Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-cand-3_06-cv-07548/USCOURTS-cand-3_06-cv-07548-3/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

NORTHERN DISTRICT OF CALIFORNIA

NAOMI STEVENSON,

Plaintiff,

 v.

MICHAEL J. ASTRUE, 

Commissioner of Social Security,

Defendant.

 

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No. 06-7548 SC

ORDER GRANTING

PLAINTIFF'S MOTION

FOR SUMMARY JUDGMENT

AND DENYING

DEFENDANT'S CROSSMOTION FOR SUMMARY

JUDGMENT

I. INTRODUCTION

This matter is before the Court on cross-motions for summary

judgment filed by the plaintiff Naomi Stevenson ("Plaintiff" or

"Claimant") and the defendant Michael J. Astrue ("Defendant"). 

Docket Nos. 12, 15. Plaintiff seeks review and reversal of the

Social Security Commissioner's final decision denying her claim

for Supplemental Security Income ("SSI") under Title XVI of the

Social Security Act. For the reasons set forth below, this Court

GRANTS Plaintiff's Motion for Summary Judgment and DENIES

Defendant's Motion for Summary Judgment.

II. BACKGROUND

Claimant, 47 years old at the time she filed her initial

disability claim in 2003, was born in 1956, completed high school,

and attended two years of college. Administrative Record ("AR")

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at 64, 89, 238-39. Claimant had worked steadily as a

receptionist, secretary, and cashier until approximately December

1999. Id. at 74. At that time, she was working as a cashier at

Ross Dress for Less but had to stop because of the pain brought on

by extended periods of standing. Id. at 86.

The parties agree that the medical evidence establishes that

Claimant suffers from impingement in the rotator cuff of her right

shoulder and has bilateral degenerative joint disease in both

knees. Id. at 26. In 1999, Claimant had two separate

arthroscopic procedures performed on her right knee. Id. at 198. 

In December 2003, Claimant applied for SSI benefits, alleging

disability beginning January 1, 2000. Id. at 73. After this

claim was denied at the initial and reconsideration stages,

Claimant requested an administrative hearing. Id. at 36-54. At

this hearing, held on May 25, 2005, Claimant testified before an

Administrative Law Judge ("ALJ"). Id. at 237. On July 12, 2005,

the ALJ denied Plaintiff's claim, a decision that became final on

May 12, 2006, when the Appeals Council declined to review the

ALJ's decision. Id. at 7. Plaintiff then filed a complaint

seeking review of the ALJ's decision with this Court on December

8, 2006. 

III. LEGAL STANDARD

Courts may set aside a decision of the ALJ if it is not

supported by substantial evidence. 42 U.S.C. § 405(g); Holohan v.

Massanari, 246 F.3d 1195, 1202 (9th Cir. 2001). "Substantial

evidence" is the relevant evidence which a reasonable person might

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accept as adequate to support the ALJ's conclusion. Reddick v.

Chater, 157 F.3d 715, 720 (9th Cir. 1998). In order to be

"substantial," the evidence must amount to "more than a

scintilla," but need not rise to the level of a preponderance. 

Holohan, 246 F.3d at 1202. Where the evidence could reasonably

support either affirming or reversing the ALJ's decision, a court

may not substitute its judgment for the ALJ's decision. Id. 

IV. DISCUSSION

The parties do not dispute the fact that Claimant suffers

from underlying medical impairments. The ALJ stated that he

"finds that claimant has bilateral knee arthritis and right

shoulder rotator cuff impingement and that these conditions

constitute a 'severe impairment' in that they have more than a

minimal effect on claimant's ability to work." AR at 23. The

only issue is whether the pain caused by these impairments is

significant enough to prevent Claimant from working at a sedentary

job. The ALJ found that Claimant's level of pain was not

sufficient to prevent her from working. Id. at 25, 26. Claimant

alleges that the ALJ erred in two respects: by rejecting the

opinion of Claimant's treating physician that Claimant's pain was

severe enough to prevent Claimant from working and by rejecting

Claimant's own testimony and documents regarding her pain. 

"Generally, a treating physician's opinion carries more

weight than an examining [or reviewing] physician's." Holohan,

246 F.3d at 1202. "Under the [Social Security Administration]

regulations, if a treating physician's medical opinion is

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supported by medically acceptable diagnostic techniques and is not

inconsistent with other substantial evidence in the record, the

treating physician's opinion is given controlling weight." Id.

(citing 20 C.F.R. § 404.1527(d)(2)). "An ALJ may reject the

uncontradicted medical opinion of a treating physician only for

clear and convincing reasons supported by substantial evidence in

the record." Id. (internal quotation marks omitted).

The ALJ essentially accepted all of the findings and opinions

of Claimant's treating physician, Dr. Kim, save for Dr. Kim's

opinion that Claimant's pain affected her concentration,

persistence, and pace to such an extent that it would seriously

interfere with the ability to perform simple, routine work on a

productive basis. AR at 24. Defendant concedes as much in his

summary judgment motion, stating that the "ALJ substantially

adopted Dr. Kim's assessment" regarding Claimant's functional

abilities but that "the ALJ disagreed with Dr. Kim's assessment

regarding concentration, persistence, and pace . . . ." Def.'s

Mot. for Summ. J. at 4-5.

The ALJ's justification for rejecting Dr. Kim's opinion of

Claimant's pain was based on the fact that the ALJ did not find

Claimant's testimony regarding her pain credible. AR at 25. In

his decision, the ALJ provided the following reasons for this

finding: Claimant "has not elected total knee replacement"; "[s]he

does not attend pain clinic nor has she attended Physical

Therapy"; she is "able to sit comfortable [sic], get on and off

the exam table and move about with the assistance of her cane";

she "reported that she was independent in her dressing, and able

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1

 It is not clear which doctor gave Claimant this

information.

5

to cook and prepare her own meals"; she "could wash dishes, take

out the garbage, vacuum, sweep and mop the floor"; and "[a]t times

she could do the laundry." Id. at 25. In light of these

activities, the ALJ concluded that "[t]hese activities suggest

that claimant's pain is not of the severity she alleges . . . . 

Thus the [ALJ] disagrees with Dr. Kim as to the effect of pain on

claimant's concentration, persistence, and pace." Id. 

For the reasons stated below, the Court finds that the ALJ's

justifications do not provide the clear and convincing reasons

supported by substantial evidence necessary to reject Dr. Kim's

medical opinion and that the ALJ's finding regarding Claimant's

subjective pain is not supported by substantial evidence. To

begin, the ALJ's reliance on Claimant's failure to undergo knee

replacement surgery is puzzling given that Claimant, during her

testimony, explained that she had not had knee replacement surgery

because she was told by a doctor that she had "to be at least 60

before they can do it."1

 Id. at 247.

The ALJ also relied on the fact that Claimant did not attend

pain clinic or physical therapy in support of his finding that

Claimant did not suffer significant pain. This finding, however,

is difficult to reconcile with the fact that Claimant provided

substantial testimony and documentary evidence detailing the

difficulty she has leaving her home. Claimant testified that in

order to get to her doctors visits, a friend has to come and pick

her up. Id. at 242. She also testified that she does not drive

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and that riding public transportation is difficult because it

requires walking various distances and standing for long periods. 

Id. at 242, 247. Claimant also submitted documentary evidence

stating that she can only walk a block before the pain in her

knees requires her to stop and rest. Id. at 111. Claimant both

testified and submitted evidence that she rarely is able to get

out of bed before 1:00 p.m. and that she typically spends her day

either lying down or sitting with her legs propped up. Id. at

113, 240-45. In a questionnaire submitted in 2003 regarding her

daily activities, Claimant stated that she sometimes needed help

getting in her bathtub, she rarely cooked because she could not

stand for even short periods, and she has trouble sleeping because

of the constant pain Id. at 111-113. Given these conditions, it

is not hard to understand why Claimant does not attend physical

therapy or a pain clinic. 

In addition, during her testimony, Claimant directly

contradicted several of the reasons put forward by the ALJ in

support of his adverse finding. For example, the ALJ stated that

Claimant can wash dishes, take out the garbage, vacuum, mop, and

do the laundry. Id. at 25. The ALJ appeared to reach these

conclusions based on a report prepared by consultative physician

Dr. Pon. See id. at 200. Although the ALJ did not cite to Dr.

Pon's report when making these conclusions, the ALJ's words are

almost verbatim to those of the report. Compare id. 25 with 200. 

Nonetheless, these statements regarding Claimant's ability to do

chores are difficult to reconcile with the following portion of

Claimant's testimony:

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Q [by the ALJ]: [Do you wash] dishes?

A: No, I don't really wash dishes.

Q: Dust?

A: I don't do no cleaning.

Q: Nothing?

A: Uh-uh

Q: No? Who does it?

A: My niece come over and do it. I stay with my

sister.

Q: I see. Laundry?

A: She does the laundry.

Q: You go to the store?

A: No. I basically send my little great-niece. She

goes to the store for me.

AR at 242. 

The ALJ provided no justification for ignoring this sworn

testimony and instead adopting part of a report prepared by a

consultative physician hired by the Social Security

Administration. Indeed, aside from Claimant's testimony, the

ALJ's reliance on the consultative physician's report is further

undermined by the fact that the report was prepared more than a

year before Claimant's hearing. Moreover, the report does not

explain how it reached the conclusion that, for example, Claimant

"does the dishes." Id. at 200. It is not clear whether the

doctor interviewed Claimant for this information or whether the

doctor reached this conclusion based on his examination of

Claimant. Given these circumstances, the ALJ's reliance on this

report, to the exclusion of Claimant's sworn testimony, is

troubling. This is especially true given that Claimant's treating

physician's report and other evidence in the record corroborate

Claimant's allegations of pain.

In his decision, the ALJ stated: "While claimant has medical

conditions which could be expected to cause some degree of pain

and restriction[,] the extent to which she testified [about this

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pain] is not credible . . . ." Id. at 25. This finding is

further undermined by reports from various doctors who

specifically found Claimant's subjective pain to be credible. In

a July 1, 2003, consultation, Claimant was found to be suffering

from bilateral knee pain, which was described as "sharp, dull,

achy pain" with occasional locking and giving way of the knees. 

AR at 198. The report specifically noted that Claimant's

"allegations are credible." Id.

In another report, a consultative physician hired by the

Social Security Administration recorded his examination of

Claimant. Id. at 186. This physician, Dr. Hebrard, noted that

Claimant's chief complaint was "bilateral knee pain, which is a

sharp, dull, achy pain with occasional locking and giving away of

the knees with any prolonged walking or [going] up and down

stairs." Id. In his decision, the ALJ relied, in part, on Dr.

Hebrard's conclusion that Claimant should not lift more than ten

pounds and should stand and walk no more than two hours out of an

eight hour day. Id. at 23. The ALJ, however, did not include Dr.

Hebrard's conclusion that "[t]he claimant's subjective complaints

are consistent with the objective findings outlined above." Id.

at 189. This conclusion by Dr. Hebrard further contradicts the

ALJ's finding that Claimant's description of her subjective pain

was not credible. 

In addition, Claimant submitted extensive doctor and clinic

reports dating back to 1999, most of which indicate that Claimant

was suffering moderate to severe pain in her knees. See, e.g.,

id. at 136, 141, 143, 144, 146, 148, 149, 151, 152, 153, 173, 174. 

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In a typical example of these reports, Claimant visited an

Orthopedic Clinic on December 20, 2004. The report from this

visit states, in part: "Objective physical findings: Pt

[patient] with extreme pain symptoms. Winces with light touch." 

Id. at 223. This report thus directly contradicts the ALJ's

finding that Claimant's description of her pain was not credible.

Finally, Claimant's treating physician corroborated these

findings and determined that Claimant's pain was severe enough

that it affected her "concentration, persistence and pace to such

an extent that it would seriously interfere with [her] ability to

perform simple, routine work on a productive basis." Id. at 220. 

Taken as a whole, Claimant's testimony and documentary evidence

submitted in support of her application for SSI provide

substantial evidence that she indeed suffers from significant

pain. 

Although "[t]he ALJ is responsible for determining

credibility and resolving conflicts in medical testimony," Saelee

v. Charter, 94 F.3d 520, 522 (9th Cir. 1995) (internal quotation

marks omitted), "[d]enial of benefits cannot be based on the ALJ's

observation of [the claimant], when [the claimant's] statements to

the contrary . . . are supported by objective evidence." 

Perminter v. Heckler, 765 F.2d 870, 872 (9th Cir. 1985). "The

ALJ's reliance on his personal observations . . . at the hearing

has been condemned as 'sit and squirm jurisprudence.'" Id. 

For the reasons stated above, the Court finds that the ALJ's

decision to deny benefits was not based on substantial evidence. 

To the contrary, the Court finds that the record contains

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substantial evidence that Claimant's pain is as severe as both she

and her treating physician assert. 

"The decision to remand the case for additional evidence or

simply to award the benefits is within the discretion of the

court." Erickson v. Shalala, 9 F.3d 813, 819 (9th Cir. 1993). 

Where the record is fully developed, remand is unnecessary. Id.

In the present case, the record is fully developed. There are no

"outstanding issues that must be resolved before a determination

of disability can be made." Harman v. Apfel, 211 F.3d 1172, 1178

(9th Cir. 2000). Nor would "additional proceedings . . . remedy

defects in the original administrative proceeding . . . ." Marcia

v. Sullivan, 900 F.2d 172, 176-77 (9th Cir. 1990) (internal

quotation marks omitted). Contrary to Defendant's assertions,

remand is not warranted in the present case.

 

V. CONCLUSION

For the foregoing reasons, the Court GRANTS Claimant's Motion

for Summary Judgment and DENIES Defendant's Motion for Summary

Judgment.

IT IS SO ORDERED.

Dated: March 28, 2008

 

UNITED STATES DISTRICT JUDGE

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