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Rudd v. Saul

United States District Court, M.D. Alabama, Southern Division

September 30, 2019

ROSETTA RUDD, Plaintiff,
ANDREW SAUL, Commissioner of Social Security,[1] Defendant.


          Susan Russ Walker United States Magistrate Judge

         Plaintiff Rosetta Rudd commenced this action on December 15, 2017, pursuant to 42 U.S.C. § 405(g), seeking judicial review of a final adverse decision of the Commissioner denying her application for supplemental security income (“SSI”) benefits. See Doc. 1; R 10-28. Plaintiff protectively filed an application for SSI benefits on May 1, 2014, alleging disability as of February 1, 2013, due to anxiety, depression, hypertension, and low back pain.[3] See R. 208, 303. On November 1, 2016, Administrative Law Judge L. Dawn Pischek (“the ALJ”) issued an adverse decision after holding a hearing on plaintiff’s application. See R. 10-28. The Appeals Council denied plaintiff’s request for review, and the ALJ’s decision became the final decision of the Commissioner. See R. 1-5.

         In the instant appeal, plaintiff asks the court to reverse the Commissioner’s decision and award benefits or, in the alternative, to remand this cause to the Commissioner under sentence four of 42 U.S.C. § 405(g). See Docs. 1 at 2; 12 at 13. This case is ripe for review pursuant to 42 U.S.C. §§ 405(g), 1383(c)(3). The parties have consented to entry of final judgment by the Magistrate Judge. See 28 U.S.C. § 636(c); see also Docs. 10, 11. For the reasons stated herein, and based upon its review of the record, the court finds that the Commissioner’s decision is due to be reversed and remanded for additional proceedings.


         The court’s review of the Commissioner’s decision is narrowly circumscribed. The function of this court is to determine whether the decision of the Commissioner is supported by substantial evidence and whether proper legal standards were applied. Richardson v. Perales, 402 U.S. 389, 390 (1971); Wilson v. Barnhart, 284 F.3d 1219, 1221 (11th Cir. 2002). This 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. A reviewing court “may not decide facts anew, reweigh the evidence, or substitute [its] decision for that of the [Commissioner].” Dyer v. Barnhart, 395 F.3d 1206, 1210 (11th Cir. 2005). In other words, this court is prohibited from reviewing the Commissioner’s findings of fact de novo, even where a preponderance of the evidence supports alternative conclusions.

         While the court must uphold factual findings that are supported by substantial evidence, 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. Cornelius v. Sullivan, 936 F.2d 1143, 1145-46 (11th Cir. 1991).

         To qualify for SSI and establish his or her entitlement for a period of disability, a claimant must be disabled as defined by the Social Security Act and the Regulations promulgated thereunder. The Regulations define “disabled” as “the inability to do 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 twelve (12) months.” 20 C.F.R. § 416.905(a). To establish an entitlement to disability benefits, a claimant must provide evidence about a “physical or mental impairment” that “must result from anatomical, physiological, or psychological abnormalities which can be shown by medically acceptable clinical and laboratory diagnostic techniques.” 20 C.F.R. § 416.908.

         The Regulations provide a five-step process for determining whether a claimant is disabled. 20 C.F.R. § 416.920(a)(4)(i-v). The Commissioner must determine, in sequence:

(1) whether the claimant is currently employed;
(2) whether the claimant has a severe impairment;
(3) whether the claimant’s impairment meets or equals an impairment listed by the Commissioner;
(4) whether the claimant can perform his or her past work; and
(5) whether the claimant is capable of performing any work in the national economy.

Pope v. Shalala, 998 F.2d 473, 477 (7th Cir. 1993) (citing to a formerly applicable C.F.R. section), overruled on other grounds by Johnson v. Apfel, 189 F.3d 561, 562-63 (7th Cir.1999); accord McDaniel v. Bowen, 800 F.2d 1026, 1030 (11th Cir. 1986). The sequential analysis goes as follows:

Once the claimant has satisfied steps One and Two, she will automatically be found disabled if she suffers from a listed impairment. If the claimant does not have a listed impairment but cannot perform her work, the burden shifts to the [Commissioner] to show that the claimant can perform some other job.

Pope, 998 F.2d at 477; accord Foote v. Chater, 67 F.3d 1553, 1559 (11th Cir. 1995). The Commissioner must further show that such work exists in the national economy in significant numbers. Foote, 67 F.3d at 1559.


         The administrative hearing was held on February 26, 2016. Plaintiff appeared and was represented by counsel. Plaintiff testified, as did a vocational expert (“VE”). R. 52-71.

         By decision dated November 1, 2016, the ALJ found that plaintiff has not engaged in substantial gainful activity since May 1, 2014.[4] R. 12. The ALJ found that plaintiff has the severe impairments of minimal early degenerative disc disease, degenerative spur on the left heel with left ankle swelling, chronic obstructive pulmonary disease, obesity, hypertension, diabetes mellitus, affective disorder, anxiety disorder, and personality disorder, but none of the impairments or combination of impairments met or medically equaled a listed impairment. R. 12-13. After considering plaintiff’s impairments, symptoms, and the record as a whole, the ALJ found that plaintiff retained the residual functional capacity (“RFC”) to perform light work, “except that she can never be exposed to unprotected heights or hazardous machinery; is limited to simple, routine tasks with occasional change in a routine work setting; can never interact directly with the public; and can work in close proximity to others but must work independently, not in a team.” R. 17-18. With the assistance of VE testimony, the ALJ determined that plaintiff was unable to perform her past relevant work, but she could perform other jobs that exist in significant numbers in the national economy. R. 26-27, 69. Upon that determination, the ALJ concluded that plaintiff has not been under a disability since May 1, 2014. R. 27-28.


         Plaintiff raises one claim on appeal-that the Commissioner’s decision is not supported by substantial evidence because it is inconsistent with the overwhelming majority of the medical opinion evidence of record. Doc. 12 at 3. Plaintiff challenges the ALJ’s findings related to the opinion evidence of Dr. Fernando Lopez, her treating psychiatrist; Dr. Mariel Clark, a consulting psychologist; Dr. Samuel Williams, a non-examining psychiatrist, and Drs. Sarah Olaso and Sam Banner; the latter two performed consulting physical exams. Doc. 12 at 7-13. The Commissioner maintains that the ALJ properly weighed the opinion evidence and the decision is supported by substantial evidence. Doc. 13.

         Because plaintiff’s challenge to the ALJ’s consideration of the psychiatric and psychological opinion evidence warrants remand for further consideration, the court does not reach her argument related to the physical consultative examiners.


         I. Summary of the psychiatric and psychological evidence

         In early 2013, plaintiff was hospitalized for three days due to suicidal thoughts.[5]See R. 415-16. Shortly thereafter, plaintiff began treatment with Dr. Lopez at SpectraCare Health Systems, Inc. (“SpectraCare”). The bulk of the mental health records in this case are from SpectraCare, including Dr. Lopez’s treatment notes and summaries from group and individual therapy sessions.[6]

         In August 2014, Dr. Clark evaluated plaintiff upon request of the DDS. On a mental status exam, Dr. Clark noted that plaintiff was alert and oriented; had an anxious and depressed affect; had intact memory; did not display evidence of obsessions or delusions; had reasonably appropriate, linear, and goal directed thoughts; and had good insight and judgment. R. 508-09. Dr. Clark diagnosed major depression, recurrent, severe with psychotic features; panic disorder with agoraphobia; rule out obsessive-compulsive disorder; physical abuse, victim; and sexual abuse of a child, victim. R. 510. She assessed a global assessment of functioning (“GAF”) score of 45 and stated that plaintiff’s prognosis was “guarded.”[7] Id. Dr. Clark determined that plaintiff “would exhibit moderate to severe impairments when expected to respond appropriately to supervision, coworkers, and work pressures encountered in the typical work environment on a sustained basis.” R. 511.

         In September 2014, Dr. Williams completed a mental RFC assessment form after reviewing plaintiff’s claim file. He found that plaintiff was “moderately limited” in her ability to understand, remember, and carry out detailed instructions; maintain attention and concentration for extended periods; work in coordination with or in proximity to others without being distracted by them; interact appropriately with the general public; accept instructions and respond appropriately to criticism from supervisors; get along with coworkers without distracting them or exhibiting behavioral extremes; and respond appropriately to changes in the work setting. R. 106-07. He determined that plaintiff could understand, remember, and carry out short and simple instructions; she could pay attention for two hour time periods; she would work best in a well-spaced area; contact with the general public and coworkers should be casual; feedback should be constructive and supportive; and changes in the workplace should be infrequent and gradual. R. 106-08.

         In November 2014, Dr. Lopez completed a form that addressed plaintiff’s degree of mental impairment in eighteen areas (Dr. Lopez’s “RFC opinion”). R. 513-15. He determined that plaintiff had “moderate” impairment in her ability to interact appropriately with the general public; ask simple questions or request assistance; understand, remember, and carry out simple instructions; and sustain a routine without special assistance; and “marked” impairment in her ability to get along with coworkers or peers; understand, remember, and carry out complex instructions; understand, remember, and carry out repetitive tasks; maintain attention and concentration for extended periods; perform activities within a schedule, maintain regular attendance, and be punctual within customary tolerances; complete a normal workday/workweek without interruption from psychologically based symptoms and perform at a consistent pace without an unreasonable number and length of rest periods; make simple work-related decisions; respond appropriately to supervision; respond appropriately to changes in the ...

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