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Westphal v. Berryhill

United States District Court, N.D. Alabama, Middle Division

May 17, 2017

NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.


          JOHN E. OTT Chief United States Magistrate Judge.

         Plaintiff Catherine Westphal brings this action pursuant to Section 205(g) of the Social Security Act (42 U.S.C. § 405(g)), seeking review of the final decision of the Acting Commissioner of Social Security (“Commissioner”)[1] denying her application for disability insurance benefits. (Doc. 1).[2] The case has been assigned to the undersigned United States Magistrate Judge pursuant to this court's general order of reference. The parties have consented to the jurisdiction of this court for disposition of the matter. (Doc. 9). See 28 U.S.C. § 636(c), Fed.R.Civ.P. 73(a). Upon review of the record and the relevant law, the undersigned finds that the Administrative Law Judge (“ALJ”) properly developed the record and was correct in his decision that Plaintiff did not have a medically determinable impairment to qualify for disability insurance benefits. Upon consideration, the court finds that the Commissioner is due to be affirmed.


         On March 19, 2012, Westphal protectively filed an application for disability insurance benefits and supplement security income benefits, alleging disability beginning on March 10, 2012. (R. 135-42, 167).[3] Westphal was initially denied benefits on June 1, 2012 (R. 69-73), and requested a hearing before an ALJ on July 20, 2012. (R. 84-86). A hearing was held on January 15, 2014. (R. 25-45). The ALJ denied Westphal's claim on April 11, 2014. (R. 10-24). The Appeals Council denied review. (R. 1-3). Westphal then filed this action under § 405(g). (Doc. 1).


         The court's review of the Commissioner's decision is narrowly circumscribed. The function of the court is to determine whether the Commissioner's decision is supported by substantial evidence and whether proper legal standards were applied. Richardson v. Perales, 402 U.S. 389, 390, 91 S.Ct. 1420, 1422 (1971); Wilson v. Barnhart, 284 F.3d 1219, 1221 (11th Cir. 2002). The court must “scrutinize the record as a whole to determine if the decision reached is reasonable and supported by substantial evidence.” Bloodsworth v. Heckler, 703 F.2d 1233, 1239 (11th Cir. 1983). Substantial evidence is “such relevant evidence as a reasonable person would accept as adequate to support a conclusion.” Id. It is “more than a scintilla, but less than a preponderance.” Id.

         The court must uphold factual findings that are supported by substantial evidence. However, it reviews the ALJ's legal conclusions de novo because no presumption of validity attaches to the ALJ's determination of the proper legal standards to be applied. Davis v. Shalala, 985 F.2d 528, 531 (11th Cir. 1993). If the court finds an error in the ALJ's application of the law, or if the ALJ fails to provide the court with sufficient reasoning for determining that the proper legal analysis has been conducted, it must reverse the ALJ's decision. See Cornelius v. Sullivan, 936 F.2d 1143, 1145-46 (11th Cir. 1991).


         To qualify for disability benefits under the Social Security Act, a claimant must show the inability to engage in “any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months.” 42 U.S.C. § 423(d)(1)(A); 42 U.S.C. § 1382(a)(3)(A). A physical or mental impairment is “an impairment that results from anatomical, physiological, or psychological abnormalities which are demonstrable by medically acceptable clinical and laboratory diagnostic techniques.” 42 U.S.C. § 423(d)(3); 42 U.S.C. § 1382(a)(3)(D).

         Determination of disability under the Social Security Act requires a five step analysis. 20 C.F.R. §§ 404.1520(a)(4). Specifically, the Commissioner must determine in sequence:

whether the claimant: (1) is unable to engage in substantial gainful activity; (2) has a sever medically determinable physical or mental impairment; (3) has such an impairment that meets or equals a Listing and meets the duration requirements; (4) can perform his past relevant work, in light of his residual functional capacity; and (5) can make an adjustment to other work, in light of his residual functional capacity, age, education, and work experience.

Evans v. Comm'r of Soc. Sec., 551 F. App'x 521, 524 (11th Cir. 2014)[4] (citing 20 C.F.R. § 404.1520(a)(4)). Plaintiff bears the burden of proving that she was disabled within the meaning of the Social Security Act. Moore v. Barnhart, 405 F.3d 1208, 1211 (11th Cir. 2005). The applicable “regulations place a very heavy burden on the claimant to demonstrate both a qualifying disability and an inability to perform past relevant work.” Id.


         Plaintiff was 24 years old on the date of the ALJ's decision. (R. 20, 167). Plaintiff has a high school education and past work as a front desk clerk and cashier. (R. 41-42, 172). Plaintiff alleges that she was disabled due to a broken left foot, broken left ankle, right femur operation, several broken ribs, and infection in the mouth. (R. 171). At her hearing, Plaintiff requested that she be treated as a “closed period” claimant for the period from February 10, 2012 to December 2013.[5] (R. 13).

         Plaintiff associates many of her alleged problems to a motor vehicle accident on March 10, 2012, but the evidence indicates that she recovered from her accident within a short period of time and did not experience any long-lasting functional limitations. Because of the accident, Plaintiff experienced fractures in her right leg and left foot. (R. 226-28, 243-49, 252-53). There was no evidence of trauma in the chest, abdomen, neck, or pelvis. (R. 250-51). Plaintiff had surgery to repair a fracture in her right leg, and was discharged from the hospital on March 15, 2012. (R. 226-27). At the beginning of April, Plaintiff underwent surgery to repair the fractures in her left foot. (R. 233-34, 261-62). Two-weeks later, Dr. Ashish Shah stated that Plaintiff was doing well post-operatively and that he would place Plaintiff in a non-weight bearing cast for four weeks. (R. 236).

         In May 2012, Dr. Zakir Khan performed a consultative examination, and found Plaintiff had the ability to sit, lift, carry, handle objects, hear, speak, and travel but that standing and walking would be difficult until treatment of her left foot injury was completed. (R. 276). In June 2012, Dr. Robert Estock, a state agency consultant, found that Plaintiff had no severe mental limitations or restrictions in mental functioning. (R. 51). In September 2012, Dr. Shah performed surgery to remove the hardware in Plaintiff's left foot. (R. 291-93, 311-12).

         Plaintiff received periodic treatment from Dr. James Tuck in 2012 and 2013. (R. 546-60). Plaintiff sought medication refills for attention deficit disorder (“ADD”), but did not report any ongoing psychological symptoms. (R. 540-60). Plaintiff continued to take college courses during this time. (R. 33).

         In July 2013, Dr. Tuck examined Plaintiff and found she had a normal neurological function, normal sensation and coordination in all extremities, and normal range of motion without pain in both lower extremities. (R. 550). Dr. Tuck noted Plaintiff was alert and oriented, could recall recent and remote events, had an appropriate mood and affect, and had an intact fund of knowledge. (Id.) In September 2013, Dr. Tuck found Plaintiff maintained normal neurological, musculoskeletal, and psychological examinations. (R. 546-47).

         In evaluating Plaintiff's application, the ALJ applied the five-step sequential evaluation process for determining whether a claimant is disabled. (R. 15-20). The ALJ first found that Plaintiff has not engaged in substantial gainful activity since the alleged onset date. (R. 15). After reviewing the medical evidence and testimony presented at the administrative hearing, the ALJ determined that “although the records reveal [Plaintiff] suffered severe impairments in a motor vehicle accident in March 2012, the records do not satisfy the requirement that an impairment must last twelve months, particularly in light of her lack of treatment from September 2012 until July 2013.” (R. 19). Although Plaintiff had seen Dr. Tuck several times between September 2012 and July 2013, the ...

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