Frances Willis v. Michael J Astrue, No. 2:2007cv07541 - Document 19 (C.D. Cal. 2008)
Court Description: MEMORANDUM OPINION AND ORDER Magistrate Judge Marc L. Goldman. This case is remanded to the Commissioner for further proceedings consistent with this opinion. (db)
Download PDF
<![CDATA[
1 2 3 4 5 6 7 8 UNITED STATES DISTRICT COURT 9 CENTRAL DISTRICT OF CALIFORNIA 10 WESTERN DIVISION 11 12 FRANCES WILLIS, 13 Plaintiff, 14 v. 15 MICHAEL J. ASTRUE, Commissioner of Social Security 16 Defendant. 17 ) ) ) ) ) ) ) ) ) ) ) Case No. CV 07-7541-MLG MEMORANDUM OPINION AND ORDER 18 19 I. Procedural and Factual History 20 Plaintiff Frances Willis ( Plaintiff ) seeks judicial review of 21 the Commissioner s final decision denying her application for Social 22 Security Disability Insurance ( DIB ) and Supplemental Security Income 23 ( SSI ) benefits. Plaintiff filed for SSI on October 26, 2001 24 (Administrative Record ( AR ) at 682) and for DIB on December 7, 2001. 25 (AR at 189). She alleges disability beginning June 20, 1998 due to 26 hypertension, osteoarthritis, and depression. (AR at 21). 27 Plaintiff was born on September 2, 1954 and was 52 years old at 28 the time of the administrative hearing. She completed a high school 1 education and two years of college. From 1985 to 1997, Plaintiff 2 worked as a counselor in a shelter for homeless parolees. (AR at 95). 3 In addition, for a few months during 2000, Plaintiff worked as a 4 counselor at a boys home. (AR at 50). 5 On January 3, 2002, Plaintiff s application was denied at the 6 initial stage of the administrative process. (AR at 18). A de novo 7 hearing was held on September 17, 2002, before Administrative Law 8 Judge ( ALJ ) Walter Fisher. (AR at 49-58). On March 18, 2003, the ALJ 9 issued an unfavorable decision ( Decision #1"), determining that 10 Plaintiff retained the residual functional capacity ( RFC ) to perform 11 her past relevant work. (AR at 128-136). Plaintiff appealed this 12 determination to the Appeals Council. On January 30, 2004, the Appeals 13 Council remanded the matter for further proceedings. (AR at 158-161). 14 On October 13, 2004, the ALJ again denied the application 15 ( Decision #2"), finding that Plaintiff retained the RFC to perform 16 her past relevant work. (AR at 162-171). Plaintiff appealed this 17 determination to the Appeals Council. On March 22, 2005, the Appeals 18 Council again remanded the matter for further proceedings. (AR at 17519 178). 20 On September 8, 2006, ALJ London Steverson denied the 21 applications ( Decision #3"), finding that Plaintiff retained the RFC 22 to perform her past relevant work. (AR at 137-145). Plaintiff appealed 23 the determination to the Appeals Council. On January 10, 2007, the 24 Appeals Council remanded for further proceedings. (AR at 183-185). 25 On June 27, 2007, the ALJ denied the applications ( Decision 26 #4"), finding that Plaintiff retained the RFC to perform her past 27 relevant work. (AR at 15-24). The ALJ found that Plaintiff s 28 hypertension and osteoarthritis were severe impairments. (AR at 20). 2 1 However, with respect to Plaintiff s claim of depression, the ALJ 2 found that she did not have a severe impairment within the meaning 3 of the Social Security regulations. (AR at 20-21); see 20 C.F.R. 4 §404.1520(c). The ALJ determined that Plaintiff could return to her 5 past relevant work as a homeless shelter counselor as it is generally 6 performed in the national economy. (AR at 23). The ALJ concluded that 7 Plaintiff was not disabled, as defined in the Social Security Act, at 8 any time from June 20, 1998 through the date of the decision. (AR at 9 24). Plaintiff appealed this determination to the Appeals Council. 10 On September 21, 2007, the Appeals Council denied Plaintiff s request 11 for review and Decision #4 became the final decision of the 12 Commissioner. (AR at 8-10). 13 Plaintiff timely commenced this action for judicial review. 14 Plaintiff contends that the ALJ erroneously concluded that Plaintiff s 15 mental impairment was not severe. The Commissioner disagrees and 16 requests that the Commissioner s final decision be affirmed. 17 After reviewing the parties respective contentions and the 18 record as a whole, the Court finds Plaintiff s contention regarding 19 the ALJ s non-severity finding to be meritorious and remands this 20 matter for further proceedings consistent with this opinion. 21 22 II. Standard of Review 23 Under 42 U.S.C. § 405(g), a district court may review the 24 Commissioner s decision to deny benefits. The Commissioner s or ALJ s 25 decision must be upheld unless the ALJ s findings are based on legal 26 error or are not supported by substantial evidence in the record as 27 a whole. Tackett v. Apfel, 180 F.3d 1094, 1097 (9th Cir. 1990); 28 Parra v. Astrue, 481 F.3d 742, 746 (9th Cir. 2007). Substantial 3 1 evidence means such evidence as a reasonable person might accept as 2 adequate to support a conclusion. Richardson v. Perales, 402 U.S. 3 389, 401 (1971); Widmark v. Barnhart, 454 F.3d 1063, 1066 (9th Cir. 4 2006). It is more than a scintilla, but less than a preponderance. 5 Robbins v. Soc. Sec. Admin., 466 F.3d 880, 882 (9th Cir. 2006). To 6 determine whether substantial evidence supports a finding, the 7 reviewing court must review the administrative record as a whole, 8 weighing both the evidence that supports and the evidence that 9 detracts from the Commissioner s conclusion. Reddick v. Chater, 157 10 F.3d 715, 720 (9th Cir. 1996). If the evidence can support either 11 affirming or reversing the ALJ s conclusion, the reviewing court may 12 not substitute its judgment for that of the ALJ. Robbins, 466 F.3d 13 at 882. 14 15 III. Discussion and Analysis 16 The Court agrees with Plaintiff that remand is warranted based 17 on the ALJ s erroneous finding that her mental impairment was non18 severe, because that decision is not supported by substantial 19 evidence. The existence of a severe impairment is demonstrated when 20 the evidence establishes that an impairment has more than a minimal 21 effect on an individual s ability to perform basic work activities. 22 Smolen v. Chater, 80 F.3d 1273, 1290 (9th Cir. 1996); 20 C.F.R. §§ 23 404.1521(a), 416.921(a). The regulations define basic work 24 activities as the abilities and aptitudes necessary to do most 25 jobs, which include physical functions such as walking, standing, 26 sitting, 27 speaking; pushing, carrying; understanding and capacities for remembering seeing, simple hearing and instructions; 28 responding appropriately in a work setting; and dealing with changes 4 1 in a work setting. 20 C.F.R. § 404.1521(b). The inquiry at this stage 2 is a de minimis screening device to dispose of groundless claims. 3 Smolen, 80 F.3d at 1290 (citing Bowen v. Yuckert, 482 U.S. 137, 153-54 4 (1987)). An impairment is not severe only if it is a slight 5 abnormality with no more than a minimal effect on an individual s 6 ability to work. See SSR 85-28; Webb v Barnhart, 433 F.3d 683, 686 7 (9th Cir. 2005); Yuckert v. Bowen, 841 F.2d 303, 306 (9th Cir. 1988). 8 Here, Plaintiff has offered sufficient evidence to demonstrate 9 that her mental impairment has more than a minimal effect on her 10 ability to perform work-related functions. Plaintiff testified 11 regarding her depression, anxiety and difficulty concentrating in four 12 separate hearings before the Social Security Administration s Office 13 of Hearings and Appeals (AR at 52-55, 67-68, 97-101, 121-122). 14 Further, Plaintiff s treating psychiatrist, Dr. Norma Aguilar, 15 diagnosed Plaintiff with depression and anxiety. Dr. Aguilar s report 16 indicates a level of impairment that meets the de minimis 17 requirement at this stage of the inquiry. Smolen, 80 F.3d at 1290. 18 The ALJ did not persuasively explain why he rejected these findings. 19 On July 15, 2003, Plaintiff began treatment at Compton Mental 20 Health Center for depression, anxiety and insomnia(AR at 605). She was 21 seen by Dr. Aguilar on a regular basis for over four years. (AR at 22 593-615). Plaintiff also received individual psychological therapy at 23 Compton Mental Health Center approximately once a month. (AR at 606). 24 In a Mental Impairment Questionnaire completed on May 2, 2005, Dr. 25 Aguilar diagnosed Plaintiff with major depressive disorder and 26 assessed Plaintiff with a Global Assessment of Functioning ( GAF ) 27 scale of 60. (AR at 606). Dr. Aguilar observed that Plaintiff was 28 disheveled and tearful and that her mood is depressed. (AR at 5 1 607). Dr. Aguilar also noted that Plaintiff felt worthless because 2 she could not take care of herself anymore. (AR at 607). Dr. Aguilar 3 found that Plaintiff s prognosis was guarded to poor. (AR at 608). 4 Dr. Aguilar determined that Plaintiff had slight limitation in the 5 activities of daily living, but extreme difficulties in maintaining 6 social functioning, constant limitation in concentration, persistence, 7 or pace, and continual limitation in work settings. (AR at 609). Dr. 8 Aguilar prescribed the prescription medications Lexapro, Desyrel and 9 Remeron, as well as monthly individual counseling. (AR at 607). 10 The ALJ did not give significant weight to Dr. Aguilar s opinion, 11 finding it to be internally inconsistent which lessens its 12 credibility. (AR at 21). The ALJ stated: Dr. Aguilar opines that the 13 claimant only has slight limitations on her ability to perform 14 activities of daily living, which suggest that her ability to maintain 15 concentration, persistence and pace is not severely limited, in 16 contrast to Dr. Aguilar s opinion that she has extreme difficulty 17 maintaining concentration, persistence or pace. (AR at 21). 18 In rejecting Dr. Aguilar s opinion, the ALJ adopted the opinion 19 of the examining physician, Dr. Suzanne Dupee. (AR at 21). Dr. Dupee, 20 who examined Plaintiff on one occasion, on December 5, 2005, concluded 21 that Plaintiff had some mild symptoms of depression, but that 22 Plaintiff had no cognitive deficits that would impair her ability to 23 work at this time. (AR at 628). The ALJ found that Plaintiff s 24 treating physician s opinion was contradicted by the consultative 25 examination by Dr. Dupee, who gave [Plaintiff] a GAF score of 65, 26 with no more than slight mental functional limitations. 27 Plaintiff contends, and the Court agrees, that the examining 28 physician s opinion was not a valid basis for rejecting the treating 6 1 physician s opinion. A treating physician s opinion must be given 2 controlling weight if it is well-supported and not inconsistent with 3 the other substantial evidence in the record. Orn v. Astrue, 495 F.3d 4 625, 631-32 (9th Cir. 2007); 20 C.F.R. § 404.1527(d)(2). The ALJ may 5 not reject the opinion of a treating physician, even if it is 6 contradicted by the opinion of another doctor, without first providing 7 specific and legitimate reasons supported by substantial evidence in 8 the record. Lester v. Chater, 81 F.3d 821, 830-31 (9th Cir. 1996); 9 Rollins v. Massanari, 261 F.3d 853, 856 (9th Cir. 2001); Murray v. 10 Heckler, 722 F.2d 499, 502 (9th Cir. 1983) ( If the ALJ wishes to 11 disregard the opinion of the treating physician, he or she must make 12 findings setting forth specific, legitimate reasons for doing so that 13 are based on substantial evidence in the record ). An examining 14 physician s opinion constitutes substantial evidence if the physician 15 relied on independent clinical findings that differ from the findings 16 of the treating physician. Orn, 495 F.3d at 631-32. 17 Even if there is evidence in the record contradicting a treating 18 physician s opinion, the opinion is still entitled to deference and 19 must be weighed using the following factors: [l]ength of the 20 treatment relationship and the frequency of examination by the 21 treating physician; and the nature and extent of the treatment 22 relationship between the patient and the treating physician. 20 23 C.F.R. §§ 404.1527(d)(2)(i)-(ii), 416.927(d)(2)(i)-(ii); Orn, 495 F.3d 24 at 631-33. Other factors to be considered include the supportability 25 of the treating physician s opinion, consistency with the record as 26 a whole, the specialization of the physician, and the extent to which 27 the physician is familiar with disability programs and evidentiary 28 requirements. 20 C.F.R. §§ 404.1527(d)(3)-(6), 416.927(d)(3)-(6). 7 1 Thus, [i]n many cases, a treating source s medical opinion will be 2 entitled to the greatest weight and should be adopted, even if it does 3 not meet the test for controlling weight. S.S.R. 96-2p; Orn, 495 F.3d 4 at 632-633. 5 Here, even if the opinion of Dr. Dupee constitutes substantial 6 evidence, Dr. Aguilar s opinion was still entitled to deference. SSR 7 96-2p; Orn, 495 F.3d at 633. Indeed, the factors identified in the 8 regulations weigh in favor of Dr. Aguilar s opinion. 20 C.F.R. §§ 9 404.1527, 416.927. 10 relationship with For example, the nature and extent of Plaintiff s Dr. Aguilar provides a unique longitudinal 11 perspective on Plaintiff s mental condition, adding weight to Dr. 12 Aguilar s opinion. See 20 C.F.R. §§ 13 416.927(d)(2)(i)-(ii); Orn, 495 F.3d at 633. 404.1527(d)(2)(i)-(ii), As discussed above, the 14 lengthy administrative record contains countless medical forms and 15 progress reports completed by Dr. Aguilar over a period of more than 16 four years. Dr. Aguilar offered diagnoses of Plaintiff s mental 17 condition, made clinical findings, assessed Plaintiff s ability to 18 work, and prescribed a variety of medications. 19 While Dr. Aguilar s progress notes do not reveal detailed 20 discussions regarding Plaintiff s mental condition, [t]he primary 21 function of medical records is to promote communication and 22 recordkeeping for health care personnel - not to provide evidence for 23 disability determinations. Orn, 495 F.3d at 634. Dr. Aguilar did, 24 however, provide a more reasoned explanation for her opinion in the 25 Mental Impairment Questionnaire by referring to Plaintiff s symptoms, 26 signs, and prognosis. (AR at 784-87, 911-14); see 20 C.F.R. §§ 27 404.1527(d)(3) ( Supportability. The more a medical source presents 28 relevant evidence to support an opinion, particularly medical signs 8 1 and laboratory findings, the more weight we will give that opinion. ), 2 416.927(d)(3) (same); see also Orn, 495 F.3d at 634 ( A medical 3 condition [need not] be mentioned in every report to conclude that a 4 physician s opinion is supported by the record. ). Thus, when viewed 5 in its entirety, the record provides ample support for Dr. Aguilar s 6 opinion. 7 Moreover, the ALJ s finding at step two of the sequential 8 analysis was not supported by substantial factual evidence. In 9 addition to his reliance on the consulting doctor s opinion in 10 concluding that Plaintiff does not suffer from a severe mental 11 impairment, the ALJ cited various facts which, even when viewed 12 collectively, do not constitute substantial evidence. (AR at 21). 13 First, the ALJ noted that there were [g]aps in [Plaintiff s] mental 14 health treatment. The ALJ did not, however, specifically identify any 15 gaps in Plaintiff s mental health history or articulate how such gaps 16 demonstrate that Plaintiff s impairment is not severe. Second, the ALJ 17 stated that the medication logs indicate that much of the cause of 18 the claimant s mental symptoms was due to her appeal of these claims, 19 rather than due to an ongoing underlying mental impairment. (AR at 20 21). The single page in Plaintiff s medical records to which the ALJ 21 refers in support of this argument merely states that, on the day of 22 her appointment with Dr. Aguilar, Plaintiff was feeling anxious 23 because she [was] going to court for SSI. (AR at 675). Third, the ALJ 24 noted that the claimant s mental health treatment consists primarily 25 of medication refills and not counseling. To the contrary, Plaintiff 26 testified at three separate hearings that she is seeing a therapist 27 for individual counseling on a monthly basis, in addition to her 28 regular visits to Dr. Aguilar (RT at 66, 100-101, 121-122). Finally, 9 1 the only other factual evidence the ALJ identified to support his 2 finding of non-severity was that Plaintiff s medication logs indicate 3 that [Plaintiff s] response was fair and she denied suicidal 4 ideations, which indicates that medication controls her symptoms, and 5 that Plaintiff has never been psychiatrically hospitalized. (AR at 6 21). 7 Given the minimal threshold required to show that an impairment 8 is severe, the ALJ s determination that Plaintiff s mental impairments 9 are not severe was not supported by substantial evidence. First, the 10 ALJ did not sufficiently articulate any reason to reject the objective 11 findings of Plaintiff s treating physician. Plaintiff s impairments 12 and complaints of anxiety and depression are consistently and 13 objectively documented in her medical records. Second, the factual 14 evidence upon which the ALJ based his decision does not, without more, 15 support a finding of non-severity. The ALJ appears not to have 16 considered the record as a whole, but instead emphasized 17 selective evidence which was unfavorable to Plaintiff. 18 the ALJ s failure to find Plaintiff s mental only Accordingly, impairment severe 19 warrants remand for further proceedings and evaluation of Plaintiff. 20 21 V. Conclusion 22 The decision whether to remand for further proceedings is within 23 this Court s discretion. Harman v. Apfel, 211 F.3d 1172, 1175-78 (9th 24 Cir. 2000). Where no useful purpose would be served by further 25 administrative proceedings, or where the record has been fully 26 developed, it is appropriate to exercise this discretion to direct an 27 immediate award of benefits. Id. at 1179 ( the decision of whether 28 to remand for further proceedings turns upon the likely utility of 10 1 such proceedings ); Benecke v. Barnhart, 379 F.3d 587, 593 (9th Cir. 2 2004). However, where there are outstanding issues that must be 3 resolved before a determination of disability can be made, and it is 4 not clear from the record that the ALJ would be required to find the 5 claimant disabled if all the evidence were properly evaluated, remand 6 is appropriate. Bunnell v. Barnhart, 336 F.3d 1112, 1115-16 (9th Cir. 7 2003); see also Connett v. Barnhart, 340 F.3d 871, 876 (9th Cir. 8 2003)(remanding case for reconsideration of credibility 9 determination). 10 Here, the evidence shows an impairment that can be considered 11 severe within the meaning of the Social Security Regulations, but 12 which might not prevent Plaintiff from performing either her past work 13 or some work in the national economy. However, that is not a 14 determination that this Court can make. Accordingly, the case is 15 remanded for further evaluation in accordance with the five-step 16 sequential process. 17 18 ORDER For the reasons stated above, it is ORDERED that this case be 19 remanded to the Commissioner for further proceedings consistent with 20 this opinion. 21 22 Dated: October 2, 2008 23 24 ________________________ Marc L. Goldman United States Magistrate Judge 25 26 27 28 11
]]>
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.
