Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-cand-3_05-cv-03345/USCOURTS-cand-3_05-cv-03345-0/pdf.json

Nature of Suit Code: 864
Nature of Suit: Social Security - SSID Title XVI
Cause of Action: 42:405 Review of HHS Decision (SSID)

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United States District Court

For the Northern District of California

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United States District Court

For the Northern District of California

IN THE UNITED STATES DISTRICT COURT

FOR THE NORTHERN DISTRICT OF CALIFORNIA

 

SENG PHOEUNG,

Plaintiff, 

 No C 05-03345 VRW

v

 ORDER

JO ANNE B BARNHART,

Commissioner of Social Security, 

 Defendant. 

_______________________________/

Plaintiff Seng Phoeung appeals from a decision of the

Social Security Administration denying benefits under Title XVI of

the Social Security Act. The parties have filed cross motions for

summary judgment. After careful review of the administrative

record, the court DENIES plaintiff’s motion and GRANTS defendant’s

motion.

//

//

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I

A

Plaintiff was born on July 3, 1958 in Cambodia. The

administrative record contains inconsistent statements regarding

plaintiff’s level of education. Plaintiff variously reported she

“has never had any education,” AR 120, had a sixth grade education,

AR 87, and had a second or third grade education, AR 255. In 1979,

plaintiff married Sun Phon. In 1982, the two immigrated to the

United States. After living for one year in New York and two years

in Texas, plaintiff and her husband settled in California.

The administrative record is also inconsistent as to

plaintiff’s facility with the English language. On June 3, 2004,

notes from a medical office visit indicated that plaintiff was

“speaking English quite well.” AR 25. On August 11, 2004, a

consultative medical examiner that reported plaintiff could speak

“no English.” AR 247. On September 7, 2004, plaintiff filed a

prehearing brief for the ALJ that reported plaintiff was “unable to

speak English.” AR 118. Plaintiff testified at her hearing on

November 30, 2004, however, that she could read and speak a little

bit of English. AR 277.

Plaintiff has four children, now approximately ages

eighteen to twenty-four. At the time of the hearing, plaintiff’s

only source of household income was cash aid for her youngest child

under the Aid To Families With Dependent Children (AFDC) program. 

AR 274. Plaintiff has never worked in the United States, AR 281,

and has not looked for a job in the past several years, AR 282. 

Plaintiff’s husband worked for three years after coming to the

United States but has not worked since coming to California in

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1985. AR 255. Plaintiff and her husband “constantly argue that

the other one should get a job.” Id.

B

Plaintiff filed for supplemental security income (SSI)

benefits on July 3, 2002. AR 69. In plaintiff’s application for

benefits, she claimed impairment due to high blood pressure,

diabetes, tuberculosis, high cholesterol, back pain, depression,

anxiety, insomnia and “heart and liver problems.” Id. Plaintiff

reported that her impairments began in June or July 1995. Id.

On November 7, 2002, internal medicine specialist Dr Amit

Rajguru administered a consultative medical examination. Dr

Rajguru noted no ataxia or dyspnea, AR 206, and that plaintiff had

a full strength in all extremities, AR 208. Plaintiff reported

right shoulder and right leg pain, but Dr Rajguru found no evidence

to support these claims. AR 205. Dr Rajguru concluded plaintiff

had “no functional limitations.” AR 208.

On November 13, 2002, licensed psychologist Dr Carol

Lewis-Wintrode administered, with the help of an interpreter, a

consultative evaluation. AR 211. Plaintiff reported insomnia and

memory and concentration problems. AR 212. After psychological

testing, Dr Lewis-Wintrode found that plaintiff had a short

attention span but plaintiff’s memory was “grossly intact” and

plaintiff could follow instructions and “complete the tasks with

moderate effort.” AR 214. Dr Lewis-Wintrode found no evidence of

hyperdistractibility or hyperactivity. Id. Dr Lewis-Wintrode

diagnosed plaintiff with probable borderline functioning but found

plaintiff could handle “ordinary job stresses.” AR 215-16.

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4

On December 6, 2002, Dr Mona Afary conducted an intake

interview of plaintiff. AR 224, 264. Plaintiff concedes that Dr

Afary is only a therapist and not a licensed psychologist. Pl Mot

(Doc #13) n2. In the interview, plaintiff reported nightmares and

insomnia. AR 224. Dr Afary noted “illiteracy” and diagnosed

plaintiff with posttraumatic stress disorder. AR 226. There is no

indication Dr Afary performed any psychological tests.

On January 3, 2003, the Social Security Administration

(SSA) determined that plaintiff was not disabled. AR 56. 

Plaintiff filed a request for reconsideration on March 4, 2003. AR

61. The prior decision was affirmed on July 21, 2003. AR 62. On

September 15, 2003, plaintiff requested a hearing before an

administrative law judge (ALJ). AR 67.

On May 14, 2003, plaintiff’s therapist, Dr Mona Afary,

reported that plaintiff complained of nightmares, insomnia and

depression, was “not able to focus or concentrate” and had “a poor

sense of orientation and memory.” AR 219, 220. Dr Afary claimed

that since plaintiff arrived in the United States, she had “not

been able to work due to her emotional and psychological problems,” 

AR 220, and had “not been able to make friends or acquaintances,” 

AR 221. In addition, Dr Afary asserted that plaintiff had “no

education,” could not follow “simple written or oral instructions”

and was “not able to keep a job.” AR 222. Dr Afary diagnosed

posttraumatic stress and major depressive disorders. Id.

On September 11, 2003, psychiatrist Dr James Gracer saw

plaintiff. AR 260, 265. The majority of Dr Gracer’s notes are

illegible. Even the legible portions often lack context because

they are preceded by unintelligible symbols or words.

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On August 11, 2004, plaintiff underwent a second medical

evaluation, this time with internal medicine specialist Dr Burton

Brody, aided by an interpreter. AR 247. Plaintiff reported

diabetes, high blood pressure, hypercholesterolemia, depression and

“tendency to headaches and light headedness,” and that she

“fatigues easily” although “[n]o complaint of bone, joint or muscle

pains.” Id. Dr Brody found “[h]ypertension controlled,” “[n]ormal

range of motion in all joints,” AR 248, and “no apparent

limitations on a medical basis.” AR 249.

On August 24, 2004, plaintiff underwent a second

consultative psychological exam administered by licensed

psychologist Dr Cecilia Hardey. AR 254. An interpreter was

present. Id. Dr Hardey noted that plaintiff “appeared to be

projecting blame onto other people, rather than taking

responsibility,” “was tearful and pessimistic” and was “somewhat

anxious” and “somewhat labile.” AR 254. Dr Hardey noted several

inconsistencies between plaintiff’s statements and Dr Afary’s

report including plaintiff’s length of disability and level of

education. AR 256. Plaintiff scored five out of fifteen on the

Rey Memory Test which “is not within normal limits and is

considered to be indicative of malingering.” AR 257. Plaintiff’s

performance on the Benton Visual Retention Test was “clearly

indicative of malingering.” Id. Dr Hardey did not find sufficient

criteria to diagnose clinical depression or post traumatic stress

disorder. Id. Dr Hardey concluded plaintiff had “the mental

ability to perform simple rote tasks, and could probably perform

even more complicated tasks with appropriate training.” AR 257-58. 

Dr Hardey’s report in the record is unsigned.

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6

On November 30, 2004, the ALJ held a hearing with

plaintiff, plaintiff’s attorney, a vocational expert and a

Cambodian interpreter present. AR 263. Plaintiff’s attorney

expressed regret about not having received notice that Dr Hardey

would be administering the psychological exam and stated that she

“would have liked to have had the opportunity to obtain additional

information from [plaintiff’s] treating source.” AR 268. The ALJ

asked, “how would sending her to Hardy have prevented you from

doing that?” Id. Plaintiff’s attorney stated she wished that SSA

had offered to pay the Jewish Family and Children Services clinic

for an assessment rather than Dr Hardey. Id.

Plaintiff introduced a report on a different patient

written by Dr Hardey that used similar language to plaintiff’s

report. AR 265. Plaintiff claimed that “Dr Hardey’s conclusions

are unreliable because they are based on a template or pattern that

she uses for multiple claimants.” AR 126. The ALJ entertained

this argument at length. AR 265.

Plaintiff’s attorney conceded that plaintiff’s “physical

impairments would permit light work.” AR 267. Plaintiff testified

to having headaches, AR 279, pain, AR 282, insomnia, AR 282,

trouble concentrating, AR 287, and shortness of breath, AR 287.

The vocational expert testified that the following jobs

required only light exertion and minimal English and were present

in significant numbers: small product assembler, dining room

attendant and sandwich maker. AR 288, 289.

A substantial volume of mostly illegible medical records

were also introduced as exhibits. A treatment note from September

17, 2002 reported that plaintiff had “no problems.” AR 187. On

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August 28, 2001, plaintiff reported she felt nervous but slept

well. AR 192. A treatment note from August 14, 2001 indicated

plaintiff was “nervous,” “feeling sad” and sleeping well. AR 195.

C

The ALJ issued a decision on February 23, 2005. AR 16. 

In the decision, the ALJ noted plaintiff had “variously alleged

that she has no education whatsoever, two or three years of

education and six years of education,” but found “six years of

education based on her signed statement on her Disability Report.” 

Id. The ALJ also quoted plaintiff’s statement to her physician she

had “no problems” on September 17, 2002.

The ALJ then reviewed the medical evidence. Dr Rajguru

found that plaintiff had blood pressure “within normal limits” and

had “normal reflexes and sensation” and plaintiff’s allegations of

right shoulder and leg pain were “without any objective findings.”

AR 16. Similarly, the ALJ noted that Dr Brody’s examination found

“no limitation” and SSA review concluded there was “no severe

impairment.” AR 16-17. The ALJ gave these weight as “supported by

objective medical evidence.” AR 17.

Next, the ALJ reviewed Dr Lewis-Wintrode’s findings that

plaintiff “was able to focus and complete tasks presented with

moderate effort” and that plaintiff had “no significant workrelated limitations.” AR 17. Of the Hardey report, the ALJ stated

that “the only diagnosis Dr Hardey was able to make was an Axis I

diagnosis of probable malingering.” Id.

The ALJ found that Dr Afary’s report and intake interview

notes were not entitled to significant weight because of many

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discrepancies between Dr Afary’s report and other evidence. AR 17. 

First, the ALJ noted that Dr Afary asserted that plaintiff was

disabled by her mental impairments for twenty-one years but

plaintiff only claimed to have had a mental impairment for two to

three years. Id. Second, Dr Afary claimed plaintiff was unable to

focus and had impaired memory but Dr Lewis-Wintrode found

plaintiff’s memory intact and plaintiff able to focus. Third, Dr

Afary alleged plaintiff was “not able to keep a job” although

plaintiff testified that she had not looked for work. Fourth, Dr

Afary reported that plaintiff had no education while plaintiff

elsewhere reported a variety of educational levels. Fifth, Dr

Afary stated that plaintiff was unable to follow simple

instructions, but Dr Lewis-Wintrode found plaintiff able to follow

simple instructions without difficulty. Because of these

discrepancies, the ALJ gave “little weight to Dr Afary’s opinion

and conclusions.” AR 17.

The ALJ also found plaintiff’s credibility to be poor

because plaintiff inconsistently reported her education and

facility with English and because plaintiff “clearly and

deliberately malingered” during Dr Hardey’s exam. AR 17. In

addition, the ALJ noted that plaintiff may have made allegations of

disability for secondary gain because only one of plaintiff’s

children was young enough to receive AFDC, AFDC was plaintiff’s

only source of income and plaintiff complained there was “no money

for rent, no food in the house and no money coming in.” AR 17-18.

In summary, the ALJ found that plaintiff “provided no

evidence showing any impairment that poses more than minimal

limitations upon her ability to perform simple, unskilled work

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existing in significant numbers in the national economy.” AR 18. 

Accordingly, the ALJ found that plaintiff did not have a “severe”

impairment. Id.

The Appeals Council denied plaintiff’s request for

review. Having received a final decision, plaintiff timely filed

her action seeking judicial review under 42 USC § 405(g).

II 

The Social Security Act provides supplemental income to

individuals who have attained age 65 or are blind or disabled. 42

USC § 1381. Plaintiff claims disability under Title XVI of the

Social Security Act. AR 69.

The SSA’s regulations specify in detail how an ALJ must

determine whether a claimant is disabled. 20 CFR § 416.920. The

regulations set forth a five-step sequential process for ALJs to

use in evaluating claims of disability: (1) first, the ALJ

considers whether the claimant is currently employed in substantial

gainful activity; (2) if not, the second step asks whether the

claimant has a severe impairment; (3) in step three, the ALJ

determines whether the claimant has a condition which meets or

equals any listed condition according to the criteria set forth in

the Listings of Impairments in Appendix 1, Subpart P of Par 404;

(4) if the claimant does not have such a condition, step four asks

whether the claimant can perform her past relevant work; (5) if

not, in step five the ALJ considers whether the claimant has the

ability to perform other work which exists in substantial numbers

in the national economy. 20 CFR § 416.960(c).

//

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After the SSA has made a final determination, the

applicant may request judicial review through a civil action filed

in the district court. 42 USC § 405(g). On review, the district

court will overturn the SSA’s decision only if it is not supported

by substantial evidence or is based on legal error. Moisa v

Barnhart, 367 F3d 882, 885 (9th Cir 2004). Substantial evidence

means such relevant evidence as a reasonable mind might accept as

adequate to support a conclusion. Young v Sullivan, 911 F2d 180,

183 (9th Cir 1990). While inferences from the record can

constitute substantial evidence, only those reasonably drawn from

the record will suffice. Widmark v Barnhart, 454 F3d 1063, 1066

(9th Cir 2006). If evidence is susceptible to more than one

rational interpretation, one of which supports the ALJ's decision,

the ALJ's conclusion must be upheld. Thomas v Barnhart, 278 F3d

947, 954 (9th Cir 2002).

When reviewing medical evidence, the ALJ must evaluate

every medical opinion received. 20 CFR § 416.927(d). Medical

opinions are statements from acceptable medical sources that

reflect judgments about the nature and severity of the claimant’s

impairment(s). 20 CFR § 416.927(a)(2). SSA distinguishes between

“medical sources” which include licensed physicians and

psychologists, 20 CFR § 416.913(a)(2), and “other sources” which

include nurse practitioners, physicians’ assistants, naturopaths,

chiropractors, audiologists, and therapists, 20 CFR §

416.913(d)(1). The ALJ may give opinions from “other sources” less

weight than opinions from acceptable medical sources. Gomez v

Chater, 74 F3d 967, 970-71 (9th Cir 1997).

//

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III

Plaintiff challenges the ALJ’s decision on six grounds. 

The court finds each of plaintiff’s arguments to be without merit.

A

First, plaintiff argues that the ALJ failed to consider

Dr Gracer’s treatment note and that “a competent treating

physician’s opinion cannot be disregarded without comment.” Doc

#13. SSA rules require consideration of every medical opinion in

the record. 20 CFR § 416.927(d). The ALJ, however, need not

discuss every piece of evidence. Howard ex rel Wolff v Barnhart,

341 F3d 1006, 1012 (9th Cir 2003).

Dr Gracer’s notes are largely illegible. AR 260. 

Legible portions such as “insomnia,” “cries a lot” and “sleep - 4

hours only” are plaintiff’s subjective complaints. Also legible

are the words “dep’d affect, calm, alert, casual, friendly.” The

presenting problem of “PTSD” is clearly labeled. The individual

words “lexapro,” “traz,” “dysthymia” and “Maj Dep” are also

legible. The words or symbols adjacent to these terms are

indecipherable.

Plaintiff contends that Dr Gracer’s notes show he “noted

Plaintiff’s complaints of frequent crying and insomnia and, during

a mental status exam, observed a depressed mood and affect.” Doc

#13. Contrary to plaintiff’s characterization, there is no

evidence Dr Gracer performed a mental status exam. Dr Gracer did

write down plaintiff’s subjective complaints. These subjective

complaints, however, are cumulative to plaintiff’s testimony and

other evidence in the record. For example, Dr Gracer observed

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plaintiff had a “dep’d affect.” AR 260. Dr Lewis-Wintrode

reported plaintiff “was remarkable for not smiling.” AR 211.

Plaintiff contends that “Dr Gracer diagnosed Major

Depression and Dysthymia.” Doc #13. Careful examination by the

court reveals no intelligible diagnosis. The words “dysthymia” and

“Maj Dep” are legible. The preceding word or symbol is

indecipherable, possibly indicating the condition was diagnosed,

suspected or successfully treated. Because of the lack of context,

the court finds no intelligible diagnosis.

Plaintiff argues these notes show Dr Gracer “prescribed

Lexapro and Trazodone.” It is unclear if the circled P means

plaintiff was already taking these prescriptions before the exam or

if Dr Gracer prescribed these medications as a result of the exam. 

Without a context, no meaning is imputed to these isolated words. 

Even if Dr Gracer’s note did show a prescription for Lexapro and

Trazodone, this merely duplicates Dr Brody’s evaluation which

indicated Lexapro and Trazodone were among plaintiff’s current

medications. AR 247.

As Dr Gracer’s note is of little evidentiary value, the

ALJ was not required to address it in his decision.

B

Plaintiff argues that the ALJ failed to evaluate Dr

Afary’s report as a “medical opinion” under 20 CFR § 416.927(d)

which lists “factors in deciding the weight [given] to any medical

opinion.” Dr Afary’s report was an “other source” not a “medical

opinion,” because Dr Afary was not a licensed psychologist. Doc

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#13 n2. Accordingly, the ALJ need not use the 20 CFR § 416.927(d)

factors in weighing Dr Afary’s report.

Plaintiff further argues that the ALJ erred by assigning

little weight to Dr Afary’s report. SSA rules allow the ALJ “to

accord opinions from other sources less weight than opinions from

acceptable medical sources.” Gomez v Chater, 74 F3d 967, 970-71

(9th Cir 1997). Accordingly, the ALJ was allowed to give less

weight to Dr Afary’s report.

In addition, the lack of objective signs and medical

findings justifies the ALJ’s decision to give Dr Afary’s report

little weight. “The more a medical source presents relevant

evidence to support an opinion, particularly medical signs and

laboratory findings, the more weight we will give that opinion.” 

20 CFR § 416.927(d)(3). Dr Afary asserted plaintiff had “a poor

sense of orientation and memory.” Dr Afary apparently did not

perform any objective memory tests such as those administered by Dr

Lewis-Wintrode. Because Dr Afary did not use objective

psychological tests to support her statements, the ALJ was

justified in giving Dr Afary’s report little weight.

In addition, the inconsistencies between Dr Afary’s

report and other evidence in the record justify giving Dr Afary’s

report little weight. The ALJ noted that “Dr Afary asserts that

the claimant has been disabled by mental impairments for 21 years,

but the claimant alleges that she has had a mental impairment for

only 2 to 3 years.” AR 17.

Plaintiff argues that “[i]t is possible that [Dr Afary]

believes that this Plaintiff has been suffering psychologically for

many years and that the Plaintiff lacked insight or recognition of

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her suffering.” Doc #13. The existence of an alternative

interpretation of the evidence is not a sufficient reason to

reverse a decision by the ALJ. “Where the evidence is susceptible

to more than one rational interpretation, one of which supports the

ALJ's decision, the ALJ's conclusion must be upheld.” Thomas v

Barnhart, 278 F3d 947, 954 (9th Cir 2002). Dr Afary’s report

states that “[d]uring her 21 years of living in the US, [plaintiff

had] not been able to work due to her emotional and psychological

problems.” AR 220. A rational person could have interpreted this

statement as factually inconsistent with plaintiff’s claims.

The ALJ also identified inconsistencies with respect to

plaintiff’s inability to focus and impaired memory. Dr Afary

stated that plaintiff was “unable to focus or concentrate” and had

“poor sense of orientation and memory.” AR 220. Dr LewisWintrode’s mental status examination revealed that plaintiff was

“oriented in all dimensions” and “was able to focus on the tasks”

and plaintiff’s “immediate memory for daily events and remote

memory for past events was grossly intact.” AR 213-14. A rational

person could find these statements to be factually inconsistent.

The ALJ also noted that Dr Afary asserted that plaintiff

was “not able to keep a job,” but plaintiff testified she had never

worked in the United States. Plaintiff argues that this

inconsistency is irrelevant because it is unrelated to Dr Afary’s

conclusion. Doc #13. Plaintiff cites no law in support of this

proposition. Further, the ALJ reasonably questioned the

credibility of the report, not its conclusion.

Plaintiff next argues that the ALJ was required by 20 CFR

§ 416.912(e) to recontact Dr Afary to gain insight into the

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inconsistencies in Dr Afary’s report. This rule, however,

explicitly applies only to “evidence we receive from your treating

physician or psychologist or other medical source.” Dr Afary is

not a physician, psychologist or medical source, so 20 CFR §

416.912(e) does not apply.

In addition, the court notes a further inconsistency not

identified by the ALJ. Dr Afary asserted that plaintiff had “not

been able to make friends or acquaintances in the two decades that

she has lived in the US.” AR 221. In a Daily Activities

Questionnaire dated October 30, 2002, plaintiff listed two names as

friends. AR 104. In addition, plaintiff testified “my friend

comes to take me to their house and we go there and just hang out

singing and eating.” AR 285.

The ALJ’s decision to give little weight to Dr Afary’s

report is legally correct and factually reasonable because Dr Afary

is an “other source,” Dr Afary did not conduct psychological tests

and Dr Afary’s report contains multiple factual inconsistencies.

C

Plaintiff argues the ALJ erred in finding that plaintiff

did not have a “severe” impairment in step two of the disability

evaluation process. Step two is a screening device to dispose of

groundless claims. Webb v Barnhart, 433 F3d 683, 687 (9th Cir

2005). The court must determine whether substantial evidence in

the record supports the conclusion that plaintiff did not have a

medically severe impairment or combination of impairments. Id.

Plaintiff points to the evidence from Dr Gracer and Dr

Afary as establishing posttraumatic stress disorder and depression. 

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As discussed above, Dr Afary’s evidence was reasonably discounted

by the ALJ and Dr Gracer’s notes did not contain any intelligible

diagnoses. Dr Lewis-Wintrode noted that plaintiff “did indicate

symptoms of depression,” but did not diagnose depression or

posttraumatic stress disorder. AR 214. Dr Hardey noted that there

“did not appear to be sufficient evidence to meet the criteria for

a diagnosis of clinical depression or post traumatic stress

disorder.” AR 257. Dr Lewis-Wintrode found that plaintiff

“appears to have the ability to handle ordinary job stresses” and

“can handle simple tasks.” AR 216. The record is devoid of any

objective evidence of any psychological impairments.

The record similarly lacks objective evidence of physical

impairments. Dr Brody reported “no apparent limitations on a

medical basis.” AR 249. Dr Rajguru concluded plaintiff had “no

functional limitations” at the time of the exam. AR 208.

Plaintiff contends “there is conflicting evidence of the

severity of Plaintiff’s impairments.” Doc #13. In fact, there is

no evidence of any significant physical or mental impairment. 

Accordingly, the court finds substantial evidence in support of the

ALJ’s finding of no severe impairment at step two.

Plaintiff also argues that the ALJ failed to apply the

special technique in evaluating the severity of mental impairments

prescribed by 20 CFR § 416.920a. Under the special technique, the

ALJ will first “determine whether you have a medically determinable

mental impairment.” 20 CFR § 416.920a(b)(1). If the ALJ finds a

medically determinable impairment, the ALJ must “rate the degree of

functional limitation resulting from impairments.” As noted above,

there is no objective or medical opinion evidence of any mental

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impairment in the administrative record. Without a medically

determinable mental impairment, the ALJ need not rate the degree of

functional limitation.

The ALJ’s decision that plaintiff did not have a severe

impairment was supported by substantial evidence.

D

Plaintiff argues that the ALJ’s reasons for finding

plaintiff’s testimony not credible were insufficient. The ALJ

noted that plaintiff inconsistently reported her educational

background. AR 17. Plaintiff argues that this inconsistency is

“immaterial,” citing no law or rule in support of this proposition. 

Plaintiff alternately attributes the inconsistency to “memory

impairment.” But Dr Lewis-Wintrode found that plaintiff’s

“immediate memory for daily events and remote memory for past

events was grossly intact.” AR 214. The court does not find

either of plaintiff’s arguments convincing.

The ALJ also found that plaintiff had not been truthful

about her facility with English. AR 17. Plaintiff argues the ALJ

cites no evidence to support this. Yet the record contains

numerous inconsistent statements already noted in Part IA, supra. 

In addition, plaintiff reported on her Daily Activities

Questionnaire of October 30, 2002 that she “can’t read.” AR 101. 

Dr Lewis-Wintrode reports that plaintiff “is able to read in her

native language.” AR 212. Plaintiff testified at trial to be able

to “read a little bit” of English. AR 277.

Finally, plaintiff argues that the ALJ should not have

relied on Dr Hardey’s report suggesting deliberate malingering to

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support a finding of poor credibility. Plaintiff contends that Dr

Hardey’s report was unreliable because it highlighted

inconsistencies between Dr Afary’s report and information obtained

directly from plaintiff. AR 125-26. But closely reading source

material, double-checking facts and reporting on inconsistencies

makes a report more, rather than less, reliable.

Plaintiff also argues that Dr Hardey’s report is based on

a template. In support, plaintiff submitted a redacted report from

another patient. Plaintiff appears to suggest that the template

was not changed and that plaintiff’s report contains information

not from plaintiff’s examination. This argument was entertained by

the ALJ at the hearing. AR 265. It is unlikely that quantitative

test results would be present in a template.

In addition, it is highly unlikely that a result noted in

numerous places in the report could be the result of failure to

change a template. The suggestion of malingering is present in

multiple places in Dr Hardey’s report: plaintiff’s score of five

out of fifteen on the Rey Fifteen Item Memory Test was “not within

normal limits” and “considered to be indicative of malingering,”

plaintiff’s performance on the Benton Visual Retention Test “was

clearly indicative of malingering,” plaintiff “failed every item”

which is “very unusual as even very severely impaired people

usually can reproduce the first few (easiest) forms.” AR 257. Dr

Hardey gave a diagnosis of “probable malingering” and concluded

that “applicant appeared to be malingering.” Id. Plaintiff has,

at best, circumstantial evidence for the claim that Dr Hardey uses

a template to prepare reports. The ALJ was entitled to include

this report in the record. Moreover, in practice, the ALJ found Dr

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Hardy’s report of limited usefulness because Dr Hardey was unable

to diagnose anything other than possible malingering.

Plaintiff argues that the ALJ “seems to have assumed that

having a low income means that the Plaintiff has a financial

incentive to lie.” Doc #13. Plaintiff is correct that a low

income, by itself, is not a valid reason for finding a claimant to

be not credible.

The ALJ, however, appears to identify “secondary gain” as

a possible motive rather than an independent ground for finding

poor credibility. Notably, the ALJ speculated that plaintiff “may

be making her allegations of disability for secondary gain.” AR

17. In contrast, the ALJ stated definitively that plaintiff “has

not been forthcoming” and “deliberately malingered.” Id. The

ALJ’s use of conditional language with regard to “secondary gain”

indicates this was a possible motive rather than an independent

ground for finding plaintiff to have poor credibility.

In addition, the ALJ could have discounted plaintiff’s

testimony as inconsistent with objective medical evidence. 

“[T]here must be medical signs and laboratory findings which show

that you have a medical impairment.” 20 CFR § 416.929(a). As

discussed in part IIIC supra, plaintiff has not produced any

objective evidence of impairment.

The ALJ’s decision to discount plaintiff’s testimony was

supported by substantial evidence.

E

Plaintiff argues the ALJ erred by failing to rule on

plaintiff’s objection to the admission of Dr Hardey’s consultative

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psychological examination report. Plaintiff cites 20 CFR §

416.1439, which relates to “the issues to be decided at the

hearing.” Because the content of the record is not an issue “to be

decided at the hearing,” 20 CFR § 416.1439 does not apply.

Plaintiff’s prehearing letter to the ALJ dated November

23, 2004 appears to be an objection under 20 CFR § 416.919j, which

states that “[y]ou or your representative may object to your being

examined by a medical source we have designated” and “[i]f there is

a good reason for the objection, we will schedule the examination

with another medical source.” Plaintiff’s attorney testified that

she did receive notice a consultative exam would be scheduled but

“didn’t realize that it would be with Dr Hardy.” AR 265. If

plaintiff’s representative wanted to know with whom the examination

was scheduled, she should have called to find out. Objections

under 20 CFR § 416.919j must be made before the examination has

occurred. Plaintiff’s objection is not timely.

Even if the ALJ failed to rule on a motion plaintiff

made, the error was harmless. When plaintiff argued at the hearing

that Dr Hardey’s report was unreliable, the ALJ directly asked how

plaintiff’s consultation with Hardey prevented her from obtaining

additional information. AR 268. Plaintiff failed to allege harm

either at the hearing or in her motion for summary judgment.

F

Plaintiff also argues that the ALJ improperly relied on

Dr Hardey’s unsigned examination report. The SSA “will not use an

unsigned or improperly signed consultative examination report” to

deny benefits. 20 CFR § 416.919o(b).

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The ALJ appears to have relied on Dr Hardey’s report only

insofar as its reports of malingering threw doubt on plaintiff’s

credibility. Dr Hardey’s report, moreover, was not the only ground

for questioning plaintiff’s credibility. Defendant correctly notes

that the ALJ did not rely on Dr Hardey’s report at all in making

plaintiff’s disability determination because “the only diagnosis Dr

Hardey was able to make was * * * probable malingering.” AR 17. 

The ALJ did not rely on Dr Hardey’s report in finding that

plaintiff’s disability was not severe.

The ALJ’s reliance on Dr Hardey’s unsigned report was,

therefore, harmless error.

IV

The ALJ’s decision was supported by substantial evidence. 

The legal errors identified were minor and, moreover, harmless. 

Accordingly, the clerk shall enter judgment in favor of defendant

and against plaintiff. The clerk shall close the file and

terminate all pending motions.

IT IS SO ORDERED.

 

VAUGHN R WALKER

United States District Chief Judge

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