI under Title XVI of the Act and for DIB under Title II of the Act. (Tr. 249–263). On September 19, 2007, the Bureau of Disability Determination denied these applications (Tr. 175–196), and Plaintiff filed a request for a hearing on October 5, 2007. (Tr. 127–28). On January 7, 2010, an ALJ held a hearing at which Plaintiff—who was represented by an attorney—and a vocational expert ("VE") appeared and testified. (Tr. 108–135). On February 9, 2010, the ALJ found that Plaintiff was not disabled and not entitled to benefits. (Tr. 148–69). Plaintiff filed a request for review with the Appeals Council, and the Appeals Council remanded to the ALJ to remedy multiple errors. (Tr. 172–74). On June 1, 2011, the ALJ held a second hearing at which Plaintiff—who was represented by an attorney—and a VE appeared and testified. (Tr. 82–107). On August 23, 2011, the ALJ found that Plaintiff was not disabled and not entitled to benefits. (Tr. 23–46). On March 26, 2013, Plaintiff filed a request for review with the Appeals Council (Tr. 8–19), which the Appeals Council denied on August 20, 2013, thereby affirming the decision of the ALJ as the "final decision" of the Commissioner. (Tr. 1–6).

On October 23, 2013, Plaintiff filed the above-captioned action pursuant to 42 U.S.C. § 405(g) to appeal the decision of the Commissioner. (Doc. 1). On January 29, 2014, the Commissioner filed an answer and administrative transcript of proceedings. (Docs. 8, 9). On April 17, 2014, Plaintiff filed a brief in support of her appeal ("Pl. Brief"). (Doc. 12). On July 30, 2014, Defendant filed a brief in response ("Def. Brief"). (Doc. 20). On September 2, 2014, Plaintiff filed a brief in reply. (Doc. 23). On April 29, 2014, the Court referred this case to the undersigned Magistrate Judge.

III. Standard of Review

When reviewing the denial of disability benefits, the Court must determine whether substantial evidence supports the denial. Johnson v. Commissioner of Social Sec. , 529 F.3d 198, 200 (3d Cir. 2008). Substantial evidence is a deferential standard of review. See Jones v. Barnhart , 364 F.3d 501, 503 (3d Cir. 2004). Substantial evidence "does not mean a large or considerable amount of evidence, but rather ‘such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.’ " Pierce v. Underwood , 487 U.S. 552, 565, 108 S.Ct. 2541, 101 L.Ed.2d 490 (1988) (quoting Consolidated Edison Co. v. NLRB , 305 U.S. 197, 229, 59 S.Ct. 206, 83 L.Ed. 126 (1938) ). Substantial evidence is "less than a preponderance" and requires only "more than a mere scintilla." Jesurum v. Sec'y of U.S. Dep't of Health & Human Servs. , 48 F.3d 114, 117 (3d Cir. 1995) (citing Richardson v. Perales , 402 U.S. 389, 401, 91 S.Ct. 1420, 28 L.Ed.2d 842 (1971) ).

IV. Sequential Evaluation Process

To receive disability or supplemental security benefits, a claimant must demonstrate an "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 12 months." 42 U.S.C. § 423(d)(1)(A) ; 42 U.S.C. § 1382c(a)(3)(A). The Act requires that a claimant for disability benefits show that he has a physical or mental impairment of such a 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. § 423(d)(2)(A) ; 42 U.S.C. § 1382c(a)(3)(B).

The Commissioner uses a five-step evaluation process to determine if a person is eligible for disability benefits. See 20 C.F.R. § 404.1520 ; see also Plummer v. Apfel , 186 F.3d 422, 428 (3d Cir. 1999). If the Commissioner finds that a Plaintiff is disabled or not disabled at any point in the sequence, review does not proceed. See 20 C.F.R. § 404.1520. The Commissioner must sequentially determine: (1) whether the claimant is engaged in substantial gainful activity; (2) whether the claimant has a severe impairment; (3) whether the claimant's impairment meets or equals a listed impairment from 20 C.F.R. Part 404, Subpart P, Appendix 1 ("Listing"); (4) whether the claimant's impairment prevents the claimant from doing past relevant work; and (5) whether the claimant's impairment prevents the claimant from doing any other work. See 20 C.F.R. §§ 404.1520, 416.920. Before moving on to step four in this process, the ALJ must also determine Plaintiff's residual functional capacity ("RFC"). 20 C.F.R. §§ 404.1520(e), 416.920(e).

The disability determination involves shifting burdens of proof. The claimant bears the burden of proof at steps one through four. If the claimant satisfies this burden, then the Commissioner must show at step five that jobs exist in the national economy that a person with the claimant's abilities, age, education, and work experience can perform. Mason v. Shalala , 994 F.2d 1058, 1064 (3d Cir. 1993). The ultimate burden of proving disability within the meaning of the Act lies with the claimant. See 42 U.S.C. § 423(d)(5)(A) ; 20 C.F.R. § 416.912(a).

V. Relevant Facts in the Record

Plaintiff was born on February 28, 1965 and was classified by the regulations as a younger individual through the date of the ALJ decision. 20 C.F.R. § 404.1563. (Tr. 37). She has a limited education and past relevant work as a help desk operator and administrative assistant. (Tr. 37). Plaintiff was treated for pain in her neck, spine, hip, and extremities, as well as for mental impairments

from 2005 through the date of the ALJ decision on August 23, 2011. Plaintiff stopped working on May 30, 2002. (Tr. 310). She applied for disability benefits on September 5, 2006. (Tr. 244). Plaintiff amended her alleged onset date at the second hearing to May 10, 2007. (Tr. 87).

A. Medical Records

On August 24, 2005, Plaintiff was evaluated by Dr. Victor Jaramillo at the Neurology Center. (Tr. 386). She had been referred by her primary care physician for evaluation of headaches. (Tr. 384). She was also complaining of neck pain, back pain, and dizziness. (Tr. 384). On exam, she had tenderness and pain on flexion, "light sensory deficit for pinprick and touch in both upper extremities," and spasm in her neck, cervical spine, and lumbar spine. (Tr. 385–86).

On September 6, 2005, Plaintiff had an MRI of her neck

. (Tr. 423). It indicated "mild disc desiccation with a mild central C5–6 disc herniation with a central disc bulge at C6–7." (Tr. 423).

On September 28, 2005, Plaintiff followed-up at the Neurology Center. (Tr. 382). On exam, she had a "slight sensory deficit for pinprick in both upper extremities in a patchy distribution," but her exam was otherwise normal and she was scheduled for additional tests....