WILLIAMS v. BARNHART

SAMUEL CONTI, United States District Judge.

I. INTRODUCTION

Plaintiff Paul Williams ("Plaintiff") has moved for summary judgment on his action seeking review of the Commissioner of Social Security's final decision denying his claim for Social Security insurance benefits. In the alternative, he has moved for a remand to the Social Security Administration for further proceedings. Defendant Jo Anne Barnhart ("Defendant") has cross-motioned for summary judgment in her favor. The case turns on whether Plaintiff was disabled prior to December of 1995, when he ceased to meet the disability insured status requirement. Plaintiff claims he was disabled starting in 1991; the Social Security Administration ("SSA") found that his disability did not begin until 1997.

For the reasons set forth below, this court denies Defendant's motion and remands the case for further administrative proceedings.

II. BACKGROUND

A. Plaintiff's Medical History

Plaintiff is a thirty-four year old male. In 1991, when he was twenty-three, an MRI revealed lesions in his brain, and he was diagnosed with multiple sclerosis ("MSS"). Tr. at 176.

Plaintiff's symptoms began in 1991 with double vision, a loss of coordination, halting speech, and feelings of numbness in his extremities. Id. at 174-79. Over the next six years, according to both medical reports and Plaintiff's testimony, he suffered from loss of coordination, difficulty in walking, difficulty with small motor skills, fatigue, vision problems, continued numbness, bladder problems, pain, and halting speech. The medical records indicate that prior to 1995 Plaintiff suffered several flareups, though Plaintiff's testimony suggests somewhat constant difficulty. Plaintiff's testimony and records agree that his deterioration accelerated around 1995.

Plaintiff's medical treatment during this period was somewhat sporadic. In 1991, when his symptoms began, he had three appointments with Dr. Norick Janian. Id. at 174-79. In 1995, he began seeing Dr. Richard Andolsen. Plaintiff had one full examination with Dr. Andolsen and several follow-up visits. Id. at 189. In September 1996, Plaintiff began seeing "integrative medicine" specialist Dr. Carl Hendel; his visits to Dr. Hendel ceased in March of 1997. Id. at 202. On June 12, 1997, Plaintiff also was examined at the University of California San Francisco's Mt. Zion Medical Center. In October of the same year, Plaintiff received a psychological evaluation, and in December Plaintiff again visited Dr. Janian. Id. at 171.

Both Dr. Janian and Dr. Andolsen filled out medical questionnaires in association with Plaintiff's application for insurance benefits. Dr. Janian's questionnaire described Plaintiff's condition since April of 1991, and Dr. Andolsen s since September of 1995. Id. at 165, 246. Dr. Andolsen did not answer all of the questions asked, and inserted the word "limited" into the signature statement at the end of the report, altering it to read, "this functional capacities report is based on my limited knowledge of the patient." Id. at 170. In particular, Dr. Andolsen left blank many of the questions asking him to quantify the frequency with which Plaintiff would need to miss work. The answers he did provide indicated that Plaintiff was capable of carrying light weights and sitting for extended periods of time, but also that Plaintiff suffered from fatigue, balance problems, poor coordination, weakness, unstable walking, numbness, emotional problems, speech difficulties, sensitivity to heat, and pain. Id. at 168. Dr. Andolsen stated that the symptoms were intermittent, but that Plaintiff's pain was often intense enough to interfere with his concentration. Id. at 165, 167.

Dr. Janian answered the questionnaire more thoroughly. He indicated that Plaintiff had only limited use of his upper extremities, could maintain a "pace and persistence of regular competitive work" for only five minutes at a time, would need to miss work frequently, and suffered frequent pain and a host of other symptoms. Id. at 246-51. If accurate, Dr. Janian's questionnaire leaves little doubt that Plaintiff would have extreme difficulty functioning in almost any workplace.

B. Plaintiff's Employment History

Prior to his MSS diagnosis in 1991, plaintiff had served in the army and then worked as an electronic door installer. At the time he was diagnosed, he was attending junior college. Shortly thereafter, he transferred to the University of California at Berkeley, where he was a student until his graduation in 1995. Plaintiff did not attend school in the Fall of 1991, however; he testified that at that time his symptoms were too severe. Id. at 12-13. Plaintiff has not worked in any significant capacity since his graduation.

C. Procedural History

In September, 1997, Plaintiff filed an application for disability insurance under Title II of the Social Security Act. The parties do not dispute that Plaintiff's eligibility for SSI benefits ceased in December, 1995, and that he could receive benefits only upon showing that he was disabled before that date. The SSA denied his claim initially and again on reconsideration, and Plaintiff sought a hearing before an Administrative Law Judge (ALJ). The ALJ denied Plaintiff's claim. Plaintiff appealed his claim to the SSA Appeals Council, which denied review. Following the Appeals Council's denial, Plaintiff filed this claim in federal court.

In denying Plaintiff's claim, the ALJ relied primarily on the opinion of a Marie McAuliffe, M.D., a medical examiner to whom he sent interrogatories and Plaintiff's medical file. The ALJ gave little weight to the opinions of Drs. Andolsen and Janian, finding that Dr. Andolsen's admittedly limited knowledge of Plaintiff's condition merited giving his opinion little weight, and that Dr. Janian's opinion could be discounted based on blatant overstatements and glossing over of the record. Likewise, the ALJ discredited Plaintiff's testimony, stating that it was unsupported by the medical evidence and was contradicted by the fact that Plaintiff was a full-time college student. The ALJ did agree that Plaintiff suffered from a severe impairment, but concluded that the impairment had not limited Plaintiff's capacity to perform sedentary work.

Plaintiff now argues: 1) that the ALJ erred in giving greater weight to Dr. McAuliffe's opinion than to those of doctors Andolsen and Janian; 2) that the ALJ violated regulations requiring consideration of all evidence when he failed to provide Dr. McAuliffe with all of Plaintiff's medical records; 3) that the ALJ improperly failed to consider evidence that Plaintiff suffered from a mental impairment; 4) that the ALJ erred in failing to consult a vocational expert; and 5) that the ALJ denied Plaintiff due process both by failing to complete the administrative records and by failing to provide Plaintiff's representative with copies of interrogatories prior to serving them upon Dr. McAuliffe.

III. LEGAL STANDARD

This Court may set aside the ALJ's decision only if it is based on an incorrect application of law or is not supported by substantial evidence. Substantial evidence means "more than a scintilla, but less than a preponderance." Reddick v. Chater, 157 F.3d 715, 720. The court must review the record as a whole, including evidence weighing both for and against the ALJ's decision, but will not substitute its judgment for that of the ALJ if the ALJ's decision is reasonable. Id. at 720-21.

In determining whether an applicant is eligible for benefits, the SSA follows a five-step process. 20 C.F.R. § 404.1520; Reddick, 157 F.3d at 721. First, the SSA determines whether the applicant is currently engaged in gainful employment. If he is, he is not disabled. 20 C.F.R. § 404.1520 (b). Second, the SSA determines whether the applicant has a severe impairment; the applicant must demonstrate that he has "anatomical, physiological, or psychological abnormalities which can be shown by medically acceptable clinical and laboratory diagnostic techniques," and that the impairment significantly interferes with his or her work activities. 20 C.F.R. § 416.908; 20 C.F.R. § 404.1520 (c). If the applicant is suffering from such an impairment, the SSA then determines whether the impairment is included on a standardized list, or is equivalent to or more serious than an ailment on the list. 20 C.F.R. § 404.1520 (d). If the applicant meets the burden of showing such an impairment, he is considered disabled. If the applicant is unable to demonstrate that his impairment is equivalent to or more severe than a listed impairment, the SSA will consider the applicant's ability to do his former job or other work based on his education, age, and experience. 20 C.F.R. § 404.1520 (e)-(f).

When deciding on an applicant's eligibility, an ALJ's consideration of both subjective testimony and medical evaluations is subject to specific rules. The opinions of treating physicians receive greater weight than those of consulting physicians, particularly if those consulting physicians do not actually see the claimant. An ALJ may disregard the opinion of a treating physician only if he provides detailed and specific reasons, based on substantial evidence in the record, for doing so.Thomas v. Barnhart, 278 F.3d 947, 956-57 (9th Cir. 2002); Morgan v. Commissioner of Social Security Admin., 169 F.3d 595, 600-01 (9th Cir. 1999). Similarly, an ALJ cannot discredit an applicant's subjective testimony without providing detailed and specific reasons. Morgan, 169 F.3d at 599.

Likewise, an ALJ must follow specific procedures when evaluating whether the applicant remains able to work. The ALJ may use the testimony of a vocational expert. Alternatively, the ALJ may evaluate the applicant's capacity by referring to the Medical-Vocational Guidelines at 20 C.F.R. pt. 404, supbt. P., app. 2. Tackett v. Apfel, 180 F.3d 1094, 1101 (9th Cir. 1999). The latter method may be used only if the guidelines "accurately and completely describe" the applicant's condition. Id. at 1102 (quoting Jones v. Heckler, 760 F.2d 993, 998 (9th Cir. 1985)).

IV. DISCUSSION

A. Weighing the Medical Opinions

Although the ALJ was not obligated to give controlling weight to the opinions of Plaintiff's treating physicians, he could not disregard those opinions without giving specific reasons, based on substantial evidence in the record, for doing so. The ALJ's reasons, however, generally lack specificity. Where they are specific, they are either based on misstatements of the record or make no sense.

The ALJ stated that he credited Dr. McAuliffe's report "as it appears to be more complete and corroborated by the ongoing medical reports in the file." Tr. at 23. He provided no further justification. Such a general, conclusory statement fails to provide any meaningful specificity and provides no basis for preferring the report of a non-examining physician to those of treating physicians.

The ALJ gave little weight to Dr. Andolsen's report because Dr. Andolsen was unable to answer one fifth of the questions asked and described himself as having only "limited" knowledge of the Plaintiff. The ALJ did not, however, provide any justification for disregarding Dr. Andolsen's specific answers to the other four fifths of the questions. As Plaintiff points out, Dr. Andolsen's candor about the limits of his knowledge should have weighed for, not against, his credibility where he did choose to answer questions, and the ALJ provided no specific reasons for disregarding those answers.

The ALJ gave less weight (he did not state how much less) to Dr. Janian's opinion because it "glosses over large gaps in the medical record and makes a rather gross overstatement that the claimant was as dysfunctional in April 1991 as he was in December 1997." Tr. at 23 (citing to Dr. Janian's questionnaire). The former statement is vague and the latter is inaccurate. The ALJ made no effort to elucidate which gaps in the record he was referring to. Moreover, while Dr. Janian did state that Plaintiff was dysfunctional in 1991, he did not state that Plaintiff's condition was as bad in 1991 as it was in 1997.

The ALJ may also have been suggesting that Dr. McAuliffe's opinion was more credible because it was consistent with Plaintiff's ability to function as a student. The ALJ noted that he did not find Plaintiff's testimony about his condition credible, and that it was inconsistent with his activity as a full-time college student. The ALJ did not, however, specifically state that this was a reason for disregarding the testimony of Plaintiff's treating physicians, and thus failed to explain his reasoning with the requisite specificity.

B. Consulting a Medical Expert

An ALJ may utilize the guidelines in 20 C.F.R. pt. 404, supbt. P., app. 2 rather than consulting a medical expert only if the claimant's condition is completely and accurately described by the grids. Tackett, 180 F.3d at 1101. Having already concluded, however, that the ALJ erred in his cursory dismissal of both Plaintiff's own testimony and his treating physicians' assessments of his condition, this Court cannot then conclude that the ALJ properly used the grids. In order to determine whether the grids are appropriately used, the ALJ must determine what the claimant's condition is, and here the ALJ had not completed that preliminary step. Accordingly, the ALJ's failure to use a vocational expert could only compound his earlier error.

C. Consideration of Plaintiff's mental impairment

Plaintiff contends that the ALJ failed to even consider evidence of his mental impairment. Plaintiff's evidence of impairment, however, is insufficient to have triggered any requirement for such consideration. Plaintiff bases his argument on one psychological evaluation in 1997 and on a letter written by Plaintiff's ex-wife in 2001. The evaluation did conclude that Plaintiff "suffered a significant deficit in the session's fundamental cognitive instruments," but did not suggest in any way that Plaintiff had suffered such a condition during the relevant time period. Tr. at 223-24. Likewise, Plaintiff's ex-wife's letter spoke of "memory lapses", but did not specifically place those lapses within the relevant time period. Tr. at 293-94. Plaintiff has offered no other evidence of mental impairment. Accordingly, Plaintiff has made no real showing of mental impairment during the relevant time period, and the ALJ did not err in failing to consider mental impairment.

D. Failure to Provide the Expert with all Relevant Evidence

Plaintiff argues that the ALJ committed legal error because Dr. McAuliffe's evaluation was not based on the entire record. Specifically, Dr. McAuliffe stated that Dr. Janian had not seen Plaintiff since 1991; Plaintiff asserts that his representative had provided the ALJ with documentation of a 1997 visit.

As Plaintiff points out, the regulations do require consideration of all relevant evidence. They require, however, that such evidence be before the ALJ and not necessarily before the medical consultant. 20 C.F.R. § 404.1545. Here, it is undisputed that the evidence in question was available to the ALJ himself. Whether the ALJ properly considered this evidence, and whether, given his awareness of Dr. McAuliffe's lack of information, he properly valued her opinion, are separate questions. Having already concluded that the ALJ erred in evaluating the weight to be given to the respective medical opinions, this Court need not determine what effect Dr. McAuliffe's mistaken assumption has upon the value of her report. Since the ALJ himself had all the relevant evidence before him, a failure to provide some of that evidence to the medical examiner is not grounds for legal error.

E. Failure to Provide Plaintiff's Representative with Copies of the Interrogatories

Plaintiff argues that the ALJ failed to provide his representative with copies of the interrogatories prior to serving them upon Dr. McAuliffe, and that this failure denied Plaintiff of due process. While this failure may reflect some sloppiness, Plaintiff's representative still did have the opportunity to review the report after it was completed. Had Plaintiff's representative suspected that the questions were skewed or somehow misleading, he could easily have raised an objection at that time; he chose not to do so. Accordingly, this failure is not sufficient grounds to conclude that Plaintiff's due process rights were violated.

F. Failure to Include the ALJ's Correspondence with the Medical Examiner in the Record

Plaintiff also alleges that the ALJ committed legal error in failing to include his correspondence with Dr. McAuliffe in the case record. The ALJ is indeed required to include all documentation upon which he based his decision in the record. Here, however, he did do so; the missing documents provided the basis for an examiner's assessment and not for the ALJ's conclusion. Plaintiff asks for a standard that would require supporting documentation for the reports of every physician upon whose opinion the ALJ relies; the regulations simply do not go that far.

Nevertheless, this Court is troubled that the ALJ was willing to rely so heavily on a two-page report that does not indicate all the documentation upon which it is based or the questions to which it responds. While such documentation may not be a legal requirement, it would certainly bolster the report's credibility, and this Court urges that upon remand the Medical Examiner and ALJ make a stronger effort to document the bases for their conclusions.

G. Remedy

This Court has discretion to reverse the ALJ's decision if the record is adequately developed and remand would simply delay payment. If, however, additional proceedings could correct deficiencies in the prior proceeding, remand is appropriate. Bilby v. Schweiker, 762 F.2d 716, 719 (9th Cir. 1985).

Here, ambiguities in the record remain and could be corrected. Further proceedings could explain the possible paradox between Plaintiff's academic achievement and his alleged inability to work. A new medical report, this time based on all of the relevant medical evidence, might shed further light on Plaintiff's condition during and prior to 1995. Accordingly, this Court will remand Plaintiff's case for further proceedings.

This Court reminds the ALJ that his ruling on these further proceedings must either credit Plaintiff's testimony or offer specific, detailed reasons for discounting it. Likewise, he is required by law to either credit the opinions of Plaintiff's treating physicians or offer similarly detailed discussion of the reasons for preferring the evaluations of another consultant or examiner. Finally, this Court urges the ALJ to provide more thorough documentation of the information provided to his medical experts.

V. CONCLUSION

For the reasons set forth above, Defendant's motion for summary judgment is DENIED, and the case is remanded for further proceedings.

IT IS SO ORDERED.