Norma Ramirez v. Michael J Astrue, No. 5:2009cv01371 - Document 23 (C.D. Cal. 2011)

Court Description: MEMORANDUM OPINION AND ORDER by Magistrate Judge Patrick J. Walsh. For these reasons, the Agency's decision is reversed and the case is remanded for further proceedings consistent with this opinion. IT IS SO ORDERED. **PLEASE READ DOCUMENT FOR FULL AND COMPLETE DETAILS** (ca)

Download PDF

Norma Ramirez v. Michael J Astrue Doc. 23 1 2 3 4 5 6 7 8 UNITED STATES DISTRICT COURT 9 CENTRAL DISTRICT OF CALIFORNIA 10 NORMA RAMIREZ, Plaintiff, 11 12 13 v. 14 MICHAEL J. ASTRUE, Commissioner of the Social Security Administration, 15 Defendant. ) ) ) ) ) ) ) ) ) ) ) ) Case No. ED CV 09-1371-PJW MEMORANDUM OPINION AND ORDER 16 17 I. 18 INTRODUCTION 19 Before the Court is Plaintiff s appeal of a decision by Defendant 20 Social Security Administration ( the Agency ), denying her 21 applications for Disability Insurance benefits ( DIB ) and 22 Supplemental Security Income ( SSI ). 23 Administrative Law Judge ( ALJ ) erred in failing to properly 24 consider: 1) lay witness testimony; 2) a treating clinician s opinion; 25 3) the opinions of two treating psychiatrists; 4) a state reviewing 26 psychiatrist s functional assessment; 5) a treating psychiatrist s 27 functional assessment; and 6) the severity of Plaintiff s mental 28 impairment. Plaintiff claims that the She claims further that he failed to pose a complete Dockets.Justia.com 1 hypothetical question to the vocational expert and also erred when he 2 determined that she could perform her past relevant work as an 3 accounting clerk. 4 the ALJ erred in his treatment of the mental health evidence and 5 remands for further proceedings consistent with this opinion. For the following reasons, the Court concludes that 6 II. 7 SUMMARY OF PROCEEDINGS 8 9 Plaintiff applied for DIB and SSI on April 9, 2007, alleging that she had been unable to work since March 31, 2001, because of major 10 depression, a panic disorder, anxiety, and pain. (Administrative 11 Record ( AR ) 131-39.) 12 and on reconsideration. 13 granted a hearing before an ALJ. 14 counsel and testified at the hearing on October 16, 2008. 15 On April 3, 2009, the ALJ issued a decision denying benefits. 16 20.) 17 (AR 1-6.) The Agency denied the applications initially (AR 64-75.) Plaintiff then requested and was (AR 78-82.) Plaintiff appeared with (AR 21-33.) (AR 7- Plaintiff appealed to the Appeals Council, which denied review. She then commenced the instant action. 18 III. 19 DISCUSSION 20 A. 21 In her first claim of error, Plaintiff contends that the ALJ 22 erred by failing to provide germane reasons for rejecting the written 23 testimony of her daughter, Terry Ramirez. 24 The Court finds this claim to be without merit. 25 Lay Witness Testimony (Joint Stip. at 3-5.) An ALJ must consider lay witness testimony. Stout v. Comm r, 26 Soc. Sec. Admin., 454 F.3d 1050, 1053 (9th Cir. 2006); Smolen v. 27 Chater, 80 F.3d 1273, 1288 (9th Cir. 1996); 20 C.F.R. 28 §§ 404.1513(d)(4),(e). Nevertheless, an ALJ need only give reasons 2 1 that are germane to the testimony in order to reject it. 2 Barnhart, 427 F.3d 1211, 1218 (9th Cir. 2005). 3 Bayliss v. In an August 13, 2007 Third Party Function Report, Plaintiff s 4 daughter stated, among other things, that Plaintiff needed to be 5 reminded to take her medicine; only rarely cooked hot meals because 6 she forgot what she was doing and fell asleep with the food on the 7 stove; got very nervous when driving a car; could not pay bills or 8 write out checks; panicked when around a crowd of people; and was 9 limited in her ability to lift, stand, walk, and climb stairs. (AR 10 241-44.) 11 and lacked the patience to concentrate. 12 closely mirrored Plaintiff s own statements on a form she submitted to 13 the Agency the same day.1 14 She also stated that Plaintiff did not handle stress well (AR 246.) These statements (AR 247-54.) The ALJ rejected the daughter s statements because they mirrored 15 Plaintiff s, which the ALJ found to be incredible. (AR 18-20.) 16 Plaintiff has not challenged the ALJ s credibility finding, thus, the 17 Court accepts it. 18 the claimant s testimony and the claimant is found to be not credible, 19 the ALJ may reject the lay witness testimony for that reason alone. 20 See Valentine v. Comm r, Soc. Sec. Admin., 574 F.3d 685, 694 (9th Cir. 21 2009) (holding that ALJ gave germane reason for rejecting claimant s 22 wife s testimony where it was similar to claimant s own complaints 23 that were properly rejected); see also Cleveland v. Astrue, 2010 WL 24 1678294, at *8 (C.D. Cal. Apr. 23, 2010) (ALJ s failure to expressly 25 provide reason for rejecting lay witness statements was harmless error Where, as here, the lay witness testimony mirrors 26 27 1 28 Plaintiff concedes that her daughter prepared both reports. (Joint Stip. at 4.) 3 1 where statements mirrored claimant s testimony that was properly found 2 not credible). 3 testimony is affirmed. As such, the ALJ s rejection of the daughter s 4 B. The Mental Health Evidence 5 The ALJ concluded that Plaintiff did not suffer from a severe 6 mental impairment. 7 Plaintiff takes issue with the ALJ s findings in this regard. 8 contends, among other things, that the ALJ did not provide legally 9 sufficient reasons for rejecting various physicians opinions and, as 10 a consequence, erred in finding that Plaintiff s mental impairment was 11 not severe. 12 ALJ erred. 13 (AR 15-17.) In claims two through seven, She For the following reasons, the Court concludes that the In August 2000, Plaintiff was driving a car for work when she was 14 involved in an accident. 15 depression and anxiety and obtained treatment, including therapy and 16 medication, from psychiatrist Herbert Marshak and psychologist Roland 17 Chabot between March 2001 and February 2002. 18 14, 2002, Dr. Chabot diagnosed her with major depressive disorder, 19 single episode, and assigned a Global Assessment of Functioning 20 ( GAF ) score of 50. 21 (AR 375.) Thereafter, she complained of (AR 378-80.) On January (AR 378.) In May 2002, a worker s compensation examiner, Dr. Donald 22 Feldman, conducted a mental status evaluation of Plaintiff, which 23 revealed that she was oriented, dressed appropriately, and that her 24 speech and thought processes were normal. 25 determined that Plaintiff s psychiatric disability was zero to 26 slight. 27 disability in relating to people and influencing people, making 28 generalizations, evaluations or decisions without supervision, and (AR 389.) (AR 382.) Dr. Feldman He believed that she would have a slight 4 1 accepting and carrying out responsibility for directions, control and 2 planning. 3 perspective, Plaintiff was fully capable of her usual and customary 4 work. 5 (AR 389.) He concluded that, from a psychiatric (AR 389.) In July 2003, Arthur Gutierrez, a social worker, conducted an 6 outpatient assessment of Plaintiff at Imperial County Behavioral 7 Health Services. 8 she had been taking Paxil, an anti-depressant, for two years. 9 339.) (AR 339-42.) Plaintiff reported to Gutierrez that (AR Though her mental health status was largely unremarkable, she 10 complained of a depressed and anxious mood and problems with worries, 11 memory, concentration, disruptive sleep, muscle tension, and fatigue. 12 (AR 340, 341.) 13 recurrent, severe, panic disorder without agoraphobia, and generalized 14 anxiety disorder. 15 341.) 16 Services Patient Progress Record set forth the identical diagnosis. 17 (AR 356.) Gutierrez diagnosed major depressive disorder, (AR 341.) He assigned a GAF score of 50. (AR On September 12, 2003, an Imperial County Behavioral Health 18 In January 2004, Dr. M. Becraft, a state agency psychiatrist, 19 reviewed Plaintiff s medical records at the request of the Agency. 20 (AR 328-37.) 21 finding of an impairment before Plaintiff s date last insured of March 22 2002, but disagreed with Dr. Feldman s determination that she had no 23 impairment because it was inconsistent with her reported social 24 limitations and panic attacks. 25 therapy had improved Plaintiff s condition but, nevertheless, 26 determined that she would be moderately limited in her ability to 27 understand, remember, and carry out detailed instructions, and in her 28 ability to interact appropriately with the public. He found that the medical evidence did not support a (AR 337.) 5 Dr. Becraft found that (AR 333-34.) Dr. 1 Becraft concluded that Plaintiff would be limited to [non-public 2 simple repetitive tasks] for now. 3 (AR 337.) On March 3, 2006, Plaintiff underwent an initial assessment at 4 the Los Angeles County Department of Mental Health. (AR 612-17.) It 5 was noted that Plaintiff had been taking Paxil, Buspar (an anti- 6 anxiety medication), and Seroquel (an anti-psychotic medication) for 7 more than a year and that these medications were effective. 8 613.) 9 functioning, and thought process were normal, though her immediate (AR Plaintiff s grooming, speech, orientation, intellectual 10 memory was impaired and she complained that she hears doorbells and 11 see[s] shadows. 12 depressive disorder, recurrent, with psychotic features; and a panic 13 disorder with agoraphobia. 14 (AR 616.) Plaintiff was diagnosed with a major (AR 617.) She was not given a GAF score.2 On September 28, 2006, consultative psychiatrist Dr. Mehboob Ali 15 Makhani evaluated Plaintiff. 16 appearance and behavior were unremarkable, her thought processes were 17 linear and goal directed with no evidence of hallucinations or 18 delusions, she was oriented, and she demonstrated appropriate 19 judgment. 20 otherwise specified, with a rule-out diagnosis for major depressive 21 disorder, adjustment disorder, and mood disorder. 22 Makhani assessed Plaintiff s GAF at between 60 and 65. 23 concluded that she would have no work-related limitations as a result 24 of her psychiatric condition. (AR 622-23.) (AR 621-24.) He noted that Plaintiff s He diagnosed depressive disorder, not (AR 623.) (AR 623.) Dr. (AR 623.) He Based on Dr. Makhani s 25 26 27 28 2 Though the ALJ found (and the parties seem to agree) that the unnamed clinician assessed a GAF score of 30, (AR 16), the record does not support this finding. In fact, the clinician did not indicate a GAF score, rather, he or she wrote 30 x NO under DMH Dual Diagnosis Code, the meaning of which the parties have not addressed. (AR 617.) 6 1 opinion, state agency reviewing psychiatrist Dr. M. G. Salib also 2 concluded in December 2006 that Plaintiff had no functional 3 limitations due to her mental impairment. 4 (AR 641-51.) On May 14, 2007, consulting psychiatrist Dr. Romualdo Rodriguez 5 evaluated Plaintiff and found that her appearance, behavior, and 6 thought processes were all unremarkable. 7 made no psychiatric diagnosis and concluded that Plaintiff had no 8 functional limitations from a psychiatric standpoint. 9 Loomis, a state agency reviewing psychiatrist, concurred on May 21, 10 11 2007, finding no psychiatric impairment. (AR 704-705.) Dr. Rodriguez (AR 706.) Dr. (AR 714.) On January 23, 2008, treating psychiatrist Dr. Maged Estafan 12 submitted a check-the-box form to Plaintiff s counsel, in which he 13 indicated that Plaintiff had extreme limitations (meaning that 14 Plaintiff had no useful ability to function) in almost every area of 15 functioning, including the ability to understand and remember very 16 short and simple instructions. 17 Plaintiff s ability to maintain socially appropriate behavior would be 18 moderately limited and her ability to set realistic goals would be 19 markedly limited. 20 (AR 811-12.) Dr. Estafan found that (AR 811-12.) In his April 3, 2009 decision, the ALJ found that the objective 21 medical evidence did not support Plaintiff s allegations that she 22 could not work due to depression and anxiety. 23 reports of examining psychiatrists Dr. Feldman, Dr. Makhani, and Dr. 24 Rodriguez, in which they concluded that Plaintiff was not functionally 25 impaired. 26 2003 diagnosis of severe, recurrent major depression, but pointed out 27 that Plaintiff treated it with only monthly counseling at Imperial 28 County Behavioral Health Services from July to November 2003. (AR 15-17.) (AR 15.) He noted the He also noted social worker Gutierrez s July 7 (AR 1 16.) As for the March 2006 Los Angeles County Department of Mental 2 Health assessment, the ALJ deemed it noteworthy, but determined 3 that, because Plaintiff received only a few months of therapy at the 4 facility, the condition had not lasted for the requisite 12 months. 5 (AR 16.) 6 in January 2008, (AR 811-12), because it was completed by an 7 unidentifiable person and there is no treating or progress records to 8 support this assessment. 9 Becraft s January 2004 assessment. The ALJ expressly rejected the form submitted by Dr. Estafan (AR 17.) The ALJ failed to mention Dr. Having found that Plaintiff had no 10 severe mental impairment, the ALJ determined that she retained the 11 residual functional capacity to perform light work, with some 12 additional postural and environmental restrictions, but with no 13 restrictions due to mental limitations. 14 15 1. (AR 17.) Arthur Gutierrez s Opinion Plaintiff argues that the ALJ was required to either accept or 16 reject social worker Arthur Gutierrez s July 2, 2003 opinion, 17 including the GAF score of 50.3 18 entitled to the same weight as a doctor s because Gutierrez was 19 working closely with a psychiatrist from the clinic when he was 20 treating Plaintiff. 21 In her view, Gutierrez s opinion was (Joint Stip. at 7-9.) As an initial matter, the Court rejects Plaintiff s invitation to 22 find that, because Gutierrez was working in conjunction with Dr. 23 Brolaski at the time of the assessment, Gutierrez should be considered 24 25 26 27 28 3 A GAF score of 41-50 indicates [s]erious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) OR any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders at 34 (4th Ed. 2000). 8 1 a treating physician whose opinion is entitled to controlling weight. 2 (Joint Stip. at 8-9.) 3 therapist is not entitled to treating physician status. 4 C.F.R. §§ 416.913(a)(1) and (3); Gomez v. Chater, 74 F.3d 967, 971 5 (9th Cir. 1996). 6 for those rare circumstances where a therapist is working so closely 7 with a doctor that the therapist s treatment is merely an extension of 8 the doctor s, Gomez, 74 F.3d at 971 (holding opinion of a nurse 9 practitioner could be viewed as an acceptable medical source where she 10 acted so closely under the supervision of the treating physician her 11 opinion should be properly considered as part of the opinion of the 12 physician), there is no evidence that that type of doctor-therapist 13 relationship existed here. 14 Plaintiff s intake interview on his own and the assessment form he 15 filled out in conjunction with that interview was not co-signed by Dr. 16 Brolaski or any other doctor. 17 Brolaski co-signed Plaintiff s client plan on July 24, 2003, almost 18 three weeks after Gutierrez completed it, does not change the 19 analysis. 20 worked with or under the close supervision of Dr. Brolaski in treating 21 Plaintiff or in preparing reports. 22 The general rule is that a social worker/ See, e.g., 20 Though there is an exception to this general rule It appears that Gutierrez conducted (AR 339-42.) The fact that Dr. Further, there is no evidence that thereafter Gutierrez That being the case, the ALJ was not required to grant the same 23 deference to Gutierrez s opinion that he would grant to a doctor s 24 opinion. 25 §§ 404.1527(d), 416.927(d)); see also Thomas v. Astrue, 2009 WL 26 151488, at *3 (C.D. Cal. Jan. 21, 2009) ( [T]he reports of licensed 27 clinical social workers are considered other sources of evidence, not 28 evidence from an acceptable medical source. ). See Social Security Ruling ( SSR ) 06-03p (citing 20 C.F.R. 9 Rather, he was only 1 required to explain the weight given to the opinion in sufficient 2 detail so that Plaintiff (and the Court) could understand it. 3 03p. 4 The ALJ fulfilled that obligation here. SSR 06- He read and considered 5 the social worker s opinion, noting that Plaintiff s affect was flat 6 and her mood was depressed, but that she was oriented times three and 7 that she denied hallucinations, delusions, or paranoia. 8 ALJ also noted that, despite Gutierrez s diagnosis of severe major 9 depression, recurrent, Plaintiff received only monthly counseling and 10 only from July to November 2003. 11 reasons to discount the social worker s opinion under SSR 06-03p. 12 The such, this claim does not merit remand or reversal.4 13 2. (AR 16.) (AR 16.) These were sufficient As The Imperial County Treating Psychiatrist s Opinion 14 Plaintiff argues that the ALJ erred by failing to address a 15 diagnosis contained in a September 12, 2003 Imperial County Behavioral 16 Health Services patient progress record. 17 psychiatrist, whose name is illegible, reached the same findings as 18 Gutierrez, i.e., that Plaintiff had a GAF of 50 and that he suffered 19 from a major depressive disorder, a panic disorder, and a generalized 20 anxiety disorder. (AR 356.) (Joint Stip. at 16-17.) The Though the ALJ erred when he failed to 21 4 22 23 24 25 26 27 28 The ALJ s failure to specifically discuss Gutierrez s GAF score of 50 was not error. The ALJ was not required to discuss every piece of evidence, only significant, probative evidence. Howard ex rel. Wolff v. Barnhart, 341 F.3d 1006, 1012 (9th Cir. 2003); Vincent v. Heckler, 739 F.2d 1393, 1394-95 (9th Cir. 1984). An individual GAF score -particularly one from a social worker--does not fall into this category. See, e.g., Mitchell v. Astrue, 2010 WL 1994695, at *9 (C.D. Cal. May 14, 2010) (concluding ALJ did not err in failing to separately discuss consultative psychiatrist s GAF rating of claimant); Alvarez v. Barnhart, 2002 WL 31466411, at *8 (W.D. Tex. Oct. 2, 2002) (finding ALJ s failure to mention GAF score not reversible error). 10 1 discuss this assessment, the Court concludes that the error was 2 harmless error. 3 An ALJ s failure to address pertinent evidence is harmless if the 4 error did not affect the outcome of the case. See Stout, 454 F.3d at 5 1055-56 (defining harmless error in the context of social security 6 cases as one not affecting the ultimate determination of disability). 7 The medical record Plaintiff raises in issue here appears to have been 8 completed by a psychiatrist (the same illegible signature appears on a 9 medication record sheet under doctor s initials (AR 343)), though 10 the record does not clarify who the doctor is or whether he or she had 11 a treating relationship with Plaintiff. 12 compelling as to require remand. 13 the September 2003 diagnosis was simply copied from Gutierrez s July 14 2003 assessment -the second page of the record states See Eval. 7-2- 15 03 for details (AR 356)--or whether it was based on independent 16 findings by the doctor. Thus, the evidence is not so Moreover, it is not clear whether 17 Even assuming that the psychiatrist in question had an ongoing 18 treating relationship with Plaintiff, the ALJ was not bound to give 19 controlling weight to the opinion because it was not supported by 20 treatment records and was not consistent with other substantial 21 evidence in the record. 22 Cir. 2007). 23 contradicted by the opinions of examining psychiatrists Feldman, 24 Makhani, and Rodriguez. 25 received only five months of treatment at this facility in 2003. 26 16, 339-63.) 27 was not so debilitating as to render her disabled. See Orn v. Astrue, 495 F.3d 625, 631 (9th Here, the unknown psychiatrist s diagnosis was plainly Moreover, as the ALJ pointed out, Plaintiff (AR Thus, it is safe to assume that Plaintiff s condition 28 11 1 Though the ALJ should have discussed the report, his failure to 2 do so does not warrant remand where, as here, the report does not 3 establish that Plaintiff had an ongoing condition that rendered her 4 disabled and, further, where it appears to merely repeat the findings 5 of an earlier evaluation, which was not material. 6 341 F.3d at 1012 (holding ALJ s failure to discuss treatment 7 provider s opinion not error where review was based on earlier report 8 that ALJ did discuss). 9 merit. 10 11 3. See, e.g., Howard, For these reasons, this claim is without The Los Angeles County Treating Psychiatrist s Opinion Plaintiff argues that the ALJ failed to properly consider a March 12 2006 assessment from a doctor at the Los Angeles County Department of 13 Mental Health. 14 the Court agrees that the ALJ erred.5 15 (Joint Stip. at 17-19.) For the following reasons, A treating doctor s opinion is given more weight than a non- 16 treating doctor s opinion. 17 Chater, 81 F.3d 821, 830 (9th Cir. 1995)). 18 doctor s opinion is contradicted by another doctor, the ALJ may not 19 reject it without providing specific and legitimate reasons for doing 20 so that are supported by substantial evidence. 21 Orn, 495 F.3d at 632 (citing Lester v. Even where the treating Id. Here, in 2006, a Los Angeles County Mental Health Department 22 doctor diagnosed Plaintiff with major depressive disorder with 23 psychotic features, noting Plaintiff s complaints of auditory and 24 visual hallucinations. (AR 617.) The ALJ found this assessment to be 25 26 27 28 5 Plaintiff argues that the assessment was carried out by a psychiatrist. (Joint Stip. at 17-19.) The provider s signature is illegible, but it appears that he or she was a psychologist, not a psychiatrist, judging by the letters PSYD next to the signature. (AR 617.) Either way, it does not affect the Court s analysis here. 12 1 noteworthy, but found that it was not supported by the medical 2 evidence because her treatment consisted of only a few months of 3 therapy and, thus, the condition did not last for 12 months or more. 4 (AR 16.) 5 Angeles ended when she moved to Riverside County. 6 record shows that she began treatment with Riverside County Department 7 of Mental Health in September 2006 and continued to receive treatment 8 through February 2008. 9 30.) As Plaintiff points out, however, her treatment in Los Thereafter, the (Joint Stip. at 18-19; AR 718-19, 721-33, 814- Thus, the ALJ s justification for rejecting the Los Angeles 10 County doctor s opinion--which undermined the ALJ s finding that 11 Plaintiff s mental impairment was not severe --does not withstand 12 scrutiny. 13 reconsideration. 14 Accordingly, the issue must be remanded for 4. Dr. Becraft s Opinion 15 Plaintiff contends that the ALJ s failure to consider Dr. 16 Becraft s January 14, 2004 mental residual functional capacity 17 assessment was error. 18 reasons, the Court agrees. 19 (Joint Stip. at 19-21.) For the following Although an ALJ is not bound by the findings of an agency 20 physician, he must consider such findings and must explain the 21 weight he gives to them. 22 Here, Dr. Becraft found that Plaintiff would have moderate limitations 23 in her ability to understand, remember, and carry out detailed 24 instructions, and in her ability to interact appropriately with the 25 public, and concluded that she should be limited to non-public simple 26 repetitive tasks. 27 findings, the ALJ found no functional limitations as a result of 28 Plaintiff s alleged mental impairment. 20 C.F.R. § 404.1527(f)(2)(I); SSR 96-6p. (AR 333-34, 337.) 13 In contrast to Dr. Becraft s (AR 17.) This was error. 1 The Agency argues that the ALJ s error was harmless, apparently 2 because it believes that Dr. Becraft s opinion was not probative of 3 disability during the period under review and because other state 4 agency physicians subsequently found that Plaintiff had no 5 determinable mental impairment or functional limitations. 6 Stip. at 12, 13.) 7 physician s opinion may be harmless error when the ALJ s opinion is 8 consistent with that opinion, see, e.g., Tibbs v. Astrue, 2008 WL 9 2705175, at *7-8 (C.D. Cal. July 7, 2008), the Court cannot find the 10 (Joint Although an ALJ s failure to address a reviewing error harmless here. 11 First, the ALJ did not reject Dr. Becraft s opinion for the 12 reasons now suggested by the Agency and the Court cannot look beyond 13 the four corners of the ALJ s decision in determining why he rejected 14 it. 15 Second, the Agency appears to overlook the fact that Plaintiff applied 16 for both DIB and SSI. 17 insured (March 2002) would be material to the SSI application. 18 e.g., Armstrong v. Comm r, Soc. Sec. Admin., 160 F.3d 587, 589 (9th 19 Cir. 1998) (noting ALJ granted SSI application after determining that 20 claimant became disabled after date last insured). 21 Becraft s findings from January 2004 are not necessarily called into 22 question by the later findings from December 2006 and May 2007 of Dr. 23 Salib and Dr. Loomis. 24 Plaintiff s claim that her mental impairment was severe, the ALJ 25 should have addressed it. 26 and explain the weight that he gives it. See Connett v. Barnhart, 340 F.3d 871, 874 (9th Cir. 2003). The evidence of disability after her date last See, Third, Dr. Because Dr. Becraft s opinion supports On remand the ALJ must consider the opinion 27 28 14 1 2 5. Dr. Estafan s Assessment Plaintiff next argues that the ALJ provided insufficient reasons 3 for rejecting the January 23, 2008 work capacity evaluation 4 assessment of his treating psychiatrist, Dr. Maged Estafan. 5 Stip. at 21-23.) 6 (Joint Here, the Court disagrees. Dr. Estafan indicated on a check-the-box form that he submitted 7 to Plaintiff s counsel that she would have extreme limitations in 8 almost every functional area, including the ability to understand and 9 remember very short and simple instructions. (AR 811-12.) He also 10 indicated that her impairment would cause her to miss three or more 11 days of work per month. 12 (AR 812.) The ALJ rejected this opinion on the grounds that he could not 13 discern who had completed and signed the form and because there were 14 no treating or progress records to support it. 15 Plaintiff correctly notes (and the Agency concedes) that it was signed 16 by Dr. Estafan, who treated Plaintiff at Riverside County Department 17 of Mental Health (AR 821), the ALJ was entitled to reject the opinion 18 on the basis that it was not supported by treatment notes. 19 the County s progress notes, or any other medical evidence in the 20 record, suggests that Plaintiff would have the extreme limitations 21 found by Dr. Estafan. 22 October 2007 that Plaintiff was showing significant improvement. 23 (AR 823.) 24 2008, are unremarkable. 25 and legitimate reason for rejecting Dr. Estafan s 26 assessment and it is supported by substantial evidence, it will be 27 upheld. 28 (9th Cir. 2004). (AR 17.) Although None of Treating psychiatrist Dr. Morales noted in Dr. Estafan s own notes from January 8 and February 1, (AR 814, 816.) Because this was a specific functional See Batson v. Comm r, Soc. Sec. Admin., 359 F.3d 1190, 1195 15 1 6. 2 3 The ALJ s Finding That Plaintiff s Mental Impairment Was Not Severe Plaintiff argues that, in light of the ALJ s failure to properly 4 consider the mental health record, he erred in concluding that her 5 mental impairment was not severe. 6 following reasons, the Court concludes that the ALJ must reconsider 7 his finding regarding the severity of Plaintiff s mental impairment on 8 remand. 9 (Joint Stip. at 23-25.) For the At step two of the sequential evaluation process, an ALJ is 10 tasked with identifying a claimant s severe impairments. 20 C.F.R. 11 §§ 404.1520(a)(4)(ii), 416.920(a)(4)(ii). 12 that significantly limits an individual's physical or mental ability 13 to do basic work activities. 14 §§ 404.1521(a), 416.921(a). 15 abilities and aptitudes necessary to do most jobs. 16 §§ 404.1521(b), 416.921(b). 17 have lasted or be expected to last for a continuous period of at least 18 12 months. 19 intended to be a de minimis screening device. 20 1290 (citing Bowen v. Yuckert, 482 U.S. 137, 153-54 (1987)). A severe impairment is one Smolen, 80 F.3d at 1290; 20 C.F.R. Basic work activities are the 20 C.F.R. For an impairment to be severe, it must 20 C.F.R. §§ 404.1509, 416.909. The step-two inquiry is Smolen, 80 F.3d at 21 As set forth above, the ALJ erred in not considering Dr. 22 Becraft s opinion and in rejecting the Los Angeles County treating 23 psychiatrist s opinion for reasons that are not supported in the 24 record. 25 reconsider whether, in light of that analysis, Plaintiff has a severe 26 mental impairment. On remand, the ALJ should address those opinions and 27 28 16 1 C. Plaintiff s Remaining Claims 2 Plaintiff contends that the ALJ erred in failing to incorporate 3 all of her limitations in his hypothetical question to the vocational 4 expert and in determining that she could perform her past relevant 5 work. 6 on the other issues outlined above, the ALJ will necessarily be 7 required to reconsider these issues on remand as well. (Joint Stip. at 25-27, 28-31.) IV. 8 9 10 11 In light of the Court s ruling CONCLUSION For these reasons, the Agency s decision is reversed and the case is remanded for further proceedings consistent with this opinion. 12 IT IS SO ORDERED. 13 DATED: March 29, 2011 14 15 16 PATRICK J. WALSH UNITED STATES MAGISTRATE JUDGE 17 18 19 20 21 22 23 24 25 26 27 28 S:\PJW\Cases-Soc Sec\RAMIREZ. N 1371\Memo_Opinion.wpd 17

Some case metadata and case summaries were written with the help of AI, which can produce inaccuracies. You should read the full case before relying on it for legal research purposes.

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.