Williams v. Berryhill ( 2020 )

1 2 3 4 UNITED STATES DISTRICT COURT 5 NORTHERN DISTRICT OF CALIFORNIA 6 7 CEDRIC WILLIAMS, Case No. 4:19-cv-02339-KAW 8 Plaintiff, ORDER GRANTING PLAINTIFF’S MOTION FOR SUMMARY 9 v. JUDGMENT AND DENYING DEFENDANT’S CROSS-MOTION FOR 10 NANCY A. BERRYHILL, SUMMARY JUDGMENT 11 Defendant. Re: Dkt. Nos. 17, 20 12 13 Plaintiff Cedric Williams seeks judicial review, pursuant to 42 U.S.C. § 405(g), of the 14 Commissioner’s final decision, and the remand of this case for payment of benefits, or, in the 15 alternative, for further proceedings. 16 Pending before the Court is Plaintiff’s motion for summary judgment and Defendant’s 17 cross-motion for summary judgment. Having considered the papers filed by the parties, and for 18 the reasons set forth below, the Court GRANTS Plaintiff’s motion for summary judgment, 19 DENIES Defendant’s cross-motion for summary judgment, and remands this case for an 20 immediate award of benefits. 21 I. BACKGROUND 22 Plaintiff filed for Title XVI benefits on July 31, 2012. Administrative Record (“AR”) 19, 23 172. Plaintiff asserted disability beginning July 31, 2012. Id. The Social Security Administration 24 (“SSA”) denied Plaintiff’s application initially and on reconsideration. AR 119-125. Plaintiff 25 then requested a hearing before an Administrative Law Judge (“ALJ”); the hearing was held on 26 June 12, 2014. AR 19. 27 Following the hearing, the ALJ denied Plaintiff’s application on September 15, 2014. AR 1 November 5, 2014. AR 7-8. The Appeals Council denied Plaintiff’s request for review on March 2 18, 2016. AR 1. On May 3, 2016, Plaintiff filed a complaint in the United States District Court, 3 challenging the Commissioner’s unfavorable decision. AR 658. On June 26, 2017, Magistrate 4 Judge Sallie Kim remanded the case for further proceedings. AR 684. On May 16, 2018, Plaintiff, 5 represented by counsel, again testified before an ALJ. AR 506-564. On November 13, 2018, 6 another ALJ issued a decision finding that Plaintiff was not disabled for the purposes of the Social 7 Security Act. AR 486-498. The ALJ’s decision became the final decision of the Commissioner 8 when the Appeals Council denied review on August 14, 2019. AR 471-473. Plaintiff commenced 9 this action for judicial review pursuant to 42 U.S.C. § 405(g). (Compl., Dkt. No. 1.) 10 On October 2, 2019, Plaintiff filed his motion for summary judgment. (Pl.’s Mot., Dkt. No. 11 17.) On November 27, 2019, Defendant filed an opposition and cross-motion for summary 12 judgment. (Def.’s Opp’n, Dkt. No. 20.) On December 18, 2019, Plaintiff filed his reply. (Pl.’s 13 Reply, Dkt. No. 23.) 14 II. LEGAL STANDARD 15 A court may reverse the Commissioner’s denial of disability benefits only when the 16 Commissioner's findings are 1) based on legal error or 2) are not supported by substantial 17 evidence in the record as a whole. 42 U.S.C. § 405(g); Tackett v. Apfel, 180 F.3d 1094, 1097 18 (9th Cir. 1999). Substantial evidence is “more than a mere scintilla but less than a 19 preponderance”; it is “such relevant evidence as a reasonable mind might accept as adequate to 20 support a conclusion.” Id. at 1098; Smolen v. Chater, 80 F.3d 1273, 1279 (9th Cir. 1996). In 21 determining whether the Commissioner's findings are supported by substantial evidence, the 22 Court must consider the evidence as a whole, weighing both the evidence that supports and the 23 evidence that detracts from the Commissioner's conclusion. Id. “Where evidence is susceptible 24 to more than one rational interpretation, the ALJ's decision should be upheld.” Ryan v. Comm’r 25 of Soc. Sec., 528 F.3d 1194, 1198 (9th Cir. 2008). 26 Under Social Security Administration (“SSA”) regulations, disability claims are evaluated 27 according to a five-step sequential evaluation. Reddick v. Chater, 157 F.3d 715, 721 (9th Cir. 1 substantial gainful activity. Id. If so, the claimant is not disabled. 20 C.F.R. § 404.1520(b). At 2 step two, the Commissioner determines whether the claimant has a “medically severe impairment 3 or combination of impairments,” as defined in 20 C.F.R. § 404.1520(c). Reddick, 157 F.3d 715 at 4 721. If the answer is no, the claimant is not disabled. Id. If the answer is yes, the Commissioner 5 proceeds to step three, and determines whether the impairment meets or equals a listed impairment 6 under 20 C.F.R. § 404, Subpart P, Appendix 1. 20 C.F.R. § 404.1520(d). If this requirement is 7 met, the claimant is disabled. Reddick, 157 F.3d 715 at 721. 8 If a claimant does not have a condition which meets or equals a listed impairment, the 9 fourth step in the sequential evaluation process is to determine the claimant's residual functional 10 capacity (“RFC”) or what work, if any, the claimant is capable of performing on a sustained basis, 11 despite the claimant’s impairment or impairments. 20 C.F.R. § 404.1520(e). If the claimant can 12 perform such work, he is not disabled. 20 C.F.R. § 404.1520(f). RFC is the application of a legal 13 standard to the medical facts concerning the claimant's physical capacity. 20 C.F.R. § 404.1545(a). 14 If the claimant meets the burden of establishing an inability to perform prior work, the 15 Commissioner must show, at step five, that the claimant can perform other substantial gainful 16 work that exists in the national economy. Reddick, 157 F.3d 715 at 721. The claimant bears the 17 burden of proof at steps one through four. Bustamante v. Massanari, 262 F.3d 949, 953-954 (9th 18 Cir. 2001). The burden shifts to the Commissioner at step five. Id. at 954. 19 III. DISCUSSION 20 Plaintiff challenges the ALJ’s decision on five grounds: (1) the ALJ erred in evaluating the 21 medical evidence (2) the ALJ erred in evaluating Plaintiff’s statement, (3) the ALJ erred in 22 determining whether Plaintiff’s impairment meet or equal a listing, (4) the ALJ erred in 23 determining Plaintiff’s RFC, and (5) the ALJ erred in determining that Plaintiff can perform his 24 past work and other work. (Pl.’s Mot. at 5-20.) 25 Since remand for an immediate award of benefits is appropriate, the Court will only 26 address those arguments that justify remand. 27 A. Whether the ALJ Properly Evaluated the Medical Evidence. 1 treat the claimant (treating physicians); (2) those who examine but do not treat the claimant 2 (examining physicians); and (3) those who neither examine nor treat the claimant (non-examining 3 physicians).” Lester v. Chater, 81 F.3d 821, 830 (9th Cir. 1995). “As a general rule, more weight 4 should be given to the opinion of a treating source than to the opinion of doctors who do not treat 5 the claimant.” Id. (citing Winans v. Bowen, 853 F.2d 643, 647 (9th Cir. 1987)). “At least where the 6 treating doctor’s opinion is not contradicted by another doctor, it may be rejected only for ‘clear 7 and convincing reasons.’” Id. (quoting Baxter v. Sullivan, 923 F.2d 1391, 1396 (9th Cir. 1991)). If 8 a treating physician’s medical opinion is contradicted by another doctor, the ALJ must identify 9 specific legitimate reasons supported by substantial evidence to give more weight to the non- 10 treating doctor’s opinion. Id. 11 Plaintiff contends that the ALJ erred in weighing the medical evidence. (Pl.’s Mot. at 6.) 12 Plaintiff asserts that the ALJ failed to provide specific and legitimate reasons for rejecting the 13 opinion of the treating psychiatrist Dr. Saini and examining psychologist Dr. Wiebe. Id. at 8. 14 i. Dr. Saini 15 Plaintiff argues that the ALJ erred in not specifically assigning any weight to Dr. Saini’s 16 opinion, and, instead, only stating that little weight was assigned to Plaintiff’s GAF score because 17 such scores are of little value in assessing a claimant’s level of function over time. (Pl.’s Mot. at 18 6.) An ALJ errs when he does not explicitly reject a medical opinion or set forth specific, 19 legitimate reasons for crediting one medical opinion over another. Garrison v. Colvin, 759 F.3d 20 995, 1012 (9th Cir. 2014). Here, the ALJ found that according to Dr. Saini’s initial assessment, 21 Plaintiff was able to understand simple oral and written instructions but had moderate limitation in 22 the ability to adapt to work situations. AR 492. The ALJ also noted that Dr. Saini’s diagnoses 23 included a psychotic disorder not otherwise specified and a history of substance-induced 24 psychosis. Id. Other than those two findings, however, the ALJ did not specify how much weight 25 was given to Dr. Saini’s opinion nor explain whether the ALJ found Dr. Saini’s opinions 26 persuasive. 27 Defendant argues that the ALJ properly considered the medical evidence, and the medical 1 could assign weight. (Def.’s Opp’n at 3.) As a result, Defendant contends that the ALJ neither 2 rejected nor dismissed Dr. Saini’s diagnoses. Id. Defendant’s assertion that the medical evidence 3 does not contain substantive functional assessment is incorrect. To the contrary, Dr. Saini 4 completed and signed his treatment notes on the Evaluation Form for Mental Disorders produced 5 by the Social Security Administration’s State Disability Determination Service division. AR 418- 6 422. The government form includes questions about Plaintiff’s mental status examination and 7 current level of functioning. Id. The form asks providers to provide specific examples of the 8 patient’s behavior, thinking and functioning that are necessary to make a determination regarding 9 limitations due to mental status. AR 418. Dr. Saini reported that, while Plaintiff is capable of 10 understanding simple oral and written instructions, his overall attention and concentration is low, 11 but that he can perform some household chores. AR 421. In regard to Plaintiff’s adaptation to 12 work, Dr. Saini noted that Plaintiff’s high anxiety and social anxiety limit his ability to adapt to a 13 work environment. Id. Dr. Saini’s treatment summary also indicated that Plaintiff is unable to 14 control his anxiety, that he is highly emotional, and that he struggles to control his anger. AR 416. 15 While the opinion of a treating physician is normally entitled to greater weight, the ALJ 16 did not address whether the treating physician Dr. Saini’s opinion was given any weight when 17 assessing the opinion evidence from all the doctors. AR 496. Accordingly, the ALJ failed to 18 articulate specific, legitimate reasons for presumably rejecting Dr. Saini’s opinion. Generally, the 19 ALJ’s failure to provide adequate reasons for rejecting medical opinions requires that they be 20 accepted as true. Lester, 81 F.3d at 834 (citing Hammock v. Bowen, 879 F.2d 498, 502 (9th Cir. 21 1989)). Thus, Dr. Saini’s opinion must be accepted as true. 22 ii. Dr. Wiebe 23 Plaintiff argues that the ALJ erred in failing to provide specific and legitimate reasons for 24 giving little weight to the opinion of examining psychologist Dr. Wiebe. (Pl.’s Mot. at 8.) The 25 ALJ assigned Dr. Wiebe’s opinion little weight because the 2014 evaluation was inconsistent with 26 Plaintiff’s treatment records and unsupported by the observations of Drs. Bodepudi and Rana. AR 27 493. The ALJ also gave little weight to the psychological evaluations performed by Dr. Wiebe on 1 impairment are generally consistent with her initial evaluation. Id. Additionally, the ALJ found 2 that Dr. Wiebe’s assessments are inconsistent with Plaintiff’s treatment records and later work 3 history. Id. Plaintiff contends that these are not specific and legitimate reasons to discount her 4 medical opinion. (Pl.’s Mot. at 9.) 5 On the initial evaluation performed on May 11, 2014, Dr. Wiebe diagnosed Plaintiff with 6 major depressive disorder, unspecified psychotic disorder, unspecified bipolar disorder, 7 unspecified trauma-and-stressor-related disorder, personality disorder, neurocognitive disorder, 8 and cocaine and alcohol dependency in sustained remission. AR 449. She opined that Plaintiff 9 had listing-level mental impairment, with marked to extreme limitation in all domains except 10 interacting with the public. AR 451. After the April 26, 2017 evaluation, Dr. Wiebe concluded 11 that Plaintiff had marked limitations in all domains except understanding simple and detailed 12 instructions and interacting with the public. AR 909. After the May 3, 2018 evaluation, Dr. Wiebe 13 opined that Plaintiff had marked limitations in all domains except understanding simple 14 instructions and interacting with the public. AR 934. 15 In opposition, Defendant contends that the ALJ properly assigned Dr. Wiebe’s opinion 16 little weight because it was inconsistent with Dr. Bodepudi and Dr. Rana’s opinions, and 17 Plaintiff’s later work history. (Def.’s Opp’n at 3-4.) As an initial matter, the ALJ found that 18 Plaintiff engaged in substantial gainful activity during a number of periods during which he 19 alleged disability, including October 2015 through February 2016, and July through December 20 2017. AR 488-90. Periods of substantial gainful activity, however, do not preclude a finding of 21 disability. See Lingenfelter v. Astrue, 504 F.3d 1028, 1038 (9th Cir. 2007) (failed attempts to 22 maintain substantial gainful employment may support disability allegations). Indeed, Plaintiff 23 testified to a sporadic work history that included providing in-home care for his sisters over a five- 24 month period. AR 488, 521. Plaintiff would bring them food, carry groceries, perform simple 25 household tasks, and watch television. AR 521. Plaintiff testified that he had to stop working for 26 his sisters due to stress and anxiety that made it so he could not function. AR 522. Plaintiff later 27 obtained two short-term construction jobs through a friend where he only occasionally worked a 1 miss work if necessary, because they knew him and he was only a laborer, but, as a result, he 2 never had a regular, full-time schedule. AR 531-32. Accordingly, the Court finds that Plaintiff’s 3 intermittent work history is not a specific and legitimate reason to discount Dr. Wiebe’s medical 4 opinion. 5 Dr. Bodepudi performed a consultative psychiatric evaluation on October 20, 2012. AR 6 353-356. Dr. Bodepudi found that Plaintiff had a good prognosis provided that he is given 7 medication. AR 356. Dr. Bodpudi opined that Plaintiff had no impairment in understanding, 8 remembering, completing simple instructions; no impairments to interact with the public, but that 9 he prefers to be alone; no impairment to perform work activities on a consistent basis, and 10 moderate difficulty with usual stressors in a competitive work environment, because Plaintiff gets 11 nervous and stressed out easily which makes it hard for him to focus. AR 356. The ALJ assigned 12 great weight to Dr. Bodepudi’s opinion. AR 496. Plaintiff argues that Dr. Wiebe met with 13 Plaintiff three times for a total of nearly 10 hours and administered a battery of tests on all three 14 occasions, in addition to reviewing Plaintiff’s medical records, while Dr. Bodepudi only examined 15 Plaintiff once for an unknown length of time, administered a mental status examination, and 16 reviewed no records. (Pl.’s Reply at 2; AR 353.) The Court agrees particularly given that the 17 Bodepudi evaluation was in 2012 and only produced a cursory, four-page report. See AR 353-356. 18 Thus, the Court finds that Dr. Bodepudi’s opinion is not a legitimate reason to discount Dr. 19 Wiebe’s significantly more comprehensive evaluations. 20 Dr. Rana’s consultative examination, which occurred on December 4, 2012, was a 21 physical, internal medicine evaluation rather than a psychological evaluation. AR 358. In using 22 Dr. Rana’s evaluation to discount Dr. Wiebe’s opinion, the ALJ stated that “claimant denied 23 suicidal ideation, delusions, or hallucinations” when asked by Dr. Rana. AR 492 (citing AR 358). 24 The Court notes that Dr. Rana’s evaluation is not internally consistent in addressing Plaintiff’s 25 medical history. AR 358. For example, on the first page she gives an inconsistent recounting of 26 his medication history, providing that Plaintiff “has never been on any medication” while also 27 acknowledging that “[h]e states that he was on some antidepressants for a short while several 1 mental health areas that may be inconsistent with Dr. Wiebe’s later assessments is not a legitimate 2 reason to discount Dr. Wiebe’s opinion. 3 Finally, the ALJ assigned little weight to Dr. Wiebe’s opinion because it was inconsistent 4 with Plaintiff’s treatment records. AR 493. Specifically, the ALJ found that Plaintiff’s sporadic 5 treatment records were inconsistent with the existence of a severe mental impairment, particularly 6 one as limiting as that to which Dr. Wiebe opined. AR 496. The Ninth Circuit has found that, 7 “while a claimant may have failed to seek psychiatric treatment for his mental condition, it is a 8 questionable practice to chastise one with a mental impairment for the exercise of poor judgment 9 in seeking rehabilitation.” Nguyen v. Chater, 100 F.3d 1462, 1465 (9th Cir. 1996). Plaintiff has a 10 history of homelessness and is marginally housed, so it is no surprise that he has had difficulty 11 obtaining consistent mental health treatment. (See Pl.’s Mot. at 3 (citing AR 892); AR 456.) 12 Plaintiff has obtained emergency psychiatric medication at Sausal Creek, psychiatric and 13 psychotherapeutic care at South County Crisis, psychiatric and psychotherapeutic care at the 14 Hume Center, and anger management at California State University East Bay. AR 368-85, 388- 15 409, 416-22, 454-56, 911. Therefore, while Plaintiff has not obtained consistent psychiatric 16 treatment, the lack of consistent treatment alone is not a legitimate reason to discredit the 17 examining physician’s opinion. 18 Based on the forgoing, the Court finds that the ALJ failed to identify specific legitimate 19 reasons supported by substantial evidence to discount Dr. Wiebe’s opinion regarding Plaintiff’s 20 mental limitation, so Dr. Wiebe’s opinion will be accepted as true. Lester, 81 F.3d at 834 (citing 21 Hammock v. Bowen, 879 F.2d 498, 502 (9th Cir. 1989)).1 22 The Court will next address how crediting Dr. Wiebe’s opinion impacts the disability 23 determination at step three. 24 B. The ALJ erred in determining that Plaintiff did not meet or equal a listing. 25 Plaintiff argues that the ALJ erred in finding that Plaintiff’s conditions did not meet or 26 27 1 That there is medical evidence in the record that could justify a rejection of those medical 1 equal a listing under 20 C.F.R. § 404, Subpart P, Appendix 1. (Pl.’s Mot. at 15.) Here, the ALJ 2 found that Plaintiff’s severe impairments consist of depressive disorder; anxiety disorder; 3 polysubstance use disorder, in remission; “schizophrenia versus psychotic disorder with history of 4 substance induced psychosis”; remote history of gunshot wounds to the legs; and reduced 5 vision/visual impairment. AR 490. The ALJ found that Plaintiff’s mental impairments did not 6 meet or medically equal a listed impairment in 20 C.F.R. § 404, Subpart P, Appendix 1, because 7 he did not satisfy the “paragraph B” criteria that he have one extreme or two marked limitations in 8 the four broad areas of functioning, which are: “understanding, remembering, or applying 9 information; interacting with others; concentrating, persisting, or maintaining pace; or adapting or 10 managing themselves.” AR 490-91. 11 In opposition, Defendant argues that Plaintiff’s “argument appears to be nothing more than 12 a substantive repeat of his previous challenges to the ALJ’s consideration of the evidence, 13 particularly Dr. Wiebe’s opinion.” (Def.’s Opp’n at 6.) The Court agrees. Dr. Wiebe’s opinion, as 14 characterized by the ALJ, was that Plaintiff “had listing-level mental impairment, with marked to 15 extreme limitation in all domains except interacting with the public.” AR 492-93 (citing AR 435- 16 52, 891-910, 916-34). Crediting Dr. Weibe’s opinion as true, the Court finds that remand for an 17 award of benefits is proper, since Plaintiff otherwise meets the listings for Section 12.03 18 (Schizophrenia spectrum and other psychotic disorders), 12.04 (Depressive, bipolar and related 19 disorders), and 12.06 (Anxiety and obsessive-compulsive disorders) in 20 C.F.R. § 404, Subpart P, 20 Appendix 1, and satisfies the paragraph B requirement that he experience one extreme limitation 21 or two marked limitations in the four areas of mental functioning. AR 490-94. 22 C. Remaining arguments 23 The Court need not address Plaintiff’s remaining arguments, because he meets a listing at 24 step three, which mandates a disability finding. 25 D. Remand for an award of benefits is appropriate 26 While remand is required, it is only proper to remand for an immediate award of benefits if 27 there are no outstanding issues that must be resolved before a determination of disability can be 1 benefits may be awarded if: 2 (1) the ALJ has failed to provide legally sufficient reasons for rejecting such evidence, (2) there are no outstanding issues that must 3 be resolved before a determination of disability can be made, and (3) it is clear from the record that the ALJ would be required to find the 4 claimant disabled were such evidence credited. 5 Smolen, 80 F.3d at 1292 (citations omitted); see also Harman v. Apfel, 211 F.3d at 1178; Revels v. 6 || Berryhill, 874 F.3d 648, 668 (9th Cir. 2017). As provided above, the ALJ’s failure to properly 7 reject the medical opinions of Plaintiff's treating and examining physicians, requires that those 8 opinions be accepted as true. See Pierce v. Astrue, 382 Fed. Appx. 618, 619-20 (9th Cir. 2010). 9 || Meeting a “listing” at step three entitles a claimant to benefits. Reddick, 157 F.3d 715 at 721. 10 || Since Plaintiff meets a listing at step three after Dr. Wiebe’s opinion is credited as true, remand for 11 an immediate award of benefits is appropriate. 12 IV. CONCLUSION 13 For the reasons set forth above, the Court GRANTS Plaintiff's motion for summary 14 || judgment, DENIES Defendant’s cross-motion for summary judgment, and REMANDS this case 3 15 to the Commissioner, pursuant to sentence four of 42 U.S.C. § 405(g), for an immediate award of a 16 || benefits. = 17 IT IS SO ORDERED. 18 || Dated: November 30, 2020 . 20 United States Magistrate Judge 21 22 23 24 25 26 27 28