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Reinhart v. Berryhill

United States District Court, W.D. Washington, Tacoma

April 16, 2018

NANCY A BERRYHILL, Deputy Commissioner of Social Security for Operations, Defendant.


          David W. Christel, United States Magistrate Judge

         Plaintiff Jason Ronald Reinhart filed this action, pursuant to 42 U.S.C. § 405(g), for judicial review of Defendant's denial of Plaintiff's applications for supplemental security income (“SSI”) and disability insurance benefits (“DIB”). Pursuant to 28 U.S.C. § 636(c), Federal Rule of Civil Procedure 73 and Local Rule MJR 13, the parties have consented to have this matter heard by the undersigned Magistrate Judge. See Dkt. 2.

         After considering the record, the Court concludes the Administrative Law Judge (“ALJ”) erred in his consideration of medical opinion evidence from Dr. J. Alex Crampton, Psy.D. Had the ALJ properly considered Dr. Crampton's opinion, the residual functional capacity (“RFC”) may have included additional limitations. The ALJ's error is therefore not harmless, and this matter is reversed and remanded pursuant to sentence four of 42 U.S.C. § 405(g) to the Acting Commissioner of Social Security (“Commissioner”) for further proceedings consistent with this Order.


         On February 12, 2014, Plaintiff filed applications for SSI and DIB, alleging disability as of December 31, 2010. See Dkt. 7, Administrative Record (“AR”) 16. The applications were denied upon initial administrative review and on reconsideration. See AR 16. ALJ James Sherry held a hearing on April 26, 2016. AR 39-71. In a decision dated May 20, 2016, the ALJ determined Plaintiff to be not disabled. AR 13-38. Plaintiff's request for review of the ALJ's decision was denied by the Appeals Council, making the ALJ's decision the final decision of the Commissioner. See AR 1-7; 20 C.F.R. § 404.981, § 416.1481.

         In Plaintiff's Opening Brief, Plaintiff maintains the ALJ erred by: (1) failing to provide legally sufficient reasons to discount medical opinion evidence; (2) finding Plaintiff did not meet Listing 12.04, 12.06, or 12.09; (3) improperly discounting Plaintiff's subjective symptom testimony; and (4) not allowing a lay witness to testify at the hearing. Dkt. 11, pp. 6-12. Plaintiff argues that due to these errors, an award of benefits is appropriate. Id. at 13.


         Pursuant to 42 U.S.C. § 405(g), this Court may set aside the Commissioner's denial of social security benefits if the ALJ's findings are based on legal error or not supported by substantial evidence in the record as a whole. Bayliss v. Barnhart, 427 F.3d 1211, 1214 n.1 (9th Cir. 2005) (citing Tidwell v. Apfel, 161 F.3d 599, 601 (9th Cir. 1999)).


         I. Whether the ALJ properly considered the medical opinion evidence.

         Plaintiff argues the ALJ erred in his consideration of the medical opinion evidence. Dkt. 11, pp. 10-12. In particular, Plaintiff asserts the ALJ erred in his consideration of opinion evidence from Dr. J. Alex Crampton, Dr. Nitin Karnik, Mr. Marshall Johnson, and by giving greater weight to non-examining sources over examining and treating physicians. Id.

         The ALJ must provide “clear and convincing” reasons for rejecting the uncontradicted opinion of either a treating or examining physician. Lester v. Chater, 81 F.3d 821, 830 (9th Cir. 1995) (citing Pitzer v. Sullivan, 908 F.2d 502, 506 (9th Cir. 1990)); Embrey v. Bowen, 849 F.2d 418, 422 (9th Cir. 1988)). When a treating or examining physician's opinion is contradicted, the opinion can be rejected “for specific and legitimate reasons that are supported by substantial evidence in the record.” Lester, 81 F.3d at 830-31 (citing Andrews v. Shalala, 53 F.3d 1035, 1043 (9th Cir. 1995); Murray v. Heckler, 722 F.2d 499, 502 (9th Cir. 1983)). The ALJ can accomplish this by “setting out a detailed and thorough summary of the facts and conflicting clinical evidence, stating his interpretation thereof, and making findings.” Reddick v. Chater, 157 F.3d 715, 725 (9th Cir. 1998) (citing Magallanes v. Bowen, 881 F.2d 747, 751 (9th Cir. 1989)).

         A. Dr. Crampton

         Dr. Crampton performed a psychological/psychiatric evaluation of Plaintiff on July 13, 2013. AR 433-46. Dr. Crampton provided his evaluation on a Washington State Department of Social & Health Services (“DSHS”) form. See AR 433. As part of his evaluation, Dr. Crampton performed a clinical interview, a mental status examination, and other psychological tests. See AR 433-46. Dr. Crampton opined Plaintiff was limited in his ability to conduct several work activities. For instance, Dr. Crampton opined Plaintiff was moderately limited in his ability to learn new tasks, perform routine tasks without special supervision, make simple work-related decisions, and understand, remember, and persist in tasks by following very short and simple instructions. AR 435. Dr. Crampton also found Plaintiff moderately limited in his ability to be aware of normal hazards and take appropriate precautions, and ask simple questions or request assistance. AR 435.

         In addition, Dr. Crampton determined Plaintiff was markedly limited in two areas: his ability to understand, remember, and persist in tasks by following detailed instructions, and his ability to perform activities within a schedule, maintain regular attendance, and be punctual within customary tolerances without special supervision. AR 435. Finally, Dr. Crampton opined Plaintiff had severe limitations in his ability to adapt to changes in a routine work setting, communicate and perform effectively in a work setting, maintain appropriate behavior in a work setting, and complete a normal work day and work week without interruptions from psychologically-based symptoms. AR 435.

         The ALJ summarized parts of Dr. Crampton's examination and then gave Dr. Crampton's opinion “little weight” for several reasons:

(1) The doctor did not have any records to review, so it was largely based on the claimant's self-report. (2) The claimant did not disclose he continued to use marijuana regularly, so the doctor was unable to make an accurate diagnosis/assessment of functioning. (3) Further, while it is agreed the claimant has some limitations due to his mental health, the severity found by Dr. Crampton was inconsistent with his reported activities to the doctor. For instance, the doctor reported the claimant had a severe limitation in his ability to adapt to changes at work, and was unable to complete a normal workday or workweek, yet the claimant was the single stay-at-home parent of three young children at the time. The severity is inconsistent with the claimant's treatment records that showed he was engaging in a wide range of activities. (4) It is further noted that Dr. Crampton is not a treating provider, and his opinion was based on a one-time exam. (5) The doctor did not think the claimant would be limited for more than six months, or permanently disabled by his condition, which is further inconsistent with his severe findings. (6) Although the claimant reported he struggled with this for years, this is belied by the lack of any evidence showing a history of treatment.
(7) The DSHS report is given limited weight for additional reasons. DSHS uses different rules and regulations to establish disability, so the same conclusions may not have been reached if applying only our regulations. Evaluations conducted for DSHS are largely based on the claimant's self-reported symptoms and complaints, and (8) in this case, the severity of the report is not consistent with the objective findings upon exam. He had some deficits, but they were not of a disabling degree.

AR 24-25 (numbering added).

         In all, the ALJ gave eight reasons to discount Dr. Crampton's opinion, but none of these reasons was specific and legitimate, or supported by substantial evidence in the record.

         First, the ALJ gave Dr. Crampton's opinion little weight because he found it largely based on Plaintiff's self-report. AR 24. An ALJ may reject a physician's opinion “if it is based to a large extent on a claimant's self-reports that have been properly discounted as incredible.” Tommasetti v. Astrue, 533 F.3d 1035, 1041 (9th Cir. 2008) (citation and internal quotation marks omitted). Notably, however, a clinical interview and mental status evaluation are ...

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