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Kiser v. Commissioner of Social Security

United States District Court, W.D. Michigan, Southern Division

July 13, 2017

RONALD W. KISER, Plaintiff,
v.
COMMISSIONER OF SOCIAL SECURITY, Defendant,

          OPINION

          HON. ROBERT J. JONKER JUDGE

         This is a social security action brought under 42 U.S.C. § 405(g) seeking judicial review of a final decision by the Commissioner of the Social Security Administration (Commissioner) denying Plaintiff's claim for disability insurance benefits (DIB) and supplemental security income (SSI) under Titles II and XVI of the Social Security Act. Section 405(g) limits the Court to a review of the administrative record, and provides that if the Commissioner's decision is supported by substantial evidence, it shall be conclusive. The Commissioner has found that Plaintiff is not disabled within the meaning of the Act.

         STANDARD OF REVIEW

         The scope of judicial review in a social security case is limited to determining whether the Commissioner applied the proper legal standards in making her decision and whether there exists in the record substantial evidence supporting that decision. See Brainard v. Sec'y of Health & Human Servs., 889 F.2d 679, 681 (6th Cir. 1989). The Court may not conduct a de novo review of the case, resolve evidentiary conflicts, or decide questions of credibility. See Garner v. Heckler, 745 F.2d 383, 387 (6th Cir. 1984). It is the Commissioner who is charged with finding the facts relevant to an application for disability benefits, and her findings are conclusive provided they are supported by substantial evidence. See 42 U.S.C. § 405(g).

         Substantial evidence is more than a scintilla, but less than a preponderance. See Cohen v. Sec'y of Health & Human Servs., 964 F.2d 524, 528 (6th Cir. 1992) (citations omitted). It is such relevant evidence as a reasonable mind might accept as adequate to support a conclusion. See Richardson v. Perales, 402 U.S. 389, 401 (1971); Bogle v. Sullivan, 998 F.2d 342, 347 (6th Cir. 1993). In determining the substantiality of the evidence, the Court must consider the evidence on the record as a whole and take into account whatever evidence in the record fairly detracts from its weight. See Richardson v. Sec'y of Health & Human Servs., 735 F.2d 962, 963 (6th Cir. 1984). The substantial evidence standard presupposes the existence of a zone within which the decision maker can properly rule either way, without judicial interference. See Mullen v. Bowen, 800 F.2d 535, 545 (6th Cir. 1986) (citation omitted). This standard affords to the administrative decision maker considerable latitude, and indicates that a decision supported by substantial evidence will not be reversed simply because the evidence would have supported a contrary decision. See Bogle, 998 F.2d at 347; Mullen, 800 F.2d at 545.

         PROCEDURAL POSTURE

         Plaintiff was forty-three years of age on the date of the ALJ's decision. (PageID.47, 134, 145.) He left high school in the tenth grade, but subsequently earned his GED. (PageID.79, 254.) Plaintiff has previously been employed as an order clerk, loan clerk, and as a floral designer. (PageID.124-125.) Plaintiff applied for benefits on February 26, 2013, alleging disability beginning February 28, 2011, due to bipolar disorder, schizophrenia, anxiety disorder, ADHD, and prominent schizopersonality traits. (PageID.134, 145, 212-226.) These applications were denied on June 4, 2013, after which time Plaintiff requested a hearing before an ALJ. (PageID.159-168.) On January 13, 2015, Plaintiff appeared with his counsel before ALJ William Leland for an administrative hearing at which time Plaintiff, Ms. Cathy Groh (Plaintiff's mother) and a vocational expert (VE) all testified. (PageID.70-132.) On January 22, 2015, the ALJ issued an unfavorable written decision that concluded Plaintiff was not disabled. (PageID.47-69.) On May 12, 2016, the Appeals Council declined to review the ALJ's decision, making it the Commissioner's final decision in the matter. (PageID.42-45.) Plaintiff subsequently initiated this action under 42 U.S.C. § 405(g).

         ALJ'S DECISION

         The social security regulations articulate a five-step sequential process for evaluating disability. See 20 C.F.R. §§ 404.1520(a-f), 416.920(a-f).[1] If the Commissioner can make a dispositive finding at any point in the review, no further finding is required. See 20 C.F.R. §§ 404.1520(a), 416.920(a). The regulations also provide that if a claimant suffers from a nonexertional impairment as well as an exertional impairment, both are considered in determining the claimant's residual functional capacity (RFC). See 20 C.F.R. §§ 404.1545, 416.945.

         Plaintiff has the burden of proving the existence and severity of limitations caused by his impairments and that he is precluded from performing past relevant work through step four. Jones v. Comm'r of Soc. Sec., 336 F.3d 469, 474 (6th Cir. 2003). At step five, it is the Commissioner's burden “to identify a significant number of jobs in the economy that accommodate the claimant's residual functional capacity (determined at step four) and vocational profile.” Id.

         ALJ Leland determined Plaintiff's claim failed at step five. At step one, the ALJ found that Plaintiff had not engaged in substantial gainful activity since his alleged disability onset date. (PageID.52.) At step two, the ALJ found that Plaintiff suffered from the severe impairments of depression, bipolar disorder, schizoaffective personality, anxiety disorder, post-traumatic stress disorder, and attention deficit disorder. (PageID.52-53.) At step three, the ALJ found that Plaintiff did not have an impairment or combination of impairments that met or equaled the requirements of the Listing of Impairments found in 20 C.F.R. Pt. 404, Subpt. P, App. 1. (PageID.53-55.) At step four, the ALJ determined Plaintiff retained the RFC based on all the impairments:

to perform a full range of work at all exertional levels but with the following nonexertional limitations: the claimant is limited to simple, routine, and repetitive tasks but not at production rate pace such as assembly line work. He is limited to simple work related decisions. The claimant can occasionally respond appropriately to supervisors, co-workers and the public. He is limited to simple work related decisions in dealing with changes in the work setting. Additionally, time off task can be accommodated by normal breaks.

         (PageID.55-56.) Continuing with the fourth step, the ALJ determined that Plaintiff was unable to perform any of his past relevant work. (PageID.63.) At the fifth step, the ALJ questioned the VE to determine whether a significant number of jobs exist in the economy that Plaintiff could perform given his limitations. See Richardson, 735 F.2d at 964. The VE testified that Plaintiff could perform work in the following representative jobs: laundry laborer (2, 000 regional and 100, 000 national positions), dryer attendant (1, 000 regional and 50, 000 national positions), and general helper (2, 000 regional and 150, 000 national positions). (PageID.125-126.) Based on this record, the ALJ found that Plaintiff was capable of making a successful adjustment to work that exists in significant numbers in the national economy. (PageID.64.)

         Accordingly, the ALJ concluded that Plaintiff was not disabled from February 28, 2011, the alleged disability onset date, through January 22, 2015, the date of decision. (PageID.64-65.)

         DISCUSSION

         Plaintiff raises a number of issues that all touch on, to some degree, the ALJ's evaluation of an opinion from Dr. Kameswara Tatineni, Plaintiff's treating psychiatrist. Accordingly, the Court begins by addressing Plaintiff's argument that the ALJ's treatment of the opinion fails to satisfy the treating physician rule.

         1. The ALJ's Evaluation of the Treating Physician Opinion.

         On January 5, 2015, Dr. Tatineni responded to prepared questions that addressed Plaintiff's impairments and limitations. (PageID.629-631.) On the same date, the doctor gave a written declaration, in Q & A format, that provided some explanation for the limitations he provided. (PageID.681-685.) In both the worksheet and in the declaration, Dr. Tatineni reported that Plaintiff was more limited than as the ALJ ultimately concluded. The ALJ concluded that the opinion did not merit “much weight.” (PageID.61.) Plaintiff argues that he is entitled to relief on the ground that the ALJ failed to articulate good reasons for discounting the opinion of his treating physician.

         A.The Treating Physician Doctrine Generally.

         By way of background, the treating physician doctrine recognizes that medical professionals who have a long history of caring for a claimant and his maladies generally possess significant insight into his medical condition. See Barker v. Shalala, 40 F.3d 789, 794 (6th Cir. 1994). An ALJ must, therefore, give controlling weight to the opinion of a treating physician if: (1) the opinion is “well-supported by medically acceptable clinical and laboratory diagnostic techniques” and (2) the opinion “is not inconsistent with the other substantial evidence in the case record.” Gayheart v. Comm'r of Soc. Sec., 710 F.3d 365, 375-76 (6th Cir. 2013) (quoting 20 C.F.R. § 404.1527). It is undisputed that Dr. Tatineni offered an opinion that was subject to the treating physician doctrine.

         Such deference is appropriate, however, only where the particular opinion “is based upon sufficient medical data.” Miller v. Sec'y of Health & Human Servs., 1991 WL 229979 at *2 (6th Cir., Nov. 7, 1991) (citing Shavers v. Sec'y of Health & Human Servs., 839 F.2d 232, 235 n.1 (6th Cir. 1987)). The ALJ may reject the opinion of a treating physician where such is unsupported by the medical record, merely states a conclusion, or is contradicted by substantial medical evidence. See Cohen, 964 F.2d at 528; Miller, 1991 WL 229979 at *2 (citing Shavers, 839 F.2d at 235 n.1); Cutlip v. Sec'y of Health & Human Servs., 25 F.3d 284, 286-87 (6th Cir. 1994).

         If an ALJ accords less than controlling weight to a treating source's opinion, the ALJ must provide “good reasons” for doing so. Gayheart, 710 F.3d at 376. Such reasons must be “supported by the evidence in the case record, and must be sufficiently specific to make clear to any subsequent reviewers the weight the adjudicator gave to the treating source's medical opinion and the reasons for that weight.” Id. This requirement “ensures that the ALJ applies the treating physician rule and permits meaningful review of the ALJ's application of the rule.” Id. (quoting Wilson v. Comm'r of Soc. Sec., 378 F.3d 541, 544 (6th Cir. 2004)). Simply stating that the physician's opinions “‘are not well-supported by any objective findings' and are ‘inconsistent with other credible evidence'” is, without more, too “ambiguous” to permit meaningful review of the ALJ's assessment. Id. at 376-77.

         If the ALJ affords less than controlling weight to a treating physician's opinion, the ALJ must still determine the weight to be afforded such. Gayheart, 710 F.3d at 376. In doing so, the ALJ must consider the following factors: (1) length of the treatment relationship and frequency of the examination; (2) nature and extent of the treatment relationship; (3) supportability of the opinion; (4) consistency of the opinoin with the record as a whole; (5) the specialization of the treating source; and (6) other relevant factors. Id. (citing 20 C.F.R. § 404.1527). While the ALJ is not required to explicitly discuss each of these factors, the record must nevertheless reflect that the ALJ considered those factors relevant to his assessment. See, e.g., Oldham v. Astrue, 509 F.3d 1254, 1258 (10th Cir. 2007); Undheim v. Barnhart, 214 F. App'x 448, 450 (5th Cir. 2007).

         B. Dr. Tatineni's Assessment.

         On the completed worksheet, Dr. Tatineni first responded to questions concerning the mental abilities and aptitudes that were needed to do unskilled work. The worksheet listed sixteen different abilities, and asked the doctor to indicate Plaintiff's limitations in one of five provided categories: being unlimited or very good, limited but satisfactory, seriously limited, unable to meet competitive standards, and no useful ability to function.[2] Dr. Tatineni checked boxes indicating Plaintiff had no useful ability to function in two areas, was unable to meet competitive standards in nine areas, was seriously limited in two areas, was limited but satisfactory in two areas, and had no limitation in one area. (PageID.629-630.)

         The doctor then described Plaintiff's functional limitations in four areas that are commonly known as the “paragraph b” criteria of a listed mental impairment. Dr. Tatineni noted that Plaintiff had marked restrictions in activities of daily living, extreme difficulties in maintaining social functioning, marked difficulties in maintaining concentration, persistence or pace, and had experienced no episodes of decompensation of extended duration within a twelve month period.[3](PageID.630.) Finally, the doctor indicated that were Plaintiff to work, he would expect Plaintiff to be absent more than four days each month and further stated that Plaintiff was incapable of managing benefits in his best interest. (PageID.631.)

         C. Analysis of the ALJ's Treatment of the Assessment.

         After summarizing Dr. Tatineni's opinion, the ALJ concluded that it was not entitled to much weight as it was inconsistent with the treatment records. (PageID.61.) Plaintiff claims that the ALJ's reasoning is unsupported by substantial evidence because the ALJ focused on a few “isolated incidents as though they signified a substantial change or improvement in [Plaintiff's] functioning.” (PageID.780.) Based on this record, the Court agrees. The medical record includes an unbroken litany of serious mental health problems beginning as early as 1991 that are fully consistent with Dr. Tatineni's opinions. The ALJ's discussion of these opinions appears to rest on a few isolated islands of normalcy along the way. This is insufficient to meet the Gayheart standard.

         i. Pre-Onset Records.

         Prior to Plaintiff's alleged onset date, Plaintiff sought treatment for emotional problems in February and March 1991 on the advice of his attorney, though he also had felt for some time that he needed counseling. (PageID.313.) A mental examination found that Plaintiff was functioning at the low end of the normal range of intellectual capabilities. The examiner noted that the results may have been skewed due to Plaintiff's acute emotional stress at the time. The test results also indicated that Plaintiff was in an acute and severe depressive state and that Plaintiff also had passive aggressive behavioral traits. He further was in a highly confused anxiety state, had a low self esteem, and a low self worth. The examiner diagnosed Plaintiff with major depressive disorder with psychotic features, a generalized anxiety disorder, and schizotypal personality disorder with prominent schizoid personality traits. (PageID.314-315.) The examiner also assigned Plaintiff a GAF score of 60.[4] In August 1991, Plaintiff attempted suicide by slashing his wrists. (PageID.580.) At that time, Plaintiff was incarcerated because of a conviction for criminal sexual conduct with a family member. Plaintiff reported he slashed his wrists because he got more depressed after being in placed in isolation. (PageID.580.) Plaintiff reported tossing and turning at night and thinking that people were out to get him. (PageID.580.)

         In 1994, Plaintiff was treated at Riverwood Community Mental Health Center as part of his probation. (PageID.582, 588.) Plaintiff reported symptoms of depression and insomnia. He also complained of a lack of energy. He would mope around, and did not do what he knew he should do. When he was around others, he felt that they might attack him. (PageID.582.) It was noted that Plaintiff tended to worry to excess and also had difficulty concentrating. (PageID.582.) Plaintiff was observed to be alert, cooperative, and in contact with the environment. Productivity and spontaneity were within the normal range, and there was no disturbance in thought association. Plaintiff's paranoia appeared to be subjective only, but his memory was a problem as he had to write things down or he would forget. His judgment appeared to be intact, and his intellectual capacity was above average. (PageID.582.) Plaintiff was prescribed a trial dose of Adapin. (PageID.583.)

         In 1996, Plaintiff was evaluated for attention deficit disorder (ADD). Plaintiff reported that when he was in school he had difficulty with concentration and organization and increasingly had became socially withdrawn. The examiner also noted Plaintiff's employment history was sporadic, and that he would change jobs frequently. (PageID.316.) On examination, Plaintiff was cooperative and readily related to the examiner, but he had a fluctuating affect which suggested to the examiner the presence of anxiety mixed with depression. (PageID.317.) Testing resulted in the exhibition of characteristics that supported an ADD diagnosis, and there were also signs of secondary anxiety and ...


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