Document ID: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-alsd-1_05-cv-00169/USCOURTS-alsd-1_05-cv-00169-3/pdf.json

Parties Involved:
Jo Anne B. Barnhart
Defendant
Patty Coblentz
Plaintiff

Document Text:

IN THE UNITED STATES DISTRICT COURT

FOR THE SOUTHERN DISTRICT OF ALABAMA

SOUTHERN DIVISION

PATTY COBLENTZ, :

Plaintiff, :

vs. CA 05-0169-C

:

JO ANNE B. BARNHART,

Commissioner of Social Security, :

Defendant.

MEMORANDUM OPINION AND ORDER

Plaintiff brings this action pursuant to 42 U.S.C. §405(g), seeking

judicial review of a final decision of the Commissioner of Social Security

denying her claim for disability insurance benefits. The parties have consented

to the exercise of jurisdiction by the Magistrate Judge, pursuant to 28 U.S.C.

§ 636(c), for all proceedings in this Court. (See Docs. 21 & 22 (“In accordance

with the provisions of 28 U.S.C. 636(c) and Fed.R.Civ.P. 73, the parties in this

case consent to have a United States Magistrate Judge conduct any and all

proceedings in this case . . . and order the entry of a final judgment, and

conduct all post-judgment proceedings.”)) Upon consideration of the

administrative record, plaintiff's proposed report and recommendation, the

Commissioner's proposed report and recommendation, and the parties'

Case 1:05-cv-00169-C Document 23 Filed 03/30/06 Page 1 of 17
1 Any appeal taken from this memorandum opinion and order and judgment shall

be made to the Eleventh Circuit Court of Appeals. (See Docs. 21 & 22 (“An appeal from a

judgment entered by a Magistrate Judge shall be taken directly to the United States Court of

Appeals for this judicial circuit in the same manner as an appeal from any other judgment of this

district court.”))

2

arguments at the March 28, 2006 hearing before the Court, it is determined that

the Commissioner's decision denying benefits should be reversed and

remanded for further proceedings not inconsistent with this decision.1

Plaintiff alleges disability due to residuals from a neck injury and

recurrent major depression. The Administrative Law Judge (ALJ) made the

following relevant findings:

3. The medical evidence establishes that the claimant has

the severe impairment of cervical pain with numbness in her

arms and hands, but that she does not have an impairment or

combination of impairments listed in, or medically equal to one

listed in, Appendix 1, Subpart P, Regulations No. 4.

4. The claimant’s subjective complaints are not credible to

the extent alleged.

5. Giving the claimant the benefit of the doubt and

assuming that she is restricted to a degree, the Administrative

Law Judge finds the claimant is able to perform a full range of

light work.

6. The claimant is able to perform her past relevant work as

director of housekeeping, patient registration [clerk], and as a

cashier.

7. The claimant was not under a disability as defined in the

Social Security Act, at any time through the date of this decision

Case 1:05-cv-00169-C Document 23 Filed 03/30/06 Page 2 of 17
3

(20 CFR 404.1520(f) and 416.920(f)).

(Tr. 25) The Appeals Council affirmed the ALJ's decision (Tr. 4-6) and thus,

the hearing decision became the final decision of the Commissioner of Social

Security.

DISCUSSION

In all Social Security cases, the claimant bears the burden of proving

that she is unable to perform her previous work. Jones v. Bowen, 810 F.2d

1001 (11th Cir. 1986). In evaluating whether the claimant has met this burden,

the examiner must consider the following four factors: (1) objective medical

facts and clinical findings; (2) diagnoses of examining physicians; (3) evidence

of pain; and (4) the claimant's age, education and work history. Id. at 1005.

Once the claimant meets this burden, it becomes the Commissioner's burden

to prove that the claimant is capable, given her age, education and work

history, of engaging in another kind of substantial gainful employment which

exists in the national economy. Sryock v. Heckler, 764 F.2d 834, 836 (11th

Cir. 1985).

The task for the Magistrate Judge is to determine whether the

Commissioner's decision to deny claimant benefits, on the basis that she can

perform her past relevant work as director of housekeeping, patient

Case 1:05-cv-00169-C Document 23 Filed 03/30/06 Page 3 of 17
2 As recognized in the ruling, use of this test is likely to be “fallacious and

insupportable” because “[w]hile ‘delivery jobs,’ ‘packaging jobs,’ etc., may have a common

characteristic, they often involve quite different functional demands and duties requiring varying

abilities and job knowledge.”

4

registration clerk and cashier, is supported by substantial evidence. Substantial

evidence is defined as more than a scintilla and means such relevant evidence

as a reasonable mind might accept as adequate to support a conclusion.

Richardson v. Perales, 402 U.S. 389, 91 S.Ct. 1420, 28 L.Ed.2d 842 (1971).

"In determining whether substantial evidence exists, we must view the record

as a whole, taking into account evidence favorable as well as unfavorable to

the [Commissioner's] decision." Chester v. Bowen, 792 F.2d 129, 131 (11th

Cir. 1986).

Although the claimant bears the burden of demonstrating the inability

to return to her past relevant work, the Commissioner of Social Security has

an obligation to develop a full and fair record. Schnorr v. Bowen, 816 F.2d

578, 581 (11th Cir. 1987) (citations omitted). Social Security Ruling 82-61

recognizes three possible tests for determining whether or not a claimant

retains the capacity to perform her past relevant work. They are as follows:

1. Whether the claimant retains the capacity

to perform a past relevant job based on a broad

generic, occupational classification of that job,

e.g., "delivery job," "packaging job," etc.2

 

 

Case 1:05-cv-00169-C Document 23 Filed 03/30/06 Page 4 of 17
3 The Dictionary of Occupational Titles' descriptions can be relied upon to define

the job as it is usually performed in the national economy.

5

 2. Whether the claimant retains the capacity

to perform the particular functional demands and

job duties peculiar to an individual job as he or

she actually performed it. 

3. Whether the claimant retains the capacity

to perform the functional demands and job duties

of the job as ordinarily required by employers

throughout the national economy.3

Under § 404.1520(e) of the Commissioner's regulations, a claimant will be

found to be "not disabled" when it is determined that she retains the residual

functional capacity to perform the actual functional demands and job duties of

a particular past relevant job or the functional demands and job duties of the

occupation as generally required by employers throughout the national

economy. SSR 82-61.

In this case, the ALJ has relied upon test three above to determine that

the claimant can perform her past relevant work as director of housekeeping,

patient registration clerk, and cashier. (Tr. 24-25 (“The claimant has past

relevant work as director of housekeeping, light in exertional demand and

skilled (SVP-8); patient registration clerk, sedentary in exertional demand and

semi-skilled (SVP-3); hospital cleaner, medium in exertional demand and unskilled (SVP-2); and cashier, light in exertional demand and unskilled (SVPCase 1:05-cv-00169-C Document 23 Filed 03/30/06 Page 5 of 17
6

3). The vocational expert testified that assuming the claimant’s age, education,

past relevant work and residual functional capacity she could return to her past

work as director of housekeeping, patient registration clerk, and as a

cashier.”)) 

Section 404.1520(e) of the Commissioner's regulations requires a

review and consideration of a plaintiff's residual functional capacity and the

physical and mental demands of the past work before a determination can be

made that the plaintiff can perform her past relevant work. Social Security

Ruling 82-62 provides that evaluation under § 404.1520(e) "requires careful

consideration of the interaction of the limiting effects of the person's

impairment(s) and the physical and mental demands of . . . her PRW to

determine whether the individual can still do that work." See also Lucas v.

Sullivan, 918 F.2d 1567, 1574 n.3 (11th Cir. 1990) (to support a conclusion

that a claimant "is able to return to her past work, the ALJ must consider all

the duties of that work and evaluate her ability to perform them in spite of her

impairments").

The RFC to meet the physical and mental demands of jobs a

claimant has performed in the past (either the specific job a

claimant performed or the same kind of work as it is customarily

performed throughout the economy) is generally a sufficient

basis for a finding of "not disabled." 

 

Case 1:05-cv-00169-C Document 23 Filed 03/30/06 Page 6 of 17
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...

The decision as to whether the claimant retains the functional

capacity to perform past work which has current relevance has

far-reaching implications and must be developed and explained

fully in the disability decision. Since this is an important and,

in some instances, a controlling issue, every effort must be made

to secure evidence that resolves the issue as clearly and

explicitly as circumstances permit. 

Sufficient documentation will be obtained to support the

decision. Any case requiring consideration of PRW will contain

enough information on past work to permit a decision as to the

individual's ability to return to such past work (or to do other

work). Adequate documentation of past work includes factual

information about those work demands which have a bearing on

the medically established limitations. Detailed information

about strength, endurance, manipulative ability, mental demands

and other job requirements must be obtained as appropriate.

This information will be derived from a detailed description of

the work obtained from the claimant, employer, or other

informed source. Information concerning job titles, dates work

was performed, rate of compensation, tools and machines used,

knowledge required, the extent of supervision and independent

judgment required, and a description of tasks and

responsibilities will permit a judgment as to the skill level and

the current relevance of the individual's work experience.

SSR 82-62. In finding that a claimant has the capacity to perform a past

relevant job, the decision of the Commissioner must contain among the

findings, a finding of fact as to the claimant's residual functional capacity, a

finding of fact as to the physical and mental demands of the past

job/occupation, and a finding of fact that the claimant's residual functional

Case 1:05-cv-00169-C Document 23 Filed 03/30/06 Page 7 of 17
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capacity would permit a return to the past job or occupation. Id.

In this case, the plaintiff contends that the ALJ committed the following

errors: (1) he erred in rejecting the residual functional capacity (“RFC”)

opinion of Dr. Henry Stonnington; (2) he erred in determining that she retains

the RFC to perform the full range of light work; and (3) he erred in finding that

she suffers from no severe mental impairment. Because the Court finds that the

ALJ erred in determining that plaintiff does not have a severe mental

impairment and in rejecting the RFC finding of Dr. Stonnington, the ALJ’s

RFC determination is only tangentially discussed. See Pendley v. Heckler, 767

F.2d 1561, 1563 (11th Cir. 1985) (“Because the ‘misuse of the expert’s

testimony alone warrants a reversal,’ we do not consider the appellant’s other

claims.”).

A. Non-severe Mental Impairment. The Commissioner's severity

regulation requires the claimant to make a threshold showing that she has an

impairment which significantly limits her physical or mental ability to perform

basic work activities. 20 C.F.R. §§ 416.920(c), 416.921(a) (1998); Bowen v.

Yuckert, 482 U.S. 137, 147 n.5, 107 S.Ct. 2287, 2294 n.5, 96 L.Ed.2d 119

(1987). Basic work activities include functions such as walking, standing,

sitting, lifting, pushing, pulling, reaching, carrying, or handling;

Case 1:05-cv-00169-C Document 23 Filed 03/30/06 Page 8 of 17
4 It is clear that in Yuckert, the Supreme Court did not impose a standard higher

than the de minimis standard set out in Brady. See Stratton v. Bowen, 827 F.2d 1447, 1451 n.7,

1452 n.9, 1452-1453 (11th Cir. 1987).

9

understanding, carrying out and remembering simple instructions; use of

judgment, responding appropriately to supervision, co-workers, and usual

work situations; and dealing with changes in a routine work setting. 20 C.F.R.

§ 416.921(b). An impairment can be considered not severe "only if it is a

slight abnormality which has such a minimal effect on the individual that it

would not be expected to interfere with the individual's ability to work,

irrespective of age, education, or work experience." Brady v. Heckler, 724

F.2d 914, 920 (11th Cir. 1984); see Yuckert, supra, 482 U.S. at 153, 107 S.Ct.

at 2297 ("The severity regulation increases the efficiency and reliability of the

evaluation process by identifying at an early stage those claimants whose

medical impairments are so slight that it is unlikely they would be found to be

disabled even if their age, education and experience were taken into

account").4

 

Inherent in a finding of a medically not severe impairment or

combination of impairments is the conclusion that the

individual’s ability to engage in SGA [substantial gainful

activity] is not seriously affected. Before this conclusion can be

reached, however, an evaluation of the effects of the

impairment(s) on the person’s ability to do basic work activities

must be made. A determination that an impairment(s) is not

severe requires a careful evaluation of the medical findings

Case 1:05-cv-00169-C Document 23 Filed 03/30/06 Page 9 of 17
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which describe the impairment(s) and the informed judgment

about its (their) limiting effects on the individual’s physical and

mental ability(ies) to perform basic work activities; thus, an

assessment of the function is inherent in the medical process

itself.

SSR 85-28. The claimant's burden at step two of the sequential evaluation

process is mild. McDaniel v. Bowen, 800 F.2d 1026, 1031 (11th Cir. 1986)

(“Step two is a threshold inquiry. It allows only claims based on the most

trivial impairments to be rejected."). 

The evidence of record in this case is replete with evidence establishing

that the claimant suffers from recurrent major depression, an impairment

which, not surprisingly, is recognized as a severe impairment. See, e.g.,

Gholston v. Barnhart, 347 F.Supp.2d 1108, 1111 (M.D. Ala. 2003)

(“‘Gholston has the following severe impairments: fibromyalgia, a history of

asthma, osteoarthritis, drug dependence, obesity, major depression,

recurrent, mild to moderate, and anxiety disorder[.]’”); Burkett v. Barnhart,

347 F.Supp.2d 1079, 1081-1082 (M.D. Ala. 2003) (“‘Burkett has the following

‘severe’ impairments: status post fracture and surgical repair of her left ankle;

arthritis; major depression, recurrent; psychological factors affecting general

medical condition; and a personality disorder not otherwise specified

(NOS).”). The evidence of record in this case regarding Coblentz’ recurrent

Case 1:05-cv-00169-C Document 23 Filed 03/30/06 Page 10 of 17
5 Interestingly, the ALJ never mentions subsection (d) of 20 C.F.R. § 404.1520a.

11

major depression includes a three-week period of stay and treatment at

Memorial Behavioral Health in the spring of 2002 (Tr. 140-148), a

consultative psychological report in December of 2002 which recognized that

plaintiff would benefit from an outpatient counseling program (Tr. 192-197),

and a psychiatric review technique form completed by a non-examining

psychologist, Dr. Linda Baker, in January of 2003, which recognized that

plaintiff’s mental impairment is a severe impairment warranting a residual

functional capacity (RFC) assessment and noting moderate degrees of

limitation in activities of daily living, maintaining social functioning, and

maintaining concentration, persistence and pace (Tr. 198-215). This evidence

easily meets the low threshold of McDaniel, supra, and establishes that

Coblentz suffers from the severe mental impairment of recurrent major

depression. 

The ALJ erred in determining that plaintiff’s recurrent major depression

was not severe by engaging in a result-oriented analysis under the regulations,

specifically 20 C.F.R. § 404.1520a(c) (Tr. 22-24),5

 and ignoring the foregoing

evidence of record establishing the severity of this impairment (see Tr. 22

(“The claimant’s pain in her left ankle and foot, hypertension, hypothyroidism,

Case 1:05-cv-00169-C Document 23 Filed 03/30/06 Page 11 of 17
12

and depressive disorder are being controlled by treatment (Exhibit 2F,

Exhibit 4F, Exhibits 6F-9F, Exhibit 12F) and do not significantly limit the

claimant’s ability to perform basic work activities[.]”)). Cf. Carril v. Barnhart,

201 F.Supp.2d 1190, 1191 (M.D. Ala. 2002) (“The record contains evidence,

in the form of a consultative evaluation report completed by Alan D. Blotcky,

Ph.D., of a severe mental impairment. Said report diagnoses Plaintiff as

suffering major depressive disorder and chronic pain. The Administrative

Law Judge rejected this evidence--the only evidence provided by a mental

health professional relating to the impairment and/or its resulting limitations--

and found that Plaintiff did not suffer a mental impairment and that he did not

have any restriction due to depression. However, rejection of the only medical

evidence of a mental health impairment is not substantial evidence to support

the Administrative Law Judge’s finding that Plaintiff did not suffer a mental

impairment.”). Section 404.1520a(d)(1) of the Commissioner’s regulations

clearly establishes that a degree of functional limitation of moderate in the

functional areas of activities of daily living, social functioning, and

concentration, persistence or pace, necessarily lends itself to a finding that a

mental impairment is severe. See id. (“If we rate the degree of your limitation

in the first three functional areas as ‘none’ or ‘mild’ and ‘none’ in the fourth

Case 1:05-cv-00169-C Document 23 Filed 03/30/06 Page 12 of 17
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area, we will generally conclude that your impairment(s) is not severe[.]”). In

this particular case, the non-examining reviewing psychologist, Dr. Baker,

completed a PRTF on January 14, 2003 (Tr. 198-214), following a review of

all mental evidence of record (compare Tr. 140-148 & 192-197 with Tr. 210

(“Clmt is a 48yo F hosp. at MHG 2/02 to 3/02 for M.D.D. Now on Effexor

prescribed by AP. Per CE with Dr. Matherne, moderate mental limitations in

June.”)), and determined plaintiff’s recurrent major depression was severe and

resulted in moderate limitations on activities of daily living, social functioning,

and concentration, persistence and pace (Tr. 198 & 208). The ALJ certainly

did not reject Dr. Baker’s PRTF and, in fact, purports to accept and rely upon

Dr. Baker’s analysis (Tr. 23 (three separate references to Exhibit 7F)), yet

amazingly reaches the conclusion that plaintiff’s recurrent major depression

is not a severe impairment (Tr. 22 & 23-24). This was clear error; as aforesaid,

the evidence of record conclusively meets the low threshold requirement of

McDaniel, supra, and the ALJ should have determined that plaintiff’s

recurrent major depression is a severe mental impairment. Accordingly, this

cause is due to be remanded to the Commissioner of Social Security for further

proceedings, including consideration of plaintiff’s recurrent major depression

as a severe impairment and the impact the functional limitations resulting from

Case 1:05-cv-00169-C Document 23 Filed 03/30/06 Page 13 of 17
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this impairment have on plaintiff’s ability to perform either her past relevant

work or other work in the national economy.

B. ALJ’s Rejection of the Opinion of the Treating Physician.

Plaintiff also contends that the ALJ erred in rejecting the June 17, 2003

physical capacities evaluation of her treating physician, Dr. Henry

Stonnington. Dr. Stonnington’s PCE reflects that plaintiff is unable to perform

even the requirements of sedentary work activity. (Tr. 225-226) 

In the Eleventh Circuit “the testimony of a treating physician must be

given substantial or considerable weight unless ‘good cause’ is shown to the

contrary.” Lewis v. Callahan, 125 F.3d 1436, 1440 (11th Cir. 1997).

The ALJ must clearly articulate the reasons for giving less

weight to the opinion of the treating physician, and the failure to

do so is reversible error. We have found “good cause” to exist

where the doctor’s opinion was not bolstered by the evidence,

or where the evidence supported a contrary finding. We have

also found good cause where the doctors’ opinions were

conclusory or inconsistent with their own medical records.

Id. (internal citations omitted). The ALJ rejected Dr. Stonnington’s June 2003

PCE solely upon his perception that “[t]he doctor apparently relied quite

heavily on the subjective report of symptoms and limitations provided by the

claimant, and seemed to uncritically accept as true most, if not all, of what the

claimant reported (Exhibit 3F, Exhibit 5F, Exhibit 10F, Exhibit 11F).” (Tr. 21)

Case 1:05-cv-00169-C Document 23 Filed 03/30/06 Page 14 of 17
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This Court simply is unable to find that the ALJ’s “apparent” or “seeming”

opinion about Dr. Stonnington’s PCE constitutes good cause for rejecting the

doctor’s PCE particularly in light of the fact that nothing on the PCE itself

reflects that Dr. Stonnington was relying upon plaintiff’s subjective complaints

as opposed to his own objective findings. In fact, the form specifically

counsels the examining physician to base his opinion regarding physical

limitations upon his examination. (Tr. 225 (“To determine your patient’s

ability to do work-related activities on a day-to-day basis in a regular work

setting, please give us your opinion--based on your examination--of how your

patient’s physical capabilities are affected by the impairment(s).”)) Moreover,

the form specifically requests the examining physician to identify the medical

findings supporting the limitations noted and Dr. Stonnington specifically

stated the following: “MRI of cervical spine shows numerous disc protrusions

and flattening of cervical cord due to [] [] after surgery.” (Id.) There is nothing

“apparently” subjective about anything on Dr. Stonnington’s PCE and,

therefore, the ALJ erred to reversal in rejecting the treating physician’s PCE

solely upon this basis. On remand, the ALJ is to reconsider Dr. Stonnington’s

PCE and the impact of same on plaintiff’s ability to perform her past relevant

work or other work existing in substantial numbers in the national economy.

Case 1:05-cv-00169-C Document 23 Filed 03/30/06 Page 15 of 17
6 In other words, a PCE completed by a non-examining DDS disability examiner,

as here (compare Tr. 216-224 (Fred Luckett does not sign on medical consultant’s signature line

but, instead, above the line) with Tr. 104, 224 & 271 (forms identifying Luckett as a DDS

disability examiner)), certainly cannot supply the substantial evidence needed to support the

ALJ’s determination that Coblentz retains the residual functional capacity to perform light work

(compare Tr. 216-224 with Tr. 25). Cf. Lamb v. Bowen, 847 F.2d 698, 703 (11th Cir. 1988)

(“The reports of reviewing nonexamining physicians do not constitute substantial evidence on

which to base an administrative decision. . . . ‘The opinions of nonexamining, reviewing

physicians, when contrary to those of examining physicians are entitled to little weight in a

disability case, and standing alone, do not constitute substantial evidence.’”). Arguably, the

opinion of the non-examining, non-physician vocational examiner in this case would be entitled

to absolutely no weight. 

There can be no doubt that the ALJ in this case relied upon the PCE completed by

Luckett (i.e., Exhibit 9F--Tr. 216-224) in determining that plaintiff retains the residual functional

capacity to perform the full range of light work. (Tr. 24 (“The claimant suffers from impairments

which restrict her ability to lift/carry more than 20 pounds occasionally, and 10 pounds

frequently. The claimant can stand for 6 hours in an 8 hour work day, and sit for 6 hours in an 8

hour work day. Her ability to push and/or pull including operation of foot and hand controls is

unlimited, other than as shown for lifting/carrying above. The claimant does not have any

postural limitations, no manipulative limitations, no visual limitations, no communicative

limitations, and no environmental limitations (Exhibit 9F).”)) Reliance upon a form completed

by a disability examiner is clear error which must be corrected on remand.

16

In light of the foregoing, the Court not only finds that the ALJ had no

good cause for rejecting Dr. Stonnington’s PCE but, as well, lacked any basis

to conclude that plaintiff retains the RFC to perform the physical requirements

of light work activity. The undersigned has indicated on previous occasions,

and indicates again today, that an ALJ’s RFC determination must be

supported by the PCE of an examining physician where, as here, the ALJ

attempts to reject the PCE of the treating physician.6

CONCLUSION

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The Court ORDERS that the decision of the Commissioner of Social

Security denying plaintiff benefits be reversed and remanded pursuant to

sentence four of § 405(g), see Melkonyan v. Sullivan, 501 U.S. 89, 111 S.Ct.

2157, 115 L.Ed.2d 78 (1991), for further proceedings not inconsistent with this

decision. The remand pursuant to sentence four of § 405(g) makes the plaintiff

a prevailing party for purposes of the Equal Access to Justice Act, 28 U.S.C.

§ 2412, Shalala v. Schaefer, 509 U.S. 292, 113 S.Ct. 2625, 125 L.Ed.2d 239

(1993), and terminates this Court’s jurisdiction over this matter.

DONE and ORDERED this the 30th day of March, 2006.

s/WILLIAM E. CASSADY 

UNITED STATES MAGISTRATE JUDGE

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