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Gerald C. v. Commissioner of Social Security

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

April 4, 2019

GERALD C. JR, Plaintiff,



         Plaintiff filed this action, pursuant to 42 U.S.C. § 405(g), for judicial review of Defendant's denial of Plaintiff's applications for 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. 3.

         After considering the record, the Court concludes the Administrative Law Judge (“ALJ”) erred when he failed to properly consider medical opinion evidence from Dr. Jennifer Irwin, M.D. Had the ALJ properly considered Dr. Irwin'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 Social Security Commissioner (“Commissioner”) for further proceedings consistent with this Order.


         On May 9, 2016, Plaintiff filed an application for DIB, alleging disability as of August 28, 2015. See Dkt. 8, Administrative Record (“AR”) 34. The application was denied upon initial administrative review and on reconsideration. See AR 34. ALJ David Johnson held a hearing on May 16, 2017, and a supplemental hearing on December 4, 2017. AR 58-110, 142-184. In a decision dated January 3, 2018, the ALJ determined Plaintiff to be not disabled. AR 142-84. The Appeals Council denied Plaintiff's request for review of the ALJ's decision, 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 failing to properly consider: (1) medical opinion evidence from Dr. Irwin, Dr. Cynthia Collwingwood, Ph.D., and Dr. Adrian Magnuson-Whyte, Ph.D.; (2) Plaintiff's subjective symptom testimony; (3) the Veterans Affairs (“VA”) Rating Decision (“VA Rating”); and (4) the RFC and Step Five findings. Dkt. 12, pp. 3-13. Plaintiff requests, as a result of the ALJ's alleged errors, the Court remand Plaintiff's claim for an award of benefits. Id. at p. 14.


         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 assessed the medical opinion evidence.

         Plaintiff first maintains the ALJ failed to properly consider medical opinion evidence from Drs. Irwin, Collingwood, and Magnuson-Whyte. Dkt. 12, pp. 3-11.

         An 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. Irwin

         Plaintiff contends the ALJ failed to provide any specific, legitimate reason to reject Dr. Irwin's opinion that Plaintiff would have difficulty maintaining regular attendance in the workplace, completing a normal workday/workweek, and dealing with the usual stress encountered in the workplace. Dkt. 12, pp. 4-8.

         On August 16, 2016, Dr. Irwin conducted a psychiatric examination of Plaintiff. AR 580-85. Dr. Irwin reviewed an adult function report and discussed with Plaintiff his history of present illness, medications, psychiatric history, medical history, and family, social, and employment history. AR 580-82. Further, Dr. Irwin conducted a mental status examination of Plaintiff. AR 582-83. Regarding Plaintiff's prognosis, Dr. Irwin determined Plaintiff's “psychosis is managed with medications and cognitive behavioral therapy, but the mood cycling persists. It is a lifelong illness and will continue for the next 12 months.” AR 583.

         Dr. Irwin opined, in relevant part, Plaintiff “would have difficulty maintaining regular attendance in the workplace due to rapid cycling bipolar disorder with unpredictable mood switching.” AR 584. Dr. Irwin found Plaintiff “would have difficulty completing a normal workday/workweek without interruption from a psychiatric condition.” AR 584. Lastly, Dr. Irwin determined Plaintiff “would have difficulty dealing with the usual stress encountered in the workplace.”[1] AR 584.

         The ALJ summarized Dr. Irwin's opinion and gave it “little weight, ” stating:

(1) [G]iven the other evidence of the claimant's activities and demonstrated capabilities, the limitations opined by Dr. Irwin would not be significant or beyond the tolerances opined by the vocational expert, especially with the limited demands in the limited work setting in the above [RFC]. (2) Dr. Irwin's opinion is also inconsistent with the treatment records indicating that the claimant's mental symptoms are well controlled with medication. (3) This opinion is also inconsistent with medical records that do not record any particular difficulties.

AR 47 (citations omitted) (numbering added).

         First, the ALJ gave Dr. Irwin's opinion little weight because he found the opined limitations not significant or beyond the limitations in the RFC given the evidence of Plaintiff's “activities and demonstrated capabilities.” AR 47. An ALJ may discount a physician's findings if those findings appear inconsistent with a plaintiff's daily activities. See Rollins v. Massanari, 261 F.3d 853, 856 (9th Cir. 2001). But an ALJ cannot reject a physician's opinion in a vague or conclusory manner. See Garrison v. Colvin, 759 F.3d 995, 1012-13 (9th Cir. 2014) (citing Nguyen v. Chater, 100 F.3d 1462, 1464 (9th Cir. 1996)); Embrey, 849 F.2d at 421-22. As the Ninth Circuit has stated:

To say that medical opinions are not supported by sufficient objective findings or are contrary to the preponderant conclusions mandated by the objective findings does not achieve the level of specificity our prior cases have required, even when the objective factors are listed seriatim. The ALJ must do more than offer his conclusions. He must set forth ...

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