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Gina G. D. v. Commissioner of Social Security

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

September 24, 2019

GINA G. D., Plaintiff,
v.
COMMISSIONER OF SOCIAL SECURITY, Defendant.

          ORDER REVERSING AND REMANDING DEFENDANT’S DECISION TO DENY BENEFITS

          David W. Christel, United States Magistrate Judge.

         Plaintiff 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. 3.

         After considering the record, the Court concludes the Administrative Law Judge (“ALJ”) erred when he failed to provide specific, legitimate reasons supported by substantial evidence for giving little weight to the medical opinion of Dr. Rex E. Head, MD. Had the ALJ properly considered Dr. Head’s opinion, Plaintiff’s 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 Commissioner of the Social Security Administration (“Commissioner”) for further proceedings consistent with this Order.

         FACTUAL AND PROCEDURAL HISTORY

         On June 29, 2015, Plaintiff filed an application for DIB and for SSI, alleging disability as of May 20, 2015. See Dkt. 8, Administrative Record (“AR”) 15. The application was denied upon initial administrative review and on reconsideration. See AR 15. A hearing was held before ALJ S. Andrew Grace on June 5, 2017. AR 15. In a decision dated November 13, 2017, the ALJ determined Plaintiff to be not disabled. AR 26. 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; 20 C.F.R. § 404.981, § 416.1481.

         In the Opening Brief, Plaintiff maintains the ALJ erred by failing to properly: (1) evaluate the medical opinion evidence; (2) evaluate Plaintiff’s subjective symptom testimony; and (3) assess Plaintiff’s RFC and Step 5 of the sequential evaluation process. Dkt. 10, p. 1.

         STANDARD OF REVIEW

         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)).

         DISCUSSION

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

         Plaintiff contends the ALJ erred in his evaluation of the medical opinion of Dr. Head, all other medical opinion evidence, and Plaintiff’s testimony.

         The ALJ must provide “clear and convincing” reasons for denying an uncontradicted opinion of either a treating or examining physician. Lester v. Chater, 81 F.3d 821, 830 (9th Cir. 1996) (citing Embrey v. Bowen, 849 F.2d 418, 422 (9th Cir. 1988); Pitzer v. Sullivan, 908 F.2d 502, 506 (9th Cir. 1990)). When either a treating or an examining physician’s opinion is contradicted, the ALJ may deny the opinion “for specific and legitimate reasons that are supported by substantial evidence in the record.” Lester, 81 F.3d at 830-831 (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 may do so 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 person is considered disabled only if she is unable to engage in any substantial gainful activity for “a continuous period of not less than 12-months” and can demonstrate such inability. 42 U.S.C. § 1382c(a)(3)(A).

         Plaintiff first asserts the ALJ improperly rejected Dr. Head’s opinion, and points to two instances where she contends the ALJ erred. First, Plaintiff argues the ALJ erred when he rejected certain parts of Dr. Head’s opinions that were “clear and specific” merely because other parts of Dr. Head’s opinions were “not very specific.” Dkt. 8, p. 24. Second, Plaintiff argues the ALJ erred when he believed that Dr. Head’s opinion may not be indicative of Plaintiff’s long-term limitations. Id.

         On October 15, 2015, Dr. Head, an examining physician, conducted a physical exam of Plaintiff. AR 386-393. He documented his findings, including Plaintiff’s diagnoses. AR 386-393. According to Dr. Head, the physical examination revealed that Plaintiff could lift/carry at one time up to 20 pounds, and lift/carry repeatedly up to 15 pounds. AR 390. Dr. Head opined Plaintiff can sit at one time for 2 hours, walk on flat level ground without a break for 10 minutes, and walk for 1 hour in an 8-hour day. AR 390. Dr. Head went on to note both Plaintiff’s posture and her overhead and ...


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