Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-azd-2_13-cv-02456/USCOURTS-azd-2_13-cv-02456-0/pdf.json

Nature of Suit Code: 863
Nature of Suit: Social Security - DIWC/DIWW (405(g))
Cause of Action: 42:405 Review of HHS Decision (SSID)

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WO 

IN THE UNITED STATES DISTRICT COURT 

FOR THE DISTRICT OF ARIZONA 

Linda Marie Gaus, 

Plaintiff, 

v. 

Carolyn W. Colvin, Acting Commissioner 

of Social Security, 

Defendant. 

No. CV-13-02456-PHX-NVW 

ORDER 

Plaintiff Linda Marie Gaus seeks review under 42 U.S.C. § 405(g) of the final 

decision of the Commissioner of Social Security (“the Commissioner”), which denied her 

disability insurance benefits and supplemental security income under sections 216(i), 

223(d), and 1614(a)(3)(A) of the Social Security Act. Because the decision of the 

Administrative Law Judge (“ALJ”) is supported by substantial evidence and is not based 

on legal error, the Commissioner’s decision will be affirmed. 

I. BACKGROUND 

Plaintiff was born in July 1961. She has had petit mal seizures since eighth grade. 

Plaintiff graduated from a one-year college program as a home health caregiver and 

worked as a home health caregiver for many years. In December 2007, Plaintiff’s 

employment was terminated when she broke her arm, her husband was out of town, and 

she accepted an invitation to stay with the patient for whom she was providing care. She 

alleges disability beginning December 8, 2007. 

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In 2009, Plaintiff first reported experiencing vertigo. In June 2010, when asked to 

describe how her symptoms prevented her from carrying out her normal workday, 

Plaintiff said “dizziness sometimes (vertigo),” her medicine made her very tired and 

caused diarrhea, and she did not work. She reported that on an average day she showers, 

gets dressed, does laundry, goes shopping, washes dishes, prepares meals, feeds her dogs, 

and does housecleaning. She said she can walk about a half mile, and she no longer 

drives. She said she assisted with trimming bushes outside her home. Plaintiff also 

reported having several seizures a month during which she did not lose consciousness. 

On May 19, 2010, Plaintiff applied for disability insurance benefits and 

supplemental security income. On September 27, 2011, Plaintiff appeared with her 

attorney and testified at a hearing before the ALJ. An impartial vocational expert also 

testified. On January 13, 2012, the ALJ issued a decision that Plaintiff was not disabled 

within the meaning of the Social Security Act. The Appeals Council denied Plaintiff’s 

request for review of the hearing decision, making the ALJ’s decision the 

Commissioner’s final decision. On December 2, 2013, Plaintiff sought review by this 

Court. 

II. STANDARD OF REVIEW 

The district court reviews only those issues raised by the party challenging the 

ALJ’s decision. See Lewis v. Apfel, 236 F.3d 503, 517 n.13 (9th Cir. 2001). The court 

may set aside the Commissioner’s disability determination only if the determination is 

not supported by substantial evidence or is based on legal error. Orn v. Astrue, 495 F.3d 

625, 630 (9th Cir. 2007). Substantial evidence is more than a scintilla, less than a 

preponderance, and relevant evidence that a reasonable person might accept as adequate 

to support a conclusion considering the record as a whole. Id. In determining whether 

substantial evidence supports a decision, the court must consider the record as a whole 

and may not affirm simply by isolating a “specific quantum of supporting evidence.” Id. 

As a general rule, “[w]here the evidence is susceptible to more than one rational 

interpretation, one of which supports the ALJ’s decision, the ALJ’s conclusion must be 

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upheld.” Thomas v. Barnhart, 278 F.3d 947, 954 (9th Cir. 2002) (citations omitted); 

accord Molina v. Astrue, 674 F.3d 1104, 1111 (9th Cir. 2012) (“Even when the evidence 

is susceptible to more than one rational interpretation, we must uphold the ALJ’s findings 

if they are supported by inferences reasonably drawn from the record.”). 

III. FIVE-STEP SEQUENTIAL EVALUATION PROCESS 

To determine whether a claimant is disabled for purposes of the Social Security 

Act, the ALJ follows a five-step process. 20 C.F.R. § 404.1520(a). The claimant bears 

the burden of proof on the first four steps, but the burden shifts to the Commissioner at 

step five. Tackett v. Apfel, 180 F.3d 1094, 1098 (9th Cir. 1999). 

At the first step, the ALJ determines whether the claimant is engaging in 

substantial gainful activity. 20 C.F.R. § 404.1520(a)(4)(i). If so, the claimant is not 

disabled and the inquiry ends. Id. At step two, the ALJ determines whether the claimant 

has a “severe” medically determinable physical or mental impairment. 

§ 404.1520(a)(4)(ii). If not, the claimant is not disabled and the inquiry ends. Id. At step 

three, the ALJ considers whether the claimant’s impairment or combination of 

impairments meets or medically equals an impairment listed in Appendix 1 to Subpart P 

of 20 C.F.R. Pt. 404. § 404.1520(a)(4)(iii). If so, the claimant is automatically found to 

be disabled. Id. If not, the ALJ proceeds to step four. At step four, the ALJ assesses the 

claimant’s residual functional capacity and determines whether the claimant is still 

capable of performing past relevant work. § 404.1520(a)(4)(iv). If so, the claimant is not 

disabled and the inquiry ends. Id. If not, the ALJ proceeds to the fifth and final step, 

where he determines whether the claimant can perform any other work based on the 

claimant’s residual functional capacity, age, education, and work experience. 

§ 404.1520(a)(4)(v). If so, the claimant is not disabled. Id. If not, the claimant is 

disabled. Id. 

At step one, the ALJ found that Plaintiff meets the insured status requirements of 

the Social Security Act through March 31, 2012, and that she has not engaged in 

substantial gainful activity since December 8, 2007. At step two, the ALJ found that 

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Plaintiff has the following severe impairments: seizures and vertigo. At step three, the 

ALJ determined that Plaintiff does not have an impairment or combination of 

impairments that meets or medically equals an impairment listed in 20 C.F.R. Part 404, 

Subpart P, Appendix 1. 

At step four, the ALJ found that Plaintiff: 

has the residual functional capacity to perform medium work as defined in 

20 CFR 404.1567(c) and 416.967(c) except the claimant cannot use 

ladders, ropes or scaffolds. Furthermore, the claimant should avoid even 

moderate exposure to hazards, including dangerous machinery and 

unprotected heights. The claimant is further limited because she must 

commute to and from work using public transportation. The claimant, 

moreover, cannot work in a fast-paced production environment. She can 

attend and concentrate for two hours and then must take a customary ten to 

fifteen minute break. She can then attend and concentrate for two more 

hours then must take the customary thirty to sixty minute lunch break. She 

can then attend and concentrate for two hours before taking a customary ten 

to fifteen minute break. She can then attend and concentrate for two more 

hours, and that ends the normal eight hour workday. 

The ALJ further found that Plaintiff is capable of performing past relevant work as a 

home health caregiver. 

IV. ANALYSIS 

A. The ALJ Did Not Err in Evaluating Plaintiff’s Credibility. 

In evaluating the credibility of a claimant’s testimony regarding subjective pain or 

other symptoms, the ALJ is required to engage in a two-step analysis: (1) determine 

whether the claimant presented objective medical evidence of an impairment that could 

reasonably be expected to produce some degree of the pain or other symptoms alleged; 

and, if so with no evidence of malingering, (2) reject the claimant’s testimony about the 

severity of the symptoms only by giving specific, clear, and convincing reasons for the 

rejection. Vasquez v. Astrue, 572 F.3d 586, 591 (9th Cir. 2009). In making a credibility 

determination, an ALJ “may not reject a claimant’s subjective complaints based solely on 

a lack of objective medical evidence to fully corroborate the claimant’s allegations.” 

Bray v. Comm’r of Soc. Sec. Admin., 554 F.3d 1219, 1227 (9th Cir. 2009) (internal 

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quotation marks and citation omitted). But “an ALJ may weigh inconsistencies between 

the claimant’s testimony and his or her conduct, daily activities, and work record, among 

other factors.” Id. 

The ALJ found that Plaintiff’s medically determinable impairments could 

reasonably be expected to cause the alleged symptoms. Then, the ALJ found Plaintiff’s 

statements regarding the intensity, persistence, and limiting effects of the symptoms not 

credible to the extent they are inconsistent with the ALJ’s residual functional capacity 

assessment, i.e., that Plaintiff can perform medium work with customary breaks after two 

hours, but not in a fast-paced production environment or around hazards. The ALJ 

concluded that Plaintiff had magnified her alleged symptoms of petit mal seizures and 

vertigo. 

The ALJ found that Plaintiff’s allegation that vertigo was one of the reasons she 

was unable to work beginning in December 2007 was not supported by the record. 

Plaintiff testified that since December 2007 she has had seizures more frequently and she 

suffers vertigo three to four times a week, sometimes up to eight hours in duration. The 

ALJ found, however, that Plaintiff’s vertigo did not begin until the summer of 2009, 

based on record evidence and Plaintiff’s attorney’s admission.1

 Therefore, from 

December 2007 until the summer of 2009, Plaintiff’s only alleged impairment is petit mal 

seizures. 

 1

 Although Plaintiff testified that vertigo was the second worst problem preventing 

her from working in December 2007, her error was corrected shortly thereafter. The 

hearing decision states that her representative “candidly admitted the claimant’s vertigo 

did not start until 2009.” But Plaintiff also readily admitted her vertigo did not begin 

until 2009. Her initially incorrect testimony is relevant to her credibility to show whether 

she is a reliable historian, but does not establish that she exaggerated symptoms. Even if 

the ALJ erred in his interpretation of her response, Plaintiff has not shown that any such 

error is harmful because the ALJ identified multiple reasons for discrediting Plaintiff’s 

subjective symptom testimony that are supported by substantial evidence. See Molina v. 

Astrue, 674 F.3d 1104, 1115 (9th Cir. 2012). 

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The ALJ identified specific record evidence demonstrating that Plaintiff’s seizures 

were under fair or good control during much of the relevant period. In December 2007, 

Plaintiff saw her neurologist, Harry S. Morehead, Jr., M.D., and reported she had had no 

seizures since approximately May 2007. In March 2008, Dr. Morehead reported she still 

had had no seizures since May 2007 and her seizures seemed to be well controlled. In 

June 2008, Dr. Morehead reported Plaintiff had three brief seizures in April and May 

2008, the first seizures she had had since May 2007. In July 2008, Dr. Morehead 

reported Plaintiff was not aware of having had any definite seizures since May. In 

September 2008, Plaintiff reported a seizure in August, and Dr. Morehead increased the 

dosage of her Keppra prescription. In December 2008, Dr. Morehead did not change 

Plaintiff’s medication because she had not had a seizure since September. He reported 

that her “spells are partial seizures and are relatively mild, associated with laughing.” In 

March 2009, Dr. Morehead reported Plaintiff had had no seizures since 2008, and they 

were minor and well controlled. He also reported that he agreed with Plaintiff that her 

epilepsy was not severe enough at the time to require surgery. 

In October 2009, Dr. Morehead reported that Plaintiff was having vertigo attacks 

with nausea and vomiting, possibly caused by the Keppra or some type of gastrointestinal 

problem. In November 2009, Plaintiff had a bout of dizziness and vertigo, with nausea 

and vomiting for about 18 hours, and Dr. Morehead suggested reducing the Keppra. In 

January 2010, Dr. Morehead reported that reducing the Keppra had been helpful; since 

November Plaintiff had only experienced a slight onset of dizziness on January 28, 2010. 

Her last seizure was also near the end of November and “was one of her minor ones as 

usual.” In March 2010, Dr. Morehead reported that Plaintiff had had one or two seizures 

since January, each lasting “only a couple of minutes,” and she had had about one vertigo 

attack every week or so, each lasting 48 hours. He also reported that it appeared that 

Plaintiff had about the same frequency of seizures on or off the Keppra, and she did not 

miss work previously with the seizures. He recommended gradually discontinuing the 

Keppra. 

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In April 2010, Plaintiff experienced three seizures and a reoccurrence of vertigo. 

On June 21, 2010, Dr. Morehead restarted the Keppra. On July 1, 2010, Dr. Morehead 

reported Plaintiff’s last seizure was on June 19, her seizures are minor, and “her vertigo 

continues from time to time.” In November 2010, Plaintiff called Dr. Morehead for 

prescription refills and reported a minor seizure on November 13 and continued vertigo. 

On February 1, 2011, Dr. Morehead saw Plaintiff for the first time since July 2010. 

Plaintiff reported that she had had seven seizures in July, one in August, one in 

November, and two in January. He also reported that Plaintiff’s vertigo “restarted this 

month and has occurred about 4 times.” In May 2011, Dr. Morehead reported that 

Plaintiff brought in a “diary showing only 7 rather minor seizures since February 8” and 

that “her vertigo has not been quite so severe.” 

On August 4, 2011, Dr. Morehead reported that on July 30 Plaintiff “had a 

moderately severe attack of vertigo, associated with nausea and vomiting.” He said that 

her vertigo attacks had “become a significant problem.” He described Plaintiff’s seizures 

as “minor spells often accompanied by laughing or nonsensical speech that lasts a few 

seconds followed by confusion,” occurring two to three times a month, lately at or just 

after bedtime. Dr. Morehead also reported that Plaintiff did not have any warning before 

a spell and did not know that she had had them.2

 On August 17, 2011, Plaintiff saw her 

primary care physician, who noted “her seizure disorders are doing well” and “her vertigo 

has been acting up a little bit, other than that she is doing well.” 

On September 30, 2011, Plaintiff began treatment with a different neurologist, 

who noted: “Patient complains of vertigo in the past 2 years and makes her nauseous. 

. . . It occurs two to three times a week and it can last up to 8 hours.” The ALJ found it 

suspicious that before the September 2011 hearing Plaintiff did not complain about 

 2

 Plaintiff testified that she only knows that she has seizures because her husband 

tells her afterward. 

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serious vertigo attacks, but after the hearing she complained of numerous vertigo attacks, 

lasting up to eight hours. 

The ALJ also found that Plaintiff’s medical history and examination findings in 

the record did not confirm her allegations. He found that, although Plaintiff had suffered 

from seizures most of her life, she never had any convulsive seizures, and her seizures 

were characterized as brief. Further, they usually occur at or just after bedtime, so they 

likely would not interfere with Plaintiff’s ability to work during a normal daytime 

workday. The ALJ found the record showed Plaintiff’s seizures were present at 

approximately the same level of severity before the alleged onset date. The fact they did 

not prevent Plaintiff from working before December 2007 suggested that they would not 

have prevented her from working after December 2007. 

The ALJ further found that the medical records showed that prescribed 

medications had been relatively effective in controlling Plaintiff’s symptoms for her 

alleged impairments. Thus, substantial evidence supports finding that the ALJ provided 

specific, clear, and convincing reasons for discrediting Plaintiff’s subjective symptom 

testimony. 

B. The ALJ Did Not Err by Failing to Recontact Dr. Morehead for an 

Opinion. 

Plaintiff contends that the ALJ committed legal error by failing to “recontact” Dr. 

Morehead for an opinion regarding Plaintiff’s functional capabilities. Although Plaintiff 

refers to “recontacting,” the record does not show that the ALJ ever contacted Dr. 

Morehead directly. The record also does not show that Plaintiff requested the ALJ to 

contact or subpoena Dr. Morehead for an opinion. 

The ALJ has a special duty to fully and fairly develop the record and assure that 

the claimant’s interests are considered, even when the claimant is represented by counsel. 

Smolen v. Chater, 80 F.3d 1273, 1288 (9th Cir. 1996). An ALJ may stop a hearing 

temporarily and continue it at a later date if he believes that there is material evidence 

missing at the hearing. 20 C.F.R. § 404.944. The ALJ may also reopen the hearing to 

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receive new and material evidence at any time before he mails a notice of the decision. 

Id. However, an “ALJ’s duty to develop the record further is triggered only when there is 

ambiguous evidence or when the record is inadequate to allow for proper evaluation of 

the evidence.” McLeod v. Astrue, 640 F.3d 881, 885 (9th Cir. 2011). An ALJ has no 

duty to request more information from treating physicians where substantially all of their 

medical records for the relevant period are before the ALJ and none of the evidence is 

unclear or ambiguous. Id. at 884. 

On March 8, 2010, Dr. Morehead wrote: 

Social Security disability is being applied for with the help of an agency 

and I filled out those forms today. The patient has about the same 

frequency of seizures on or off the Keppra it appears, and did not miss 

work with them previously. The problem of course is that she is unable to 

obtain a driver’s license. 

He also wrote, “I completed the paperwork to assist in her social security disability, but it 

appears that the vertigo is more of a disabling problem frequency-wise than seizures.” 

The record does not indicate what paperwork Dr. Morehead completed. During the 

hearing on September 27, 2011, Plaintiff’s counsel said she thought Dr. Morehead 

referred to “some sort of questionnaire,” but she was not sure that it was included in the 

record. 

Later during the hearing, the ALJ said he would keep the record open for Plaintiff 

to submit her vertigo log, her seizure log, and all of the updated medical records from Dr. 

Morehead. The ALJ then said, “I think that’s the only way I’ll be able to make a proper 

evaluation in this case.” At the end of the hearing, the ALJ asked Plaintiff’s counsel if 

she would be able to get the information he identified to him by October 14, 2011, and 

counsel said she believed so. The ALJ then said if she could not get all of the 

information in by October 14, she should send a motion asking for more time and assume 

it is granted, but she should not send items piecemeal. The ALJ repeated that he wanted 

the seizure log, the vertigo log, and all updated Dr. Morehead records. Plaintiff’s counsel 

previously had mentioned that Plaintiff and her significant other had completed “seizure 

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questionnaires,” which were in the record. At the end of the hearing, Plaintiff’s counsel 

said she had found “the questionnaire” from Dr. Morehead, and the ALJ said to send it 

with the other missing evidence. The ALJ then asked, “And you said there was a seizure 

questionnaire?” Counsel responded, “Yes. This would be part of Dr. Morehead’s 

records that he sent.” The ALJ stated that the records were incomplete. He then 

summarized that counsel was to submit “seizure log, vertigo log, updated Morehead 

records, a seizure questionnaire” and asked Plaintiff’s counsel if there was anything else 

he needed to keep the record open for. Counsel responded, “I don’t think so.” 

On October 27, 2013, Plaintiff’s counsel requested an additional 21 days to secure 

and submit post-hearing medical evidence. She said medical records from Dr. Ahmadieh 

had been requested but not yet received. She did not mention Dr. Morehead, and she did 

not request that the ALJ subpoena Dr. Morehead for a medical source statement. In the 

hearing decision dated January 13, 2012, the ALJ noted that the record remained open 

following the hearing for the submission of additional medical records, and the additional 

records were received and admitted as Exhibits 8F, 9F, and 10F. The ALJ also stated that 

Dr. Morehead noted that he filled out disability paperwork, but there was no medical 

source statement from Dr. Morehead in the record, and the record was left open after the 

hearing to obtain such a statement. 

Although it is unclear what Dr. Morehead meant when he said he had completed 

disability “forms” and “paperwork” and what Plaintiff’s counsel meant when she said she 

had found “the questionnaire” from Dr. Morehead, the ALJ gave Plaintiff ample time and 

opportunity to obtain a medical source statement from Dr. Morehead regardless of 

whether he had completed one previously. Moreover, all of Dr. Morehead’s treatment 

records were submitted and considered by the ALJ, and they were not unclear or 

ambiguous. Dr. Morehead did not observe Plaintiff’s seizures or vertigo. He described 

her seizures as infrequent “minor spells” that had not changed significantly after 

December 2007, and he did not think her vertigo was a significant problem until August 

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2011. Therefore, the ALJ did not err by failing to “recontact” Dr. Morehead for an 

opinion regarding Plaintiff’s functional capabilities. 

C. The ALJ Did Not Err by Giving Some Weight to the Opinions of NonExamining State Agency Physicians or by Giving Significant Weight to 

Dr. Hurd’s Opinion. 

Plaintiff contends the ALJ erred by giving some weight to the opinions of nonexamining State agency physicians because opinions of treating physicians are to be 

given greater weight and the record reviewed by the non-examining physicians did not 

include an opinion from treating physician Dr. Morehead. As concluded above, Dr. 

Morehead may not have given an opinion regarding Plaintiff’s functional capabilities, 

Plaintiff had opportunity to submit it or obtain one, and Dr. Morehead’s records are 

complete and unambiguous. The ALJ acknowledged that the opinions of non-examining 

physicians generally do not deserve as much weight as those of treating or examining 

physicians and found these to be deserving of some weight because there were a number 

of other reasons to reach similar conclusions. 

Plaintiff also contends that the ALJ committed legal error by giving significant 

weight to consultative examiner Dr. Richard Hurd’s opinion that she was capable of 

work-related activities and of doing her past work as a home care attendant because “the 

Commissioner will not give ‘any special significance’ to the source of an opinion on 

issues reserved to the Commissioner” and because his “opinion states nothing of 

Plaintiff’s functional capabilities.” Both contentions are incorrect. 

The Commissioner has final responsibility for determining whether a claimant 

meets the statutory definition of disability, and a statement by a medical source that the 

claimant is “disabled” or “unable to work” is not controlling. 20 C.F.R. §§ 404.1527(d), 

416.927(d). The Commissioner considers opinion evidence along with other evidence 

regarding the nature and severity of a claimant’s impairments and a claimant’s residual 

functional capacity, but the Commissioner does not give any special significance to the 

source of an opinion on such issues. Id. In other words, an opinion from a treating 

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source on such issues is not given greater weight than one from a non-treating source. 

Thus, the ALJ did not err by considering Dr. Hurd’s opinion on issues reserved to the 

Commissioner just as he would such opinions from other sources, considering its 

consistency with Plaintiff’s statements and with the objective evidence, without 

abdicating his responsibility for deciding the ultimate issue of whether Plaintiff is capable 

of performing her past relevant work as a home health caregiver. 

Further, Dr. Hurd’s examination report stated a great deal about Plaintiff’s 

functional capabilities. On August 7, 2009, Dr. Hurd examined Plaintiff and wrote a 

detailed examination report. He said “she freely admits that she is able to do all activities 

of daily living to include cooking, laundry, grocery shopping, cleaning house, doing the 

dishes.” Dr. Hurd said that Plaintiff “says she can walk for long periods of time, stand 

for prolonged periods of time, and also has no trouble sitting.” He also reported that 

Plaintiff said she could lift ten to twenty pounds comfortably. Dr. Hurd observed that 

Plaintiff moved easily on and off the examination table and between sitting and supine 

positions without any evidence of discomfort. Based on his observations, he stated that 

she was able to perform all of the physical exam maneuvers with very little effort or 

difficulty. He noted that testing of the shoulder muscles “revealed a very strong 

individual, 5/5 bilaterally.” He found normal range of motion in Plaintiff’s shoulders, 

wrists, hips, ankles, and feet. 

Dr. Hurd also said Plaintiff reported that she had seizures about once or twice a 

week and they last for 20 to 30 seconds. He concluded: 

Based upon the claimant’s history, the physical exam, and also my careful 

observation of the claimant, it is my professional opinion that Ms. Gaus is 

capable of work-related activities. Apparently she has had petit mal 

seizures since she was in the 8th grade with a similar pattern, and she has 

been able to work at least 16 to 18 years. Apparently in the past worked 

[sic], even though she has petit mal seizures, they have not interfered with 

her work as a home care attendant. I feel that she is certainly capable of 

doing this activity at this time. 

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The ALJ said he gave significant weight to Dr. Hurd’s opinion because it was consistent 

with the history described by Plaintiff as well as with his examination results. Even 

though the ALJ gave “significant weight” to Dr. Hurd’s opinion, the ALJ gave Plaintiff 

“the benefit of the doubt” and found her to be more limited than did Dr. Hurd. The ALJ 

did not err in his consideration and weighing of Dr. Hurd’s examination report. 

D. The ALJ Did Not Err by Relying on an Incomplete Hypothetical 

Question to the Vocational Expert. 

Plaintiff contends the ALJ erred by relying on the vocational expert’s opinion that 

Plaintiff is capable of performing her past relevant work as a home health caregiver 

because the hypothetical posed to the vocational expert did not include limitations that 

Dr. Morehead may have opined. The hypothetical included all of the limitations 

supported by Dr. Morehead’s medical records. Thus, the ALJ did not err by relying on 

the vocational expert’s opinion. 

IT IS THEREFORE ORDERED that the final decision of the Commissioner of 

Social Security is affirmed. The Clerk shall enter judgment accordingly and shall 

terminate this case. 

Dated this 31st day of October, 2014. 

Neil V. Wake

United States District Judge 

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