“[l]ay testimony as to a claimant’s symptoms is 13 competent evidence that an ALJ must take into account, unless he or she expressly determines to 14 disregard such testimony”
How later courts described this case
- “[l]ay testimony as to a claimant’s symptoms is 13 competent evidence that an ALJ must take into account, unless he or she expressly determines to 14 disregard such testimony”
- remanding the case “for further proceedings evaluating the credibility of [the 24 claimant’s] subjective complaints . . .”
- the “lack of medical evidence cannot form the sole basis for discounting pain testimony”
- “subjective pain testimony cannot be rejected on the sole ground that it 21 is not fully corroborated by objective medical evidence”
Written by the judges who cited it.
The opinion
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8 UNITED STATES DISTRICT COURT
9 EASTERN DISTRICT OF CALIFORNIA
10
11 SENG SAETEURN, ) Case No.: 1:18-cv-0538 - JLT
)
12 Plaintiff, ) ORDER REMANDING THE ACTION FOR
) FURTHER PROCEEDINGS PURSUANT TO
13 v. ) SENTENCE FOUR OF 42 U.S.C. § 405(g)
)
14 ANDREW M. SAUL1, )
Commissioner of Social Security, ) ORDER DIRECTING ENTRY OF JUDGMENT IN
15 ) FAVOR OF PLAINTIFF SENG SAETEURN AND
) AGAINST DEFENDANT ANDRWE M. SAUL,
16 Defendant. ) COMMISSIONER OF SOCIAL SECURITY
)
17
18 Seng Saeteurn asserts she is entitled to a period of disability and disability insurance benefits
19 under Title II of the Social Security Act. Plaintiff argues the administrative law judge erred in
20 evaluating the record and seeks judicial review of the decision to deny her application for benefits.
21 Because the ALJ failed to apply the proper legal standards in evaluating Plaintiff’s testimony and the
22 credibility of her subjective complaints, the decision is REMANDED for further proceedings pursuant
23 to sentence four of 42 U.S.C. § 405(g).
24 BACKGROUND
25 Plaintiff filed an application for benefits on February 3, 2014, alleging disability beginning in
26 May 2008, due to depression, anxiety, migraines, asthma, arthritis, weakness in her arms, pain in her
27
28 1 This action was originally brought against Nancy A. Berryhill in her capacity as then-Acting Commissioner.
1 left heel, and treatment for seizure. (Doc. 11-6 at 13; 11-4 at 13) The Social Security Administration
2 denied her application at the initial level and upon reconsideration. (See Doc. 11-3 at 13-42; Doc. 11-
3 5 at 16-26) After requesting a hearing, Plaintiff testified before an ALJ on November 29, 2016. (Doc.
4 11-3 at 21, 39) The ALJ determined she was not disabled and issued an order denying benefits on
5 December 22, 2016. (Id. at 18-31) When the Appeals Council denied Plaintiff’s request for review on
6 February 13, 2018 (id. at 2-4), the ALJ’s findings became the final decision of the Commissioner of
7 Social Security.
8 STANDARD OF REVIEW
9 District courts have a limited scope of judicial review for disability claims after a decision by
10 the Commissioner to deny benefits under the Social Security Act. When reviewing findings of fact,
11 such as whether a claimant was disabled, the Court must determine whether the Commissioner’s
12 decision is supported by substantial evidence or is based on legal error. 42 U.S.C. § 405(g). The
13 ALJ’s determination that the claimant is not disabled must be upheld by the Court if the proper legal
14 standards were applied and the findings are supported by substantial evidence. See Sanchez v. Sec’y of
15 Health & Human Serv., 812 F.2d 509, 510 (9th Cir. 1987).
16 Substantial evidence is “more than a mere scintilla. It means such relevant evidence as a
17 reasonable mind might accept as adequate to support a conclusion.” Richardson v. Perales, 402 U.S.
18 389, 401 (1971) (quoting Consol. Edison Co. v. NLRB, 305 U.S. 197 (1938)). The record as a whole
19 must be considered, because “[t]he court must consider both evidence that supports and evidence that
20 detracts from the ALJ’s conclusion.” Jones v. Heckler, 760 F.2d 993, 995 (9th Cir. 1985).
21 DISABILITY BENEFITS
22 To qualify for benefits under the Social Security Act, Plaintiff must establish she is unable to
23 engage in substantial gainful activity due to a medically determinable physical or mental impairment
24 that has lasted or can be expected to last for a continuous period of not less than 12 months. 42 U.S.C. §
25 1382c(a)(3)(A). An individual shall be considered to have a disability only if:
26 his physical or mental impairment or impairments are of such severity that he is not
only unable to do his previous work, but cannot, considering his age, education, and
27 work experience, engage in any other kind of substantial gainful work which exists in
the national economy, regardless of whether such work exists in the immediate area in
28 which he lives, or whether a specific job vacancy exists for him, or whether he would
be hired if he applied for work.
1 42 U.S.C. § 1382c(a)(3)(B). The burden of proof is on a claimant to establish disability. Terry v.
2 Sullivan, 903 F.2d 1273, 1275 (9th Cir. 1990). If a claimant establishes a prima facie case of disability,
3 the burden shifts to the Commissioner to prove the claimant is able to engage in other substantial
4 gainful employment. Maounois v. Heckler, 738 F.2d 1032, 1034 (9th Cir. 1984).
5 ADMINISTRATIVE DETERMINATION
6 To achieve uniform decisions, the Commissioner established a sequential five-step process for
7 evaluating a claimant’s alleged disability. 20 C.F.R. §§ 404.1520, 416.920(a)-(f). The process requires
8 the ALJ to determine whether Plaintiff (1) engaged in substantial gainful activity during the period of
9 alleged disability, (2) had medically determinable severe impairments (3) that met or equaled one of the
10 listed impairments set forth in 20 C.F.R. § 404, Subpart P, Appendix 1; and whether Plaintiff (4) had
11 the residual functional capacity (“RFC”) to perform to past relevant work or (5) the ability to perform
12 other work existing in significant numbers at the state and national level. Id. The ALJ must consider
13 testimonial and objective medical evidence. 20 C.F.R. §§ 404.1527, 416.927.
14 A. Medical Background
15 Plaintiff reported having left foot pain and was diagnosed with calcaneal spurs in October 2009.
16 (Doc. 11-9 at 25) She was later diagnosed with left plantar fasciotomy and Achilles tendon tear, for
17 which she received surgery on December 22, 2010. (Doc. 11-8 at 3)
18 In January 2011, Dr. Eduardo Villarama completed a “Treating Physician General medical
19 Evaluation.” (Doc. 11-8 at 64-66) Dr. Villarama noted Plaintiff had left foot pain with limited range of
20 motion following surgery, and she was in a wheelchair, “unable to bear [weight]” with her left foot.
21 (Id. at 65, 66) He also indicated Plaintiff had right lateral epicondylitis and migraine headaches. (Id. at
22 65) Dr. Villarama opined Plaintiff had normal reflexes, senses, and normal range of motion in all joints
23 other than her left foot. (Id.) Dr. Villarama noted Plaintiff did not have seizures. (Id.) According to
24 Dr. Villarama, Plaintiff had “mild depression but [it was] controlled by medications.” (Id. at 66)
25 Dr. Birgit Siekerkotte performed a consultative evaluation on March 27, 2011. (Doc. 11-8 at
26 67) Plaintiff reported she was “on various inhalers” for asthma, and had “shortness of breath at night
27 when she [went] to bed” or exercising. (Id.) She told Dr. Siekerkotte that she had pain in her left foot,
28 right arm, and left shoulder pain; headaches “3-4 times a week;” depression; stress; and insomnia. (Id.
1 at 68) Plaintiff told Dr. Siekerkotte that she “use[d] a wheelchair prescribed by her podiatrist,” and Dr.
2 Siekerkotte noted she used crutches. (Id. at 69) In addition, she told Dr. Siekerkotte she “need[ed] help
3 with everything including washing herself and dressing herself,” with which her daughter helped. (Id.
4 at 68) Dr. Siekerkotte observed Plaintiff had “tenderness in the lower back area.” (Id. at 70) She also
5 determined Plaintiff had reduced strength in her right hand gripping at 4/5, right bicep at 4+/5, and
6 quadriceps at 4+/5. (Id.) In addition, she found Plaintiff had “decreased sensation along the left leg
7 laterally.” (Id.) Dr. Siekerkotte opined Plaintiff could stand and walk for “[u]p to four hours based on
8 decreased muscular strength” and sit without limitation. (Id. at 71) According to Dr. Siekerkotte,
9 Plaintiff should continue use of her crutches and a wheelchair, “as recommended by the podiatrist … to
10 prevent the claimant from following.” (Id.) She determined Plaintiff should continue using a right
11 elbow brace “for pain control,” and she did not identify any amount of weight Plaintiff could lift and
12 carry “based on the need to use crutches and to hold onto the crutches.” (Id.) Further, Dr. Siekerkotte
13 concluded Plaintiff could never climb, balance, stoop, kneel, crouch, or crawl “based on [her] decreased
14 grip strength and the need to use crutches with observed balance problems and decreased strength of
15 the upper and lower extremities.” (Id.) Dr. Siekerkotte opined Plaintiff could frequently reach, handle,
16 and finger “when in a seated position,” but never do so while walking due to her crutches. (Id.)
17 In November 2013, Plaintiff went to a clinic where she complained of “[f]acial weakness and
18 numbness,” along with “left upper extremity weakness and numbness.” (Doc. 11-10 at 12) Plaintiff
19 was transported by ambulance from the clinic to an emergency room, where she was admitted for a
20 “transient ischemic attack and to rule out cerebrovascular accident.” (Id.) Plaintiff had an MRI of her
21 brain and CT scan of her head, which were each normal. (Id. at 22) An EEG test “revealed abnormal
22 sharp waves occurring on the left side, with phase reversal in either of the tip of the left temporal lobe
23 or the posterolateral left frontal lobe,” which was “consistent with a seizure focus in the same area.”
24 (Id.) Dr. Dinesh Chhagahlal diagnosed Plaintiff with sensory seizures. (Id. at 22-23) Plaintiff was
25 discharged two days later, on November 14, with a prescription for Keppra. (Id. at 23)
26 On November 19, 2013, Plaintiff had a follow-up appointment at Golden Valley Heath Center
27 regarding her transient ischemic attack. (Doc. 11-12 at 40) Dr. Sukhdip Kang noted that Plaintiff
28 appeared depressed, and diagnosed her with anxiety and depression. (Id. at 40, 42) Dr. Kang opined
1 Plaintiff’s motor strength was 5/5 and her cranial nerves were intact. (Id. at 43) In addition, he
2 determined Plaintiff was “oriented to time, place, person, and situation.” (Id. at 43) Dr. Kang referred
3 Plaintiff to Dr. Vang Leng Mouanoutoua for treatment of her depression. (Id. at 43, 46)
4 Dr. Mouanoutoua performed a case consultation on November 20, 2013 and noted Plaintiff
5 reported “depressed feeling, tearfulness, much worries, forgetfulness, frequent anger, poor sleep of
6 about 3-4 hours a night, sadness, and suicidal wishes without a plan 1-2x a day.” (Doc. 11-12 at 46)
7 She also described symptoms of anxiety, including “episodes of nervousness, sweating, heart racing,
8 cold flushes, scary feeling[s], body uptight, and shaking feeling.” (Id.) Dr. Mouanoutoua diagnosed
9 Plaintiff with Panic Disorder and Major Depressive Disorder, recurrent, and severe. (Id.)
10 In December 2013, Dr. Mouanoutoua performed an intake evaluation. (Doc. 11-12 at 50) He
11 noted Plaintiff’s reported symptoms were severe and “poorly controlled.” (Id.) In addition, Plaintiff
12 stated her “symptoms… prevented her from performing daily chores and relating constructively with
13 people.” (Id.) Dr. Mouanoutoua opined Plaintiff was “oriented to person and place,” and her “mood
14 [was] anxious and depressed.” (Id. at 51) In addition, he observed Plaintiff’s attention was “gained,
15 directed and distracted;” and he determined Plaintiff’s memory was intact. (Id.) Dr. Mouanoutoua gave
16 Plaintiff a GAF score of 50.2 (Id. at 52)
17 On July 22, 2014, Dr. Mouanoutoua opined Plaintiff made “[m]inimal progress … [with] her
18 chronic depression.” (Doc. 11-19 at 2) He observed that Plaintiff “remain[ed] hopeless and depressed,
19 but [was] more expressive in verbalizing her sadness, distress and grief.” (Id. at 3)
20 Dr. Chang-Wuk Kang completed a mental residual functional capacity assessment on July 23,
21 2014. (Doc. 11-4 at 21) According to Dr. Kang, Plaintiff’s mental impairment was not severe, based
22 upon review of medical records from Dr. Abordo in 2011 that indicated Plaintiff had a depressive
23 disorder that “was controlled by medication.” (Id.)
24 On July 24, 2014, Dr. Roy Brown completed a physical residual functional capacity assessment.
25 (Doc. 11-4 at 22-24) Dr. Brown opined Plaintiff could lift and carry 25 pounds occasionally and 20
26
27 2 GAF scores range from 1-100, and in calculating a GAF score, the doctor considers “psychological, social, and
occupational functioning on a hypothetical continuum of mental health-illness.” American Psychiatric Association,
Diagnostic and Statistical Manual of Mental Disorders, 34 (4th ed.) (“DSM-IV). A GAF score between 41-50 indicates
28 “[s]erious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) OR any serious impairments in
1 pounds frequently; stand and/or walk “[a]bout 6 hours in an 8-hour workday;” and sit “[a]bout 6 hours
2 in 8-hour workday.” (Id. at 22) He determined Plaintiff had environmental limitations and needed to
3 “[a]void concentrated exposure” to extreme cold, fumes, odors, dusts, gases, and hazards. (Id. at 23)
4 Dr. Yee also reviewed Plaintiff’s medical record and completed a physical residual functional
5 capacity assessment on October 29, 2014. (Doc. 11-4 at 35-38) Dr. Yee determined Plaintiff could lift
6 and carry 20 pounds occasionally and 10 pounds frequently; sit about six hours in an eight-hour day;
7 and stand about six hours in an eight-hour day. (Id. at 36) Dr. Yee opined Plaintiff could occasionally
8 climb ramps and stairs, balance, stoop, kneel, crouch, and crawl; and never climb ladders, ropes, and
9 scaffolds. (Id.) Dr. Yee also found Plaintiff had environmental limitations and needed to “[a]void
10 concentrated exposure to extreme cold, fumes, odors, dust, gas, and poor ventilation. (Id. at 37) In
11 addition, Dr. Yee opined Plaintiff needed to “[a]void even moderate exposure” to hazards, such as
12 machinery and heights. (Id.)
13 Dr. Mouanoutoua completed a mental residual functional capacity questionnaire on May 30,
14 2015. (Doc. 11-16 at 47) He noted that he treated Plaintiff on a bimonthly basis, and her diagnoses
15 included Major Depressive Disorder, Panic Disorder, and “chronic medical problems.” (Id.) He
16 opined Plaintiff’s prognosis was “poor to guarded.” (Id.) According to Dr. Mouanoutoua, for 15% or
17 more of an eight-hour day, Plaintiff was precluded from understanding, remembering and carrying out
18 detailed instructions; maintaining attention and concentration for extended periods; performing
19 activities within a schedule; maintaining regular attendance, punctuality, and an ordinary routine; and
20 all activities of adaptation. (Id. at 48-49) In addition, Dr. Mouanoutoua opined that for 5% or more of
21 a workday, Plaintiff was precluded from understanding, remembering, and carrying out very short and
22 simple instructions. (Id. at 48) Further, he concluded Plaintiff had difficulties with social interaction.
23 (Id.) He concluded Plaintiff would be unable to complete an eight-hour workday and was likely to miss
24 work five days or more per month. (Id.)
25 Dr. Mouanoutoua completed a second statement on June 10, 2016. (Doc. 11-19 at 15-16) He
26 opined Plaintiff continued to suffer from “Major Depressive [Disorder], Severe, Recurrent.” (Id. at 15)
27 According to Dr. Mouanoutoua, Plaintiff’s impairment precluded her performance for 15% or more of
28 an eight-hour workday with remembering work-like procedures; maintaining attention for two-hour
1 segments; maintaining attendance, punctuality, an ordinary routine, and a normal workday; performing
2 at a consistent pace; accepting instructions; responding appropriately to criticism from supervisors;
3 dealing with normal work stress; and getting along with co-workers and peers. (Id.) In addition, he
4 opined Plaintiff was precluded from understanding, remembering, and carrying out very short and
5 simple instructions for 10 % of an eight-hour day. (Id.) Dr. Mouanoutoua opined Plaintiff was likely
6 to be absent from work more than four days per month due to her impairments. (Id. at 16)
7 B. Disability Reports
8 In May 2014, Plaintiff completed a “Disability Report- Adult” form in connection with her
9 application for benefits. (Doc. 11-7 at 41) She identified the following medical conditions: depression,
10 anxiety, migraines, asthma, arthritis, “right and left arm very weak,” surgery on her left heel, and
11 “treat for seizure.” (Id. at 42) Plaintiff indicated that she stopped working because of her conditions
12 on May 1, 2008. (Id.)
13 She completed a second Disability Report related to her request for reconsideration in August
14 2014. (Doc. 11-7 at 57) Plaintiff reported she had “more discomfort with [her] arthritis on both arms,”
15 and felt “more weakness on [her] body and muscle due to nerve damage.” (Id.) Plaintiff noted: “My
16 seizure and migraines interfere significantly [and] limit my ability to work.” (Id.) She stated she had
17 surgery on her left heel and felt pain when walking. (Id.) In addition, Plaintiff stated she suffered from
18 anxiety and depression, which made her “unable to adjust to emotional stresses.” (Id.) Plaintiff
19 reported her daughters did the laundry, cooked, and ran errands. (Id. at 61) She also indicated her
20 daughters also bathed and dressed her because her “arm hurt[] to[o] much.” (Id.)
21 Plaintiff completed a third Disability Report in November 2014, and again reported her
22 daughters would “help... with cooking, do [her] laundry, do grocery shopping, and assist [her] with
23 bathing.” (Doc. 11-7 at 70) Plaintiff stated she could not “lift more than one pound object[s], cannot
24 walk very far, [and] can only stand for [a] couple minutes here and there.” (Id.) She noted that her left
25 heel continued to hurt, and a doctor prescribed a cane. (Id. at 67)
26 C. Administrative Hearing Testimony
27 Plaintiff testified before an ALJ on November 29, 2016. (Doc. 11-3 at 40) She stated that she
28 previously worked as a poultry cutter for Valley Fresh and Foster Farms, where she cut chickens and
1 sometimes used her hand for peeling. (Id. at 44)
2 She said she lived in a house with her husband and two daughters. (Doc. 11-3 at 43) Plaintiff
3 reported that one of her daughters helped her with personal hygiene by getting her clothes and
4 “turn[ing] the water on for [her] to take a shower.” (Id.) Plaintiff stated she was able to dress herself,
5 but did so very slowly because she did not want help dressing. (Id. at 52) Plaintiff testified she did not
6 do any household chores or cook because she “lit fires.” (Id. at 43) She said she would “sometimes ...
7 use a microwave.” (Id.) Plaintiff stated she did not engage in social activities. (Id.)
8 Plaintiff stated she continued to have pain in her heel following surgery, indicating she “lots
9 [of] pain” if she walked without shoes. (Doc. 11-3 at 44-45) She also said that she had pain with her
10 back and right shoulder, and she could “[]not lift anything.” (Id. at 45) Plaintiff testified she took
11 medication for pain—including ibuprofen, hydrocodone, Vicodin, Norco, and Tylenol with codeine—
12 but “the only thing” she could do to help with her pain was “to lay down, or ... to lay down on the
13 side.” (Id. at 45-46, 47) In addition, Plaintiff said she suffered from headaches “all the time,” and
14 medication helped “just a little bit, 30, 40 minutes only.” (Id. at 46)
15 She stated she also suffered from depression following the death of her son, and her legs and
16 hands felt numb when she thought about it. (Doc. 11-3 at 48) Plaintiff said she was in therapy and
17 receiving grief counseling. (Id. at 49) She stated she was unable to pay attention to things she
18 watched on television, and she suffered from memory problems. (Id.) Plaintiff testified that she had
19 suicidal thoughts “[a]lmost every night” (Id. at 52)
20 Plaintiff estimated that she could lift and carry two pounds at most, attributing the limitation to
21 weakness in her left hand and pain in her right elbow. (Doc. 11-3 at 47) Plaintiff believed she could
22 stand for ten minutes for she needed to sit, walk only around her house, and sit for 20 to 30 minutes at
23 one time. (Id. at 47-48) Plaintiff said she was unable to bend over without feeling dizzy and she could
24 not climb stairs. (Id. at 48) She testified she would lay down “[t]wo or three times a day, after [she
25 took] a medication,” for forty minutes to one and a half hours each time. (Id. at 51)
26 D. The ALJ’s Findings
27 Pursuant to the five-step process, the ALJ determined first that Plaintiff “did not engage in
28 substantial gainful activity during the period from her alleged onset date of May 1, 2008 through her
1 date last insured of December 31, 2013.” (Doc. 11-3 at 23) At step two, the ALJ found Plaintiff’s
2 severe impairments included: “lumbar degenerative joint disease; left wrist degenerative joint disease;
3 left elbow degenerative joint disease; obesity; left calcaneal spurs, status post left plantar fasciotomy
4 and Achilles tendon repair; asthma; and a major depressive disorder.” (Id.) At step three, the ALJ
5 determined Plaintiff did not have an impairment, or combination of impairments, that met or medically
6 equaled a Listing. (Id. at 23-24) Next, the ALJ determined:
7 [T]hrough the date last insured, the claimant had the residual functional capacity to
perform a range of work at the light exertional level as defined in 20 CFR 404.1567(b).
8 Specifically, she was able to lift and carry 20 pounds occasionally and 10 pounds
frequently, stand and walk six to eight hours, and sit six to eight hours in an eight-hour
9 workday. She could occasionally stoop, crouch, crawl, and climb, and she was capable
of performing forceful gripping and grasping with the non-dominant left upper
10 extremity. The claimant further needed to avoid concentrated exposure to dusts, gases,
fumes, and heights. In addition, she was limited to performing only simple routine tasks.
11
12 (Id. at 25) Based upon this RFC, the ALJ concluded Plaintiff was “capable of performing past
13 relevant work as a poultry boner,” both as Plaintiff performed the work and as generally performed in
14 the national economy (Id. at 30) Therefore, the ALJ concluded Plaintiff was “not under a disability,
15 as defined in the Social Security Act, at any time from May 1, 2008, the alleged onset date, through
16 December 31, 2013, the date last insured.” (Id.)
17 DISCUSSION AND ANALYSIS
18 Appealing the decision to deny her application for benefits, Plaintiff asserts the ALJ failed “to
19 provide a clear and convincing reasons based on substantial evidence to discount [her] testimony.”
20 (Doc. 21 at 21, emphasis omitted) On the other hand, the Commissioner argues “[s]ubstantial
21 evidence supports the ALJ’s finding that Plaintiff’s subjective allegations were not consistent with the
22 evidence.” (Doc. 22 at 12)
23 A. ALJ’s Credibility Analysis
24 In evaluating credibility, an ALJ must determine first whether objective medical evidence
25 shows an underlying impairment “which could reasonably be expected to produce the pain or other
26 symptoms alleged.” Lingenfelter v. Astrue, 504 F.3d 1028, 1035-36 (9th Cir. 2007) (quoting Bunnell v.
27 Sullivan, 947 F.2d 341, 344 (9th Cir. 1991)). Where the objective medical evidence shows an
28 underlying impairment, and there is no affirmative evidence of a claimant’s malingering, an “adverse
1 credibility finding must be based on clear and convincing reasons.” Id. at 1036; Carmickle v. Comm’r
2 of Soc. Sec. Admin., 533 F.3d 1155, 1160 (9th Cir. 2008). The ALJ determined Plaintiff’s “medically
3 determinable impairments could reasonably be expected to cause the alleged symptoms.” (Doc. 11-3 at
4 29) However, the ALJ found Plaintiff’s “statements concerning the intensity, persistence and limiting
5 effects of these symptoms [were] not entirely consistent with the medical evidence and other evidence
6 in the record.” (Id.)
7 1. Failure to address hearing testimony
8 As an initial matter, to evaluate a claimant’s residual function capacity, the ALJ “must consider
9 all relevant evidence in the record, including, . . . medical records, lay evidence, and the effects of
10 symptoms, including pain, that are reasonably attributed to a medically determinable impairment.”
11 Robbins v. Social Sec. Admin., 466 F.3d 880, 883 (9th Cir. 2006) (internal quotations omitted); see
12 also Lewis v. Apfel, 236 F.3d 503, 511 (9th Cir. 2001) (“[l]ay testimony as to a claimant’s symptoms is
13 competent evidence that an ALJ must take into account, unless he or she expressly determines to
14 disregard such testimony”). Thus, an ALJ has a burden to address a claimant’s statements from an
15 administrative hearing.
16 The ALJ failed to discuss Plaintiff’s testimony at the administrative hearing concerning her
17 functional limitations. Instead, the ALJ focused upon statements found in her disability reports and
18 generally referred to her hearing testimony:
19 In this case, the claimant’s statements and allegations are not fully consistent with the
medical and other evidence. For example, she alleged seizures limit her ability to work
20 (see Exhibit 8E, p. 2), but the objective medical evidence does not support this. While
she was hospitalized ... from November 12, 2013 to November 14, 2013 with
21 complaints of facial weakness and numbness and weakness in the left upper extremity
(see Exhibits 9F, pp. 11-14; 10F), this was a single isolated incident. Physicians did
22 diagnose sensory seizures and prescribe Keppra, but that was because a transient
ischemic attack (TIA) and cerebrovascular accident were both ruled out (Exhibits 9F,
23 pp. 21-22; 10F). In addition, a magnetic resonance image (MRI) of the brain was
normal (see Exhibit 9F, p. 15) and she did not have or receive treatment for another
24 seizure after this hospitalization (see Exhibit 21F, p. 232). Accordingly, the objective
medical evidence does not support the allegation that seizures limit her ability to work.
25
The claimant alleged suffering from significant mental and physical limitations (see
26 Exhibits 6E, p. 1; 9E, pp. 2-3; 11E; 13E; hearing testimony), but that is inconsistent
with the medical and other evidence. For example the alleged mental limitations are
27 inconsistent with reports from primary care providers showing the claimant was
oriented times three with a normal thought process (see Exhibit 11F, p. 5), an intact
28 memory and no suicidal or homicidal ideation (see Exhibit 12F, pp. 49-51). As for the
alleged physical limitations, they are inconsistent with the negative examination of the
1 musculoskeletal system and the claimant’s full motor strength (Exhibits 12F, pp. 39-43;
21F, pp. 195-199).
2
3 (Doc. 11-3 at 17; see also Doc. 11-7 at 32 [Exh. 6E], 41-44 [Exh. 8E] 50-52 [Exh. 9E], 57-63 [Exh.
4 11E], and 66-72 [Exh. 13E])
5 Significantly, Plaintiff testified regarding her abilities, stating she was unable to pay attention to
6 things she watched on television, and she suffered from memory problems. (Doc. 11-3 at 48) She
7 estimated that she could lift and carry two pounds at most, attributing the limitation to weakness in her
8 left hand and pain in her right elbow. (Id. at 47) Plaintiff believed she could stand for ten minutes,
9 walk only around her house, and sit for 20 to 30 minutes at one time. (Id. at 47-48) Plaintiff stated she
10 was unable to bend over without feeling dizzy and she could not climb stairs. (Id. at 48) However, the
11 ALJ failed to address this testimony, or provide reasons for ignoring the limitations identified by
12 Plaintiff during the hearing. Consequently, the ALJ failed to address relevant evidence in the record
13 and erred in his analysis. See Robbins, 466 F.3d at 883; Lewis, 236 F.3d at 511; see also Shimotsu ex
14 rel. Shimotsu v. Colvin, 2016 U.S. Dist. LEXIS 56886 (C.D. Cal. Apr. 27, 2016) (finding error where
15 “the ALJ failed to acknowledge Plaintiff’s hearing testimony, let alone provide reasons for disregarding
16 it”).
17 2. Rejection of statements based upon the objective medical record
18 To the extent the ALJ purported to find Plaintiff lacked credibility due to statements identified
19 in the disability reports, the credibility analysis is also flawed. Factors that may be considered by an
20 ALJ in assessing a claimant’s credibility include, but are not limited to: (1) the claimant’s reputation
21 for truthfulness, (2) inconsistencies in testimony or between testimony and conduct, (3) the claimant’s
22 daily activities, (4) an unexplained, or inadequately explained, failure to seek treatment or follow a
23 prescribed course of treatment, and (5) testimony from physicians concerning the nature, severity, and
24 effect of the symptoms of which the claimant complains. Fair v. Bowen, 885 F.2d 597, 603 (9th Cir.
25 1989); see also Thomas v. Barnhart, 278 F.3d 947, 958-59 (9th Cir. 2002).
26 The ALJ determined, “The medical evidence of record does not support the extent of the
27 claimant’s subjective complaints and her statements and allegations are not fully consistent with the
28 medical and other evidence.” (Doc. 11-3 at 29-30) Notably, though the ALJ indicated Plaintiff’s
1 statements were not consistent with “other evidence” in the record, the ALJ failed to specifically
2 identify such evidence. Instead, the ALJ identified only medical evidence in the record as conflicting
3 with Plaintiff’s statements concerning “alleged mental limitations” and “alleged physical limitations.”
4 (See Doc. 11-3 at 29) In particular, the ALJ noted Plaintiff had a normal MRI of her brain, she “was
5 oriented times three with a normal thought process..., an intact memory and no suicidal or homicidal
6 ideation” and had a “negative examination of the musculoskeletal system” with “full motor strength.”
7 (Id.) Thus, the ALJ concluded Plaintiff’s statements were “inconsistent with the medical and other
8 evidence”—but only identified conflicting medical evidence. (Id.)
9 Importantly, in 1984, Congress amended the statutes governing disability to address allegations
10 of pain. See Bunnell, 947 F.2d at 347; 42 U.S.C. § 423(d)(5)(A). With the amendment, “Congress
11 clearly meant that so long as the pain is associated with a clinically demonstrated impairment, credible
12 pain testimony should contribute to a determination of disability.” Howard v. Heckler, 782 F.2d 1484,
13 1488 n.4 (9th Cir. 1986). The Ninth Circuit observed,
14 [D]espite our inability to measure and describe it, pain can have real and severe
debilitating effects; it is, without a doubt, capable of entirely precluding a claimant
15 from working. Because pain is a subjective phenomenon, moreover, it is possible to
suffer disabling pain even where the degree of pain, as opposed to the mere existence of
16
pain, is unsupported by objective medical findings.
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18 Fair v. Bowen, 885 F.2d 597, 601 (9th Cir. 1989). Therefore, an ALJ may not base an adverse
19 credibility determination solely upon the medical evidence. Id.; see also Rollins v. Massanari, 261
20 F.3d 853, 857 (9th Cir. 2001) (“subjective pain testimony cannot be rejected on the sole ground that it
21 is not fully corroborated by objective medical evidence”); Burch v. Barnhart, 400 F.3d 676, 681 (9th
22 Cir. 2005) (the “lack of medical evidence cannot form the sole basis for discounting pain testimony”).
23 Indeed, the Commissioner acknowledges that “how consistent Plaintiff’s statements were with
24 the objective medical evidence... could not be the ALJ’s sole reason for rejecting [her] statements about
25 symptoms.” (Doc. 22 at 13) The Commissioner also argues findings in the medical record are
26 inconsistent with Plaintiff’s statements (id. at 13-14), yet fails to acknowledge that the ALJ did, in fact,
27 only address the medical record to reject Plaintiff’s statements concerning the limiting effects of her
28 impairments. Because the ALJ identified only evidence in the medical record to discount Plaintiff’s
1 statements and did not consider any other factors identified by the Regulations or the Ninth Circuit, the
2 ALJ erred in evaluating Plaintiff’s credibility.
3 B. Remand is Appropriate
4 The decision whether to remand a matter pursuant to sentence four of 42 U.S.C. § 405(g) or to
5 order immediate payment of benefits is within the discretion of the district court. Harman v. Apfel,
6 211 F.3d 1172, 1178 (9th Cir. 2000). Except in rare instances, when a court reverses an administrative
7 agency determination, the proper course is to remand to the agency for additional investigation or
8 explanation. Moisa v. Barnhart, 367 F.3d 882, 886 (9th Cir. 2004) (citing INS v. Ventura, 537 U.S.
9 12, 16 (2002)). Generally, an award of benefits is directed when:
10 (1) the ALJ has failed to provide legally sufficient reasons for rejecting such evidence,
(2) there are no outstanding issues that must be resolved before a determination of
11 disability can be made, and (3) it is clear from the record that the ALJ would be required
to find the claimant disabled were such evidence credited.
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13 Smolen v. Chater, 80 F.3d 1273, 1292 (9th Cir. 1996). In addition, an award of benefits is directed
14 where no useful purpose would be served by further administrative proceedings, or where the record is
15 fully developed. Varney v. Sec’y of Health & Human Serv., 859 F.2d 1396, 1399 (9th Cir. 1988). The
16 Ninth Circuit explained that “where the ALJ improperly rejects the claimant’s testimony regarding his
17 limitations, and the claimant would be disabled if his testimony were credited,” the testimony can be
18 credited as true, and remand is not appropriate. Lester, 81 F.3d at 834.
19 Courts retain flexibility in crediting testimony as true, and a remand for further proceedings
20 regarding the credibility of a claimant is an appropriate remedy. See, e.g., Bunnell, 947 F.2d at 348
21 (affirming the district court’s order remanding for further proceedings where the ALJ failed to explain
22 with sufficient specificity the basis for rejecting the claimant’s testimony); Byrnes v. Shalala, 60 F.3d
23 639, 642 (9th Cir. 1995) (remanding the case “for further proceedings evaluating the credibility of [the
24 claimant’s] subjective complaints . . .”). Here, the findings of the ALJ are insufficient to determine
25 whether Plaintiff’s statements should be credited as true. Consequently, the matter should be
26 remanded for the ALJ to re-evaluate the evidence.
27 CONCLUSION AND ORDER
28 For the reasons set forth above, the Court finds the ALJ failed to address Plaintiff’s testimony
1 from the administrative hearing and failed to set forth findings “sufficiently specific to allow a
2 reviewing court to conclude the ALJ rejected the claimant’s testimony on permissible grounds.” Moisa
3 v. Barnhart, 367 F.3d 882, 885 (9th Cir. 2004). Consequently, the administrative decision should not
4 be upheld. See Sanchez, 812 F.2d at 510. Because remand is appropriate for further proceedings, the
5 Court offers no findings related the remaining issue identified in Plaintiff’s opening brief.
6 Accordingly, the Court ORDERS:
7 1. The matter is REMANDED pursuant to sentence four of 42 U.S.C. § 405(g) for further
8 proceedings consistent with this decision; and
9 2. The Clerk of Court IS DIRECTED to enter judgment in favor of Plaintiff Seng
10 Saeteurn and against Defendant, Andrew M. Saul, Commissioner of Social Security.
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12 IT IS SO ORDERED.
13 Dated: September 4, 2019 /s/ Jennifer L. Thurston
14 UNITED STATES MAGISTRATE JUDGE
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