Matilde Michel Sanchez v. Michael J Astrue, No. 2:2011cv07869 - Document 25 (C.D. Cal. 2012)
Court Description: MEMORANDUM OPINION AND ORDER by Magistrate Judge Victor B. Kenton. this matter will be remanded for further hearing consistent with this Memorandum Opinion. IT IS SO ORDERED. 1 (gr)
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1 2 3 4 5 6 UNITED STATES DISTRICT COURT CENTRAL DISTRICT OF CALIFORNIA WESTERN DIVISION 7 8 9 10 11 MATILDE MICHEL SANCHEZ, 12 Plaintiff, 13 14 15 v. MICHAEL J. ASTRUE, Commissioner of Social Security, 16 Defendant. ) ) ) ) ) ) ) ) ) ) ) ) No. CV 11-07869-VBK MEMORANDUM OPINION AND ORDER (Social Security Case) 17 18 This matter is before the Court for review of the decision by the 19 Commissioner of Social Security denying Plaintiff s application for 20 disability benefits. Pursuant to 28 U.S.C. §636(c), the parties have 21 consented that the case may be handled by the Magistrate Judge. The 22 action arises under 42 U.S.C. §405(g), which authorizes the Court to 23 enter judgment upon the pleadings and transcript of the Administrative 24 Record ( AR ) before the Commissioner. The parties have filed the 25 Joint Stipulation ( JS ), and the Commissioner has filed the certified 26 AR. 27 28 Plaintiff raises the following issues: 1. Whether the decision of the Administrative Law Judge ( ALJ ) 1 2 is supported by substantial evidence (JS at 3); and 2. Whether the ALJ failed to provide clear and convincing 3 reasons to reject Plaintiff s subjective symptoms (JS at 4 13). 5 6 This Memorandum Opinion will constitute the Court s findings of 7 fact and conclusions of law. After reviewing the matter, the Court 8 concludes 9 Commissioner must be reversed and the matter remanded. that for the reasons set forth, the decision of the 10 11 I 12 THE ALJ FAILED TO PROVIDE CLEAR AND CONVINCING REASONS 13 TO REJECT PLAINTIFF S SUBJECTIVE COMPLAINTS 14 15 A. Introduction. 16 This is a case in which Plaintiff received a very significant 17 amount of treatment for joint pain, ultimately resulting in a 18 diagnosis of an autoimmune disorder. 19 treatment notes, yet there is not an opinion from a treating physician 20 as to Plaintiff s exertional capacity. 21 agency or the ALJ for failure to provide this information. The agency 22 requested Plaintiff s treating sources to provide such statements (AR 23 191, 345), and the ALJ issued a subpoena to Harbor-UCLA Medical Center 24 requiring it to produce Plaintiff s medical records (AR 141, 392-431). 25 Plaintiff is not a native English speaker, and was assisted by an 26 interpreter at the hearing before the ALJ. (AR 35-48.) 27 Plaintiff s preferred language is Spanish and she does speak or 28 understand English. (AR 156.) There are hundreds of pages of The Court cannot fault the Indeed, The highest grade of school that 2 1 Plaintiff completed was fifth grade in Mexico. (AR 162.) 2 Consequently, while, as the Court has indicated, the agency and the 3 ALJ took appropriate steps to develop the record, nevertheless, it may 4 also be observed that Plaintiff may not have had the sophistication 5 herself to obtain diagnostic and treatment records, and the fact that 6 she did not have the assistance of counsel underscores the point. 7 What results from the above combination of factors is a medical 8 record which is replete with extensive treatment notes, but a lack of 9 diagnostic opinions from treating sources. Thus, the ALJ made a 10 determination of Plaintiff s RFC based primarily upon the analysis of 11 a DDS analyst who does not appear to be a physician, and a one-time 12 examination by a consultative internist. (See AR 29, 386-391, 379- 13 384.) 14 which the ALJ determined Plaintiff s RFC. The Court is sympathetic to 15 this argument, but, for reasons to be stated, sees no need to make an 16 ultimate determination. 17 may well have been justified in relying upon a single examination of 18 a consultative examiner and a report of a DDS analyst in determining 19 Plaintiff s RFC. 20 for further hearing based upon Plaintiff s second issue, and, it is 21 likely that Plaintiff will be represented at the remand proceedings, 22 there 23 developed. 24 is the credibility determination. 25 // 26 // 27 // 28 // Plaintiff s first issue focuses upon the sparse basis upon will be From a strictly legal point of view, the ALJ But, since the Court will be remanding this matter a better chance that the record may be further Therefore, the Court will turn to the second issue, which 3 1 II 2 THE ALJ S CREDIBILITY DETERMINATION IS DEFICIENT, 3 AND PLAINTIFF S CREDIBILITY WILL BE REEVALUATED ON REMAND 4 The following constitutes the entire credibility discussion and 5 analysis of the ALJ as contained in his Decision: 6 However, I must also address the credibility of 7 [Plaintiff] as it relates to statements made regarding the 8 extent and severity of [Plaintiff s] impairments and the 9 limitations they cause. 10 credibility 11 prescription 12 treating physicians. 13 going back to the late 1990s. 14 had access to treatment and continues to have access to 15 treatment for her conditions. 16 that she has access to treatment through Medi-Cal. In spite 17 of 18 [Plaintiff s] condition was not always diagnosable, meaning 19 that [Plaintiff] had numerous complaints but did not always 20 have a formal diagnosis to correspond to her complaints. 21 Additionally, even though her records show a diagnosis of 22 systemic sclerosis, [Plaintiff] testified that the specific 23 diagnosis for her condition is still uncertain. 24 [Plaintiff] has access to treatment and is using her access 25 to seek treatment for her numerous complaints; however, her 26 complaints do not always receive a formal diagnosis which 27 shows little support for here overall allegations. 28 find [Plaintiff s] credibility is diminished. the is her One factor affecting [Plaintiff s] treatment medications access to given history to including [Plaintiff] by the her [Plaintiff] has records of treatment This shows that [Plaintiff] treatment 4 [Plaintiff] even testified the records show that In sum, Thus, I 1 Also affecting [Plaintiff s] credibility is the 2 consistency of her statements with the medical evidence of 3 record and with other statements she made concerning her 4 condition. 5 a result of her physical condition. However, [Plaintiff] has 6 not sought treatment for her alleged depression. 7 [Plaintiff] does not feel her depression is disabling even 8 though she alleges that it is present. 9 allegations [Plaintiff] indicated that she is depressed as of depression evidence of Therefore her inconsistent record. with 10 objective 11 Thus, I the [Plaintiff s] credibility is further diminished. 12 medical are As such find (AR 30.) 13 14 The ALJ is certainly correct in observing that Plaintiff has 15 undergone extensive and continuous treatment for her symptoms. 16 previously 17 treatment notes. The relevant period for this case begins in December 18 2006. Plaintiff was treated at La Vida Multi-Specialty Medical, where 19 her 20 shoulders, knees, and her finger bones. (AR 386-391.) 21 fact that Plaintiff indicated that she was prescribed and was taking 22 Prednisone, she indicated her symptoms had continued for the past four 23 to five months. 24 physical 25 tenderness, weakness and swelling of the hands and the finger joints, 26 pain and swelling of the wrists, and effusion of the knees. (Id.) 27 doctor doubled her Prednisone prescription and added another drug, 28 Methotrexate. noted, symptoms the included record pain contains and substantial swelling in her and As extensive hands, wrists, Despite the The treating doctor confirmed her complaints, and on examination, found that there was swelling and edema, The She was diagnosed at that time with inflammatory 5 1 arthritis ruling out a diagnosis of scleroderma. 2 In February 2007, there are followup treatment notes which appear 3 to corroborate Plaintiff s pain complaints. 4 her pain was so intense that the drug Darvocet provided only minor or 5 mild benefit. 6 finger flexion, and painful inflammation of her finger. (AR 366.) Her 7 diagnosis 8 medications were changed from Prednisone, which had only helped her 9 minimally, to another drug, Lisinopril and extra-strength Vicodin. at In fact, she indicated An examination indicated she had a markedly decreased that time was systemic sclerosis. Her treatment 10 She was ordered off work until August of 2007. 11 considered her disabled in February 2007 until at least August of that 12 year. (AR 368.) 13 Her treating doctors There are further treatment notes from La Vida which document 14 continued 15 presented with weakness, swelling, and trouble even making a fist. (AR 16 366.) 17 improvement, 18 shoulder, hands and knee pain. (AR 363.) 19 November 2007 she still complained of pain in her knees, fingers and 20 shoulders. 21 continued as systemic sclerosis and she was restarted on Lisinopril. 22 (AR 360.) 23 similar Although she symptoms by but September still fail 2007 suffered to she from show had improvement. some diffuse She temporary mild arthralgias with In treatment notes from In 2008, treatment notes indicate that the diagnosis was Plaintiff also received treatment at St. Francis Medical Center 24 and Clinica Medica Virgin de Guadalupe. 25 records from St. Francis and 101 pages from Clinica Medica Virgin de 26 Guadalupe which document these symptoms, which continued. In addition 27 there are 40 pages of records from Harbor UCLA which document that 28 Plaintiff suffered from continued pain, weakness and swelling in her 6 There are 165 pages of 1 joints. (AR 396.) 2 In May 2008, treatment notes indicate she again presented with 3 joint pain over her body, back pain, shortness of breath, positive 4 edema to upper and lower extremities, bilateral weakness of the upper 5 and lower extremities, weak grip straight bilaterally and lower 6 extremity weakness. (AR 401.) 7 Plaintiff complained of generalized fatigue, bilateral upper and lower 8 extremity swelling, shortness of breath. 9 indication of scarring in her right lung and nodules in her left lung 10 In other notes, it is indicated that In testing, there was an related to systemic sclerosis.1 11 An ALJ faces a high burden if he or she chooses to diminish 12 Plaintiff s credibility. It must be based upon clear and convincing 13 reasons. 14 citing Dodrill v. Shalala, 12 F.3d 915, 918 (9th Cir. 1993). 15 Reddick v. Chater, 157 F.3d 715, 722 (9th Cir. 1998)(citing Lester v. 16 Chater, supra). See Smolen v. Chater, 80 F.3d 1273, 1282 (9th Cir. 1966), See also 17 In this case, the factors cited by the ALJ, contained in the 18 above quoted portion of his Decision, are irrelevant to a credibility 19 determination, and come close to being a non sequitur. 20 Court 21 articulation of his reasons for diminishing Plaintiff s credibility. 22 The has fact had that extensive Plaintiff difficulty sought and in understanding obtained Indeed, the the treatment ALJ s and was 23 24 25 26 27 28 1 It is of some significance that the one consultative examiner, Dr. Lynn, failed to review any of these medical records. Without doubt, Dr. Lynn s failure to review any records, and instead rely only on a short, one-time examination, must reflect on the weight of his opinion, particularly in view of the fact that he is the only physician who rendered information as to Plaintiff s physical exertional abilities, and the ALJ substantially relied upon this opinion in his Decision. 7 1 prescribed powerful medications for her pain would seem, in itself, to 2 support her credibility as to pain complaints, rather than to detract 3 from it. 4 absolutely no fault of her own. The fact that her condition was difficult to diagnose is 5 As to the ALJ s indication that Plaintiff s complaints are not 6 consistent with the medical evidence of record and other statements 7 she made concerning her condition, this is so vague and ambiguous 8 that the Court has no basis to review it. 9 records would seem to indicate that there is consistency between 10 Plaintiff s pain complaints and the corroboration of those complaints 11 by her doctors, who treated her and, as indicated, prescribed strong 12 prescription medications. But a review of the medical 13 Finally, Plaintiff claimed to be depressed as a result of her 14 condition, but the ALJ found that this diminished her credibility 15 because she has not sought treatment for depression. Again, the Court 16 has difficulty understanding this rationale. 17 that a person who suffers from continuous and painful joint pain 18 throughout her body would experience some depression. 19 Plaintiff did not go to a psychiatrist or seek to be medicated for 20 this depression has no relevance to the analysis. 21 Plaintiff used the term depression in the generic sense, not in the 22 psychiatric context, and indeed, Plaintiff makes no claim here that 23 she is disabled for mental health reasons. 24 should be considered along with her substantial work record. In other 25 words, it would appear that Plaintiff has done her best to cope with 26 her pain. 27 28 It would seem obvious The fact that It is clear that That is laudable, and Plaintiff has asked the Court to remand the case for calculation of benefits. After some consideration, the Court declines to do so, 8 1 because it would seem clear that on remand, Plaintiff s RFC must be 2 reevaluated carefully, and not just based upon the opinion of a DDS 3 analyst and a one-time consultative examiner who never reviewed the 4 extensive 5 credibility factors cited in this decision will be relied upon. 6 7 8 medical records. Further, on remand, none 11 the For the foregoing reasons, this matter will be remanded for further hearing consistent with this Memorandum Opinion. IT IS SO ORDERED. 9 10 of DATED: November 5, 2012 /s/ VICTOR B. KENTON UNITED STATES MAGISTRATE JUDGE 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 9
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