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Thomas v. Berryhill

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

September 25, 2018





         On June 23, 2014, the claimant protectively applied for disability and disability insurance benefits under Title II of the Social Security Act and for supplemental security income under Title XVI. In both applications, the claimant alleged disability beginning on December 5, 2011, because of diabetes; high cholesterol; lung problems; high blood pressure; arthritis and neuropathy in her feet; bone spurs in her right foot; and broken left and right ankles with pins, plates, and screws. The Commissioner denied the claim on August 26, 2014. The claimant filed a timely request for a hearing before an Administrative Law Judge, and the ALJ held a video hearing on December 15, 2015. (R. 33-80, 94, 123-31, 132-34, 189-96).

         In a decision dated January 26, 2016, the ALJ found that the claimant was not disabled as defined by the Social Security Act and was, therefore, ineligible for Social Security benefits. On April 27, 2017, the Appeals Council denied claimant's request for review. Consequently, the ALJ's decision became the final decision of the Commissioner of the Social Security Administration. The claimant has exhausted his administrative remedies, and this court has jurisdiction pursuant to 42 U.S.C. §§405(g) and 1383 (c)(3). For the reasons stated below, this court REVERSES and REMANDS the decision of the Commissioner to the ALJ for reconsideration. (R. 1-3, 16-27).


         Whether the ALJ erred in not assigning weight given to the medical opinion of Dr. John Haney, PhD., who personally examined the claimant and reviewed her medical records.


         The standard for reviewing the Commissioner's decision is limited. This court must affirm the ALJ's decision if he applied the correct legal standards and if substantial evidence supports his factual conclusions. See 42 U.S.C. § 405(g); Graham v. Apfel, 129 F.3d 1420, 1422 (11th Cir. 1997); Walker v. Bowen, 826 F.2d 996, 999 (11th Cir. 1987).

         “No . . . presumption of validity attaches to the [Commissioner's] legal conclusions, including determination of the proper standards to be applied in evaluating claims.” Walker, 826 F.2d at 999. This court does not review the Commissioner's factual determinations de novo. This court will affirm those factual determinations that are supported by substantial evidence. “Substantial evidence” is “more than a mere scintilla. It means such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” Richardson v. Perales, 402 U.S. 389, 402 (1971).

         The court must keep in mind that opinions, such as whether a claimant is disabled, the nature and extent of a claimant's residual functional capacity, and the application of vocational factors, “are not medical opinions . . . but are, instead, opinions on issues reserved to the Commissioner because they are administrative findings that are dispositive of a case; i.e., that would direct the determination or decision of disability.” 20 C.F.R. §§ 404.1527(d), 416.927(d). Whether a claimant meets a Listing and is qualified for Social Security disability benefits is a question reserved for the ALJ, and the court “may not decide facts anew, reweigh the evidence, or substitute [its] judgment for that of the Commissioner.” Dyer v. Barnhart, 395 F.3d 1206, 1210 (11th Cir. 2005). Thus, even if the court were to disagree with the ALJ about the significance of certain facts, the court has no power to reverse that finding as long as substantial evidence in the record supports it.

         The court must “scrutinize the record in its entirety to determine the reasonableness of the [Commissioner]'s factual findings.” Walker, F.2d at 999. A reviewing court must not only look to those parts of the record that support the decision of the ALJ, but also must review the record in its entirety and take account of evidence that detracts from the evidence relied on by the ALJ. Hillsman v. Bowen, 804 F.2d 1179, 1180 (11th Cir. 1986).


         The ALJ must state with particularity the weight he gave different medical opinions and the reasons for them; the failure to do so is reversible error. Sharfarz v. Bowen, 825 F.2d 278, 279 (11th Cir. 1987); see also MacGregor v. Bowen, 786 F.2d 1050, 1053 (11th Cir. 1986). If the ALJ at a minimum does not state with “some measure of clarity” the reasons for his decision in discrediting the opinion of an examining physician, it is reversible error. McClurkin v. SSA, 625 Fed.Appx. 960, 960 (11th Cir. 2015).

         V. FACTS

         The claimant was fifty-eight years old at the time of the ALJ's final decision; has a GED; has past relevant work as a waitress, meat clerk, and a convenience store clerk; and alleges disability based on diabetes, high cholesterol, lung problems, high blood pressure, arthritis and neuropathy in her feet, bone spurs in her right foot, and broken right and left ankles with pins, plates, and screws. (R. 21, 27, 46-47, 69, 189, 198, 205, 211, 241).

         Physical and Mental Impairments

         On February 7, 2012, the claimant saw Dr. Michael Dick of Alabama Medicine and Rheumatology complaining of ankle and back pain that resulted from a prior car accident in 1985. The claimant stated that her symptoms were constant and achy and that the pain radiates down both her thighs to just above her ankles. She reported that walking and prolonged standing worsen her pain. The claimant described her pain as an 10/10 in severity, with the past month ranging from 6/10 as a minimum to 10/10 as a maximum. Dr. Dick noted tenderness in both “gluteal and ischial bursae as well as over both sacroiliac joint margins.” He also noted that she was tender in her hips and behind the bottom of both her knees. Additionally, Dr. Dick noted extra bone growth in both ankles and tenderness across the back of both ankles and on the sides. Dr. Dick diagnosed her with inflammation of her hips and pain in both legs; compressed nerves and traumatic osteoarthritis in both ankles, with the right being greater than the left. Dr. Dick prescribed Lortab for pain management. (R. 795-94).

         At the request of the Social Security Administration, the claimant completed a “Function Report-Adult” on August 16, 2012. In that report, the claimant stated that she takes care of her two-year-old grandson; can cook and clean, but it takes her all day because she only can do things a little at a time; and cannot stand, sit, or lay for a long time. The claimant further stated that she can feed herself and use the toilet, but it takes her a while to care for her hair, dress, shave, or bathe herself. The claimant also stated that she prepares her meals daily, but it takes her most of the day; can clean daily; can do laundry twice a week; can iron once a week; and can grocery shop in stores twice a month for two hours. The claimant mentioned that she does not drive because does not have a license and she wouldn't feel comfortable driving with pain. (R. 221-224).

         Regarding her activities, the claimant stated in her Function Report that she watches TV off and on daily between daily chores, and typically talks to and goes to take care of personal business with others. She further stated she regularly goes to pay bills and shop for groceries and clothes twice a month; however, she needs someone to accompany her. (R. 225).

         Regarding her abilities, the claimant stated in her Function Report that she has pain when lifting, squatting, bending, standing, reaching, walking, sitting, kneeling, stair climbing, completing tasks, and using her hands. The claimant mentioned she cannot walk far at all before needing to stop and rest; when she does rest, she stated that it takes her two to three minutes before she can resume walking. She further stated that her pain affects her ability to see, concentrate, and sleep because it wakes her up. Additionally, the claimant stated that she can pay attention for a span of fifteen minutes; can finish what she starts; can follow written and spoken instructions well; gets along with authority figures; has never been fired or laid off from a job because of problems getting along with other people; does not handle stress well; does not handle changes in routine well; and has experienced anxiety as a result of her pain. (R. 226-27).

         On September 9, 2012, the claimant's live-in friend, Paul Benson, also completed a “Function Report-Adult-Third Party, ” similar to the report completed by the claimant. Mr. Benson explained that he is usually at work six days a week but, when he can, he is the one who mainly takes the claimant to run her errands. He mentioned the claimant does chores a little at a time but gets everything done. Mr. Benson further stated that the claimant does not need any help or encouragement doing these activities. He explained that the claimant rarely goes shopping. Mr. Benson further explained that the claimant can pay attention well; finishes what she starts; rarely follows written instructions; can follow spoken instructions; gets along with authority figures; handles stress well; and handles changes in routine well. He mentioned the claimant worries how she is going to be able to take care of herself should something happen to him. (R. 229-35).

         At the request of the Social Security Administration, the claimant met with Dr. John Haney, PhD, for a consultative psychological examination on September 25, 2012. The claimant informed Dr. Haney that her friend drove her to the appointment. Dr. Haney then personally examined the claimant and reviewed her medical records. He noted that the claimant appeared sad and tearful but was alert, polite, and cooperative. He further noted that the claimant was not certain as to the reason for the appointment, but her conversation was logical and goal directed.

         The claimant informed Dr. Haney that she stopped working because of severe pain from arthritis in her legs and ankles that she has experienced since a motor vehicle accident she suffered in 1985. She explained that she underwent surgery on both ankles and also has severe diabetes and high blood pressure. The claimant further stated that she had “three or four” arrests for possession of a controlled substance and crack cocaine, and served a three year prison sentence until 2006. She explained that, while she occasionally drinks alcohol, she has not used crack cocaine in over five years and has not smoked marijuana in the past seven months. However, she informed Dr. Haney that she smokes one pack of cigarettes daily. When asked if she had any psychiatric hospitalizations and outpatient mental health treatment, the claimant responded that she had not, but she received substance abuse counseling while in prison. (R. 391).

         During his psychological examination of the claimant, Dr. Haney noted that she was oriented to time, place, and person; was unable to subtract serial sevens but was able to count forward by threes; had difficulty performing most simple problems in change making and arithmetic; was able to find some abstract similarities between paired objects and interpret simple proverbs; gave little accurate general information; recalled four digits forward and four backward and none of three objects after five minutes; appeared “generally intact” regarding her recent and remote memory; and had an estimated low average to borderline range of intelligence. (R. 391).

         Dr. Haney additionally noted that the claimant showed no psychotic symptoms, such as auditory or visual hallucinations, delusions, ideas of reference or grandiosity. The claimant admitted to Dr. Haney that she had been feeling more depressed since her son overdosed on drugs and died in January 2012. The claimant stated she has experienced sadness; crying spells; pain; worry; an inability to feel happiness; poor memory and concentration; inability to relax; and disturbed sleep, lack of energy, and decreased appetite. However, when asked if she had any suicidal thoughts or attempts, she informed Dr. Haney that she had not. Dr. Haney also noted that the claimant's insight appeared poor but that she seemed able to manage her own funds, should any be awarded to her. (R. 392).

         When asked to describe an average day, the claimant explained to Dr. Haney that her day begins around four-thirty in the morning. She further explained that she mostly stays home, cares for her grandson, does light household chores, and denied other hobbies or leisure or ...

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