Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-alnd-2_15-cv-00204/USCOURTS-alnd-2_15-cv-00204-0/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 (DIWC)

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UNITED STATES DISTRICT COURT

NORTHERN DISTRICT OF ALABAMA

SOUTHERN DIVISION

SHARON DENISE CAMERON, )

)

Plaintiff )

)

vs. ) Case No. 2:15-cv-00204-HGD

)

COMMISSIONER, SOCIAL SECURITY )

ADMINISTRATION, )

)

Defendant )

MEMORANDUM OPINION

Plaintiff, Sharon Denise Cameron, protectively filed applications for

Supplemental Security Income (SSI), a period of disability, and disability benefits(DIB)

on February 17, 2012, alleging that she became disabled on November 1, 2010. The

Agencydenied her applications.Plaintiffrequestedahearingbeforeanadministrative law

judge (ALJ). A hearing was held in September 2013. (Tr. 31-81). The ALJ found

plaintiff to be not disabled by a decision rendered on September 27, 2013. (Tr. 11-23).

The Appeals Counsel denied plaintiff’s request for review on December 4, 2014.

Plaintiff appealed and his claim is now ripe for review pursuant to 42 U.S.C. §§405(g)

and 1383(c)(3).

FILED

 2016 Mar-30 PM 12:49

U.S. DISTRICT COURT

N.D. OF ALABAMA

Case 2:15-cv-00204-HGD Document 14 Filed 03/30/16 Page 1 of 16
I. ALJ Decision

Disability under the Act is determined under a five-step test. 20 C.F.R.

§ 404.1520. First, the ALJ must determine whether the claimant is engaging in

substantial gainful activity. 20 C.F.R. § 404.1520(a)(4)(i). “Substantial work activity”

is work that involves doing significant physical or mental activities. 20 C.F.R. §

404.1572(a). “Gainful work activity” is work that is done for pay or profit. 20 C.F.R. §

404.1520(b). Second, the ALJ must determine whether the claimant has a medically

determinable impairment or a combination of medical impairments that significantly

limits the claimant’s ability to perform basic work activities. 20 C.F.R. §

404.1520(a)(4)(ii). Absentsuch impairment, the claimant may not claim disability. Id.

Third, the ALJ must determine whether the claimant’s impairment meets or medically

equals the criteria listed in 20 C.F.R. § 404, Subpart P, Appendix 1. See 20 C.F.R. §§

404.1520(d), 404.1525 and 404.1526. If such criteria are met, the claimant is declared

disabled. 20 C.F.R. § 404.1520(a)(4)(iii).

If the claimant does not fulfill the requirements necessary to be declared disabled

under the third step, the ALJ may still find disability under the next two steps of the

analysis. TheALJfirstmustdetermine the claimant’sresidualfunctional capacity (RFC),

which refers to the claimant’s ability to work despite his impairments. 20 C.F.R. §

404.1520(e). In the fourth step, the ALJ determines whether the claimant has the RFC

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to perform past relevant work, 20 C.F.R. § 404.1520(a)(4)(iv). If the claimant is

determined to be capable of performing past relevant work, then the claimant is deemed

not disabled. Id. If the ALJ finds that the claimant is unable to perform past relevant

work, then the analysis proceeds to the fifth and final step. 20 C.F.R. §

404.1520(a)(4)(v). In the last part of the analysis, the ALJ must determine whether the

claimant is able to perform any other work commensurate with his RFC, age, education

and work experience. 20 C.F.R. § 404.1520(g). Here, the burden of proof shifts from

the claimant to the ALJ to prove the existence in significant numbers of jobs in the

national economy that the claimant can do given the RFC, age, education and work

experience. 20 C.F.R. §§ 404.1520(g) and 404.1560(c).

Following thisfive-step procedure, the ALJfound that plaintiff hasthe following

severe impairments: paranoid schizophrenia and bipolar disorder. However, the ALJ

found that these conditions did not preclude all work by plaintiff. (Tr. 16). The ALJ

further found that plaintiff’s condition did not meet or medically equal the severity of

one of the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1. 20 C.F.R.

§§ 404.1520(d), 404.1520(d), 404.1525, 404.1526, 416.920(d), 416.925 and 416.926.

(Tr. 17).

The ALJ determined that plaintiff had theRFCto performa full range of all work

at all exertional levels but with the following non-exertional limitations: the plaintiff is

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able to performsimple routine, and repetitive tasksin awork environmentfree fromfastpacedproductionrequirements;involvingonlysimplework-relateddecisions and routine

workplace changes; with no interaction with the public, and only occasional interaction

with co-workers; and no tandem tasks. (Tr. 18).

The plaintiff was 25 years old with no past relevant work experience at the time

of the ALJ’s decision. (Tr. 21-22). Based on the testimony of a vocational expert (VE),

the ALJ found that someone with plaintiff’s limitations would be able to perform the

requirements oftheoccupations of cleaner,food preparationworker, andkitchenworker,

all of which have available jobs in the local and national economy. (Tr. 22).

II. Plaintiff’s Argument for Reversal

Plaintiff assertsthat theCommissioner’s decision should be reversed because the

ALJ failed to consider key portions of the opinion of Dr. Robert Estock, a reviewing

physician. (Doc. 11, Plaintiff’s Brief, at 3). Dr. Estock opined that plaintiff could

perform unskilled work involving simple tasks, would miss one to two days per month,

and could benefit from a flexible schedule. (Tr. 21). The ALJ further stated that,

although this opinion was considered, he believed that the record as a whole suggests

greater difficultieswith socialinteraction due to plaintiff’smental health symptoms. (Tr.

21). Plaintiff asserts that the ALJ’s decision does not address the absenteeism issue as

it relates to plaintiff’s case, made significant by the fact that the VE testified that an

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employer would tolerate no more than one to one and a half days of unscheduled

absences per month. (Tr. 77; Doc. 11, Plaintiff’s Brief, at 4-5).

III. Standard of Review

Judicial review is limited to whether the record reveals substantial evidence to

sustain the ALJ’s decision,see 42 U.S.C. § 405(g); Walden v. Schweiker, 672 F.2d 835,

838 (11th Cir. 1982), and whether the correct legal standards were applied. See Lamb

v. Bowen, 847 F.2d 698, 701 (11th Cir. 1988); Chester v. Brown, 792 F.2d 129, 131

(11th Cir. 1986). Title 42 U.S.C. § 405(g) mandates that the Commissioner’s findings

are conclusive if supported by “substantial evidence.” Martin v. Sullivan, 894 F.2d

1520, 1529 (11th Cir. 1990). The district court may notreconsider the facts, re-evaluate

the evidence, or substitute its judgment for that of the Commissioner; instead, it must

review the final decision as a whole and determine if the decision is reasonable and

supported by substantial evidence. See id. (citing Bloodsworth v. Heckler, 703 F.2d

1233, 1239 (11th Cir. 1983)).

Substantial evidence fallssomewhere between a scintilla and a preponderance of

evidence; “[i]t issuch relevant evidence as a reasonable personwould accept as adequate

to support a conclusion.” Martin, 894 F.2d at 1529 (quoting Bloodsworth, 703 F.2d at

1239) (other citations omitted). If supported by substantial evidence, the

Commissioner’s factual findings must be affirmed even if the evidence preponderates

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against the Commissioner’s findings. See Martin, 894 F.2d at 1529. While the court

acknowledgesthatjudicialreviewoftheALJ’sfindingsislimited in scope,the court also

notes that review “does not yield automatic affirmance.” Lamb, 847 F.2d at 701.

IV. Evidence

In his decision, the ALJ notesthat plaintiff claimsthatshe became unable to work

in November 2010 because her paranoia became worse and she thought someone was

trying to kill her. She was hospitalized in late November 2010 because she would not

leave her house. She acknowledged that she was not taking her medication prior to her

hospitalization. She further stated that, when she took her medication, it helped a lot.

She was discharged with medications, but did not immediately follow up. (Tr. 19).

Plaintiff did begin to be seen on a monthly basis by Dr. Rachel Julian, M.D., a

psychiatrist. Dr.Julian adjusted her medication due to side effects. Plaintiffreportsthat

her current medication does not cause side effects. However, she asserts that she

continuesto see things on thewall, hear voices daily, and have panic attacksthree to four

times per week despite medication. (Id.)

Plaintiff testified that she lives with her mother in an apartment, that her mother

performs all the household chores, and thatshe provides no assistance. She testified that

the day before her hearing before the ALJ, she got up, showered, ate breakfast, read a

magazine, and went outside and down the street to get the mail. She stated that she

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generally spends her days watching television and going to the store with the help of her

mother. (Id.).

The ALJ found that there is evidence that plaintiff suffers from medically

determinable impairments that could reasonably be expected to cause the alleged

symptoms, but that her statements concerning the intensity, persistence and limiting

effects of these symptoms are not entirely credible. (Id.).

According to the ALJ, the evidence as a whole shows that plaintiff is capable of

performing unskilled work with limited social interaction, as set forth in the RFC. He

noted that plaintiffwas hospitalized inNovember 2010 for approximately oneweekwith

command hallucinations. She was not taking her prescribed medication at that time.

However, her symptoms improved significantly with medication. (Id.).

She received no further mental health treatment until April 2011, when she began

seeing Dr.Julian. She reported symptoms of auditory hallucinations and depression had

increased without proper medication. Her symptoms improved with medication.

Treatment notes in May 2011 show that plaintiff was going to the store and doing

housework, despite hermental health symptoms. InAugust 2011,shewasspending time

with her extended family. Contrary to her hearing testimony, plaintiff reported in

November 2011 thatshe was helping her momaround the house. She also stated that her

auditory hallucinations had decreased. In January 2012,she reported thatshe wanted to

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find employment. Dr. Julian offered to increase her medication due to reports of

incoherent mumbling; however, plaintiff declined. In April 2012, treatment notes

indicate that plaintiff’s goal was to be working within the next year. (Tr. 19-20).

Treatment notesfrom July 2012 reflect that plaintiff’s hallucinations were better.

September 2012treatment notesindicate thatshehad stopped taking hermedications and

was experiencing paranoid thoughts and auditory hallucinations. After restarting

medications, her condition improved. In December 2012, plaintiff reported that her

medications were working well. She reported the same in March 2013. In April 2013,

Dr.Julian noted only mild to moderate symptoms. However, plaintiff reported thatshe

was scared to go out of her house. In May 2013, Dr. Julian noted mild to moderate

symptoms. Dr. Julian noted mildly decreased memory and concentration, mild energy

problems and situational anxiety, and moderate problems with delusions and

hallucinations. Plaintiff reported that she was happy with her current medication. In

August 2013, Dr. Julian noted the same mild to moderate symptoms and that plaintiff

desired no medication changes. (Tr. 20).

According to the ALJ, in all, the treatment records show that plaintiff’s mental

health symptoms cause only mild to moderate functional limitations when plaintiff is

compliant with medication. (Id.). The ALJ noted that, despite this evidence in the

medical record, Dr. Julian provided medical source statements in May and September

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2013. In these statements, she opines that plaintiff’s mental health symptoms caused

mostly marked limitations in functioning, despite treatment notes suggesting, at most,

moderate functional limitations in 2013, as set out above. Accordingly, the ALJ gave

little weight to these statements because they contradicted her treatment notes. In

addition, there is also evidence in the record of malingering, as set out below. (Id.).

The ALJ also referenced the consultative examination of Dr. Dan Lowery, Ph.D.,

who examined plaintiff in July 2011. Dr. Lowery suspected malingering and noted that

the information provided by plaintiff was unreliable. He suspected malingering due to

her poor effort during thementalstatus examination,resulting in inconsistentresponses.

For example,shewas able to performsome simple arithmetic problems, while struggling

with others. She also mis-spelled the word “world.” The ALJ also made note ofthe fact

that plaintiff reported to Dr. Lowery thatshe prepared simple meals and did housework

as part of her daily activities although she testified that her mother performed all

household tasksincludingmeal preparation. TheALJ gave thisreportsignificantweight

in assessing plaintiff’s credibility. (Id.).

Dr. Sylvia Colon, M.D., examined plaintiff in July 2012. Dr. Colon noted that

plaintiff was a poor historian, with difficulty recalling dates and events of her illness.

Contrary to her testimony, plaintiff again reported daily activities including household

chores, laundry, washing dishes, simple cooking, grocery shopping, visiting with

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neighbors, taking walks, and going to the mall. Dr. Colon noted that plaintiff may have

been exaggerating her responses to calculations. Contrary to her examination by Dr.

Lowery, plaintiff was able to correctly spell the word “world” forward and backwards

during her evaluation by Dr. Colon. Plaintiff was able to do three-step commands, but

was unable to give responsesto abstract thinking questioning. Dr. Colon could not give

a functional assessment, but gave plaintiff a poor prognosis based on her history of noncompliance with medication. The ALJ gave great weight to Dr. Colon’s report in

assessing plaintiff’s credibility. (Tr. 21).

The ALJ found that the consultative reports lessened the credibility of plaintiff’s

allegations. She gave poor effort, exaggerated responses, and inconsistent responses

during the examinations. Further, her reported daily activities contradicted her hearing

testimony wherein she testified that she performs no household activities and goes

shopping only with family. (Id.).

In July 2011, Steven Dobbs, Ph.D., the state agency consultant, concluded that

there was insufficient evidence to assess plaintiff’s functioning due to possible

malingering and poor effort. In July 2012, Dr.RobertEstock,M.D., concluded thatthere

was insufficient evidence prior to plaintiff’s last insured date to assess her functioning

as it related to her Title II claim for benefits. However, the ALJ found that evidence

submitted at the hearing level established the existence of plaintiff’ssevere impairments

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prior to her date last insured. Regarding her Title XVI claim for benefits, Dr. Estock

opined that plaintiff could perform unskilled work involving simple tasks, would miss

one to two days of work per month, and could benefitfroma flexible schedule. The ALJ

stated that, although considered, the evidence of record as a whole suggests “greater

difficultieswith social interaction” as a result of plaintiff’smental health symptoms. (Tr.

21).

V. Discussion

Plaintiff contendsthat the ALJshould have included in his RFCfinding the State

agency psychological consultant’s opinion that plaintiff would miss one to two days of

work monthly which, based on the VE’s testimony, would preclude work.

While the ALJ’sRFCfinding does not include a limitation that plaintiff may miss

one to two days of work per month, the RFC is supported by the record as a whole. As

noted above, the ALJ considered treatment records from November 2010, when plaitiff

washospitalized for hallucination aftershe stopped takinghermedication. Her condition

improved markedly when she was put back on her medication. She went five months

before seeking psychiatric treatment again, supposedly due to financial difficulties. At

that time, she reported that she had been off her medication for two months and was

experiencing depression, paranoia and daily auditory hallucinations. Once placed back

on medication, her condition again improved to the point that she reported doing

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housework and going to the store. She also stated that her goal wasto be working in the

nextyear. InAugust 2011,hersymptomswere “verymanageable” andratednomore than

“mild” in severity. In November 2011, hersymptoms were again rated as no more than

mild, and plaintiff reported that her auditory hallucinations had decreased and that she

was helping with housework. Dr. Julian indicated that plaintiff’s condition was

improving.

Although plaintiffreported some hallucinationsin January 2012,she declinedDr.

Julian’s offer to increase her medication dosage. Hersymptoms were assessed as noneto-mild in severity. In April 2012, two months after applying for disability benefits,

plaintiff again stated that she hoped to secure employment in the next year.

In July 2012, her hallucinations had decreased and her symptoms were assessed

as none-to-moderate in severity. Plaintiff stopped taking her medication in September

2012, and reported hallucinations again. Dr.Julian restarted her on her medications and

by December 2012, her hallucinations were rated as mild, her mood wasstable, and she

reported that she felt that her medication was effective. In March 2013, plaintiff again

reported that she was feeling better on her medication, and Dr. Julian assessed her with

only mild symptoms. In August 2013, Dr.Julian indicated that plaintiff was doing well,

with a much-improved mood, no side effects, and auditory hallucinations that she was

able to ignore.

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Based on this evidence in themedicalrecord, the finding by the ALJ, that plaintiff

had only mild to moderate limitations when she was compliant with her medication, is

well supported. Furthermore, Dr. Julian did not suggest in any of her reports that

plaintiff’s condition would cause her to miss any work.

Likewise, the report of consultative examiner Dan Lowery, Ph.D., indicated that

plaintiff wassuspected of malingering during the mentalstatus examination and did not

indicate that her condition would cause her to miss any work.

Dr. SylviaColon also conducted a consultative examination and similarly opined

that plaintiff may have exaggerated the severity of her mental impairment. She also did

not indicate that plaintiff’s condition would cause her to miss one to two days monthly.

Only State agency psychological consultant Charles Estock, M.D., opined that

plaintiff may miss one to two days a month due to psychological symptoms. The ALJ

stated that he considered Dr. Estock’s opinion but found the evidence of record as a

whole supported greater difficultiesin social functioning than that found by Dr. Estock.

Accordingly, the ALJlimited plaintiff to occupations where she had no interaction with

the public and only occasional interaction with co-workers. A greater difficulty in social

functioning does not suggest that plaintiff may miss more days of work than those

suggested by Dr. Estock. Furthermore, Dr. Estock only opined that plaintiff may miss

work one to two days a month due to her psychologicalsymptoms. The ALJ considered

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plaintiff’s reported daily activities (which contrast greatly with her testimony at the

hearing)whereinsheadmitted toshopping, doing laundry, cookingsimplemeals, visiting

neighbors, and going to the mall. Accordingly, the ALJ found that her subjective

complaints were not entirely credible, and his stated RFC is an implicit rejection of the

conclusion that she would, in fact, miss two days of work a month. The objective

medical evidence and the other evidence considered by the ALJ, taken as a whole, do not

indicate that plaintiff’s condition caused limitations beyond those set forth in the ALJ’s

RFC findings. The ALJ adequately explained his reasons for making these findings.

Wilson v. Barnhart, 284 F.3d 1219, 1226 (11th Cir. 2002) (noting that the “ALJ made

a reasonable decision to reject [the claimant’s] subjective testimony, articulating, in

detail, the contrary evidence as his reasons for doing so”). There is simply no evidence

in the record to conclude that plaintiff would miss one to two days of work a month.

Although the VE testified that employers would normally tolerate only one to one and

a half missed days a month, remand is not necessary because, as noted above, Dr.

Estock’s opinion that plaintiff “may”miss one to two days per month was equivocal and

unsupported.

Plaintiff also complainsthat because the ALJ did not assign controlling weight to

the opinion of Dr. Julian, he should have, but failed, to indicate the weight that he gave

to Dr. Estock’s opinion. Plaintiff does not challenge the ALJ’s failure to give Dr.

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Julian’s opinion controlling weight. While the ALJ did not explicitly state the weight

that he gave Dr. Estock’s opinion, he discussed this opinion but stated that he found

plaintiff to be more limited regarding social functioning. Thus, it is clear that he gave

some weight to the opinion of Dr. Estock because theRFCfinding is consistent with Dr.

Estock’s opinion that plaintiff could perform simple, routine and repetitive tasks.

Thus, even assuming thattheALJshould have explicitly stated theweight he gave

to Dr. Estock’s opinion, the incorrect application of the regulations results in harmless

error because the correct application would not contradict the ALJ’s ultimate findings.

See Diorio v. Heckler, 721 F.2d 726, 728 (11th Cir. 1983). It is clear from the ALJ’s

decision that he properly evaluated all of the evidence in finding plaintiff not disabled.

Therefore, any failure to explicitly give the weight which he attributed to Dr. Estock’s

opinion was harmless.

VI. Conclusion

Because the court has determined that the hypothetical question contained all of

plaintiff’s credible limitations, assupported by the record, theALJ properly relied on the

VE’s testimony to determine the work plaintiff could perform. Because the ALJ’s

decision is supported by substantial evidence, the decision of the Commissioner is due

to be AFFIRMED. A separate order will be entered.

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DONE this 30th day of March, 2016.

HARWELL G. DAVIS, III

UNITED STATES MAGISTRATE JUDGE

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