The opinion
UNITED STATES DISTRICT COURT
MIDDLE DISTRICT OF FLORIDA
JACKSONVILLE DIVISION
MIKE ANGEL MARTINEZ,
Plaintiff,
v. CASE NO. 3:18-cv-1359-J-MCR
COMMISSIONER OF THE SOCIAL
SECURITY ADMINISTRATION,
Defendant.
______________________________/
MEMORANDUM OPINION AND ORDER1
THIS CAUSE is before the Court on Plaintiff’s appeal of an administrative
decision denying his applications for a period of disability, disability insurance
benefits (“DIB”), and supplemental security income (“SSI”). Following an
administrative hearing held on August 16, 2018, the assigned Administrative Law
Judge (“ALJ”) issued a decision,2 finding Plaintiff not disabled from May 30,
2008, the alleged disability onset date, through September 13, 2018, the date of
1 The parties consented to the exercise of jurisdiction by a United States
Magistrate Judge. (Doc. 19.)
2 Previously, the ALJ issued a decision (after a hearing held on November 26,
2013), finding Plaintiff not disabled from May 30, 2008, the alleged disability onset date,
through April 3, 2014, the date of that decision. (Tr. 2-44, 62-72.) The Appeals Council
affirmed the ALJ’s April 3, 2014 decision, but on appeal to this Court, the ALJ’s April 3,
2014 decision was reversed and remanded for further proceedings. (See Tr. 45-47,
544-54.) Because Plaintiff filed a claim for DIB on October 29, 2015, in its remand order
of February 3, 2018, the Appeals Council directed the ALJ to “consolidate the claims
files, associate the evidence, and issue a new decision on the consolidated claims.”
(Tr. 562-63.) The ALJ’s new decision, issued on September 13, 2018, is currently
under review.
the ALJ’s decision.3 (Tr. 203, 207, 270, 453-94, 701.) Based on a review of the
record, the briefs, and the applicable law, the Commissioner’s decision is
REVERSED and REMANDED.
I. Standard of Review
The scope of this Court’s review is limited to determining whether the
Commissioner applied the correct legal standards, McRoberts v. Bowen, 841
F.2d 1077, 1080 (11th Cir. 1988), and whether the Commissioner’s findings are
supported by substantial evidence, Richardson v. Perales, 402 U.S. 389, 390
(1971). “Substantial evidence is more than a scintilla and is such relevant
evidence as a reasonable person would accept as adequate to support a
conclusion.” Crawford v. Comm’r of Soc. Sec., 363 F.3d 1155, 1158 (11th Cir.
2004). Where the Commissioner’s decision is supported by substantial
evidence, the district court will affirm, even if the reviewer would have reached a
contrary result as finder of fact, and even if the reviewer finds that the evidence
preponderates against the Commissioner’s decision. Edwards v. Sullivan, 937
F.2d 580, 584 n.3 (11th Cir. 1991); Barnes v. Sullivan, 932 F.2d 1356, 1358 (11th
Cir. 1991). The district court must view the evidence as a whole, taking into
account evidence favorable as well as unfavorable to the decision. Foote v.
Chater, 67 F.3d 1553, 1560 (11th Cir. 1995); accord Lowery v. Sullivan, 979 F.2d
3 Plaintiff had to establish disability on or before September 30, 2013, his date
last insured, in order to be entitled to a period of disability and DIB. (Tr. 453.)
835, 837 (11th Cir. 1992) (stating the court must scrutinize the entire record to
determine the reasonableness of the Commissioner=s factual findings).
II. Discussion
Plaintiff contends that the ALJ erred by failing to evaluate the opinion
evidence consistent with the regulations, Agency policy, and Eleventh Circuit
precedent, which was further compounded by the ALJ’s failure to consider
Plaintiff’s need for a supportive living environment. Plaintiff points out that the
opinions of his treating psychiatrist, Dr. Madkaiker, and the examining licensed
psychologist, Dr. Nay, establish far greater limitations than assessed by the ALJ.
Plaintiff adds that the ALJ erred in giving little or some weight to Dr. Madkaiker’s
treating opinions and little weight to Dr. Nay’s examining opinions, which were
consistent with each other and the other medical evidence, while according
significant or substantial weight to the outdated opinions of the State agency non-
examining medical consultants. Plaintiff points out that the ALJ never requested
an updated review of the record by a State agency consultant and did not
arrange for a consultative examination4 of Plaintiff. Plaintiff further argues that
the ALJ erred by failing to consider Plaintiff’s need for a supportive living
environment and/or need for ongoing accommodations related to his mental
impairments. Defendant responds that substantial evidence supports the ALJ’s
evaluation of the medical and non-medical opinions of record, as well as the
4 The only consultative examination in this case was performed by Dr. Nay upon
referral by Plaintiff’s counsel.
ALJ’s finding that Plaintiff can perform a reduced range of medium work without
the presence of a family member as a condition to performing that work.
A. Standard for Evaluating Opinion Evidence
The ALJ is required to consider all the evidence in the record when making
a disability determination. See 20 C.F.R. §§ 404.1520(a)(3), 416.920(a)(3). With
regard to medical opinion evidence, “the ALJ must state with particularity the
weight given to different medical opinions and the reasons therefor.” Winschel v.
Comm’r of Soc. Sec., 631 F.3d 1176, 1179 (11th Cir. 2011). Substantial weight
must be given to a treating physician’s opinion unless there is good cause to do
otherwise. See Lewis v. Callahan, 125 F.3d 1436, 1440 (11th Cir. 1997).
“‘[G]ood cause’ exists when the: (1) treating physician’s opinion was not
bolstered by the evidence; (2) evidence supported a contrary finding; or (3)
treating physician’s opinion was conclusory or inconsistent with the doctor’s own
medical records.” Phillips v. Barnhart, 357 F.3d 1232, 1240-41 (11th Cir. 2004).
When a treating physician’s opinion does not warrant controlling weight, the ALJ
must nevertheless weigh the medical opinion based on: (1) the length of the
treatment relationship and the frequency of examination, (2) the nature and
extent of the treatment relationship, (3) the medical evidence supporting the
opinion, (4) consistency of the medical opinion with the record as a whole, (5)
specialization in the medical issues at issue, and (6) any other factors that tend
to support or contradict the opinion. 20 C.F.R. §§ 404.1527(c)(2)‒(6),
416.927(c)(2)‒(6).
Although a treating physician’s opinion is generally entitled to more weight
than a consulting physician’s opinion, see Wilson v. Heckler, 734 F.2d 513, 518
(11th Cir. 1984) (per curiam), 20 C.F.R. §§ 404.1527(c)(2), 416.927(c)(2), “[t]he
opinions of state agency physicians” can outweigh the contrary opinion of a
treating physician if “that opinion has been properly discounted,” Cooper v.
Astrue, No. 8:06-cv-1863-T-27TGW, 2008 WL 649244, *3 (M.D. Fla. Mar. 10,
2008). Further, “the ALJ may reject any medical opinion if the evidence supports
a contrary finding.” Wainwright v. Comm’r of Soc. Sec. Admin., No. 06-15638,
2007 WL 708971, *2 (11th Cir. Mar. 9, 2007) (per curiam); see also Sryock v.
Heckler, 764 F.2d 834, 835 (11th Cir. 1985) (per curiam) (same).
“The ALJ is required to consider the opinions of non-examining state
agency medical and psychological consultants because they ‘are highly qualified
physicians and psychologists, who are also experts in Social Security disability
evaluation.’” Milner v. Barnhart, 275 F. App’x 947, 948 (11th Cir. 2008) (per
curiam); see also SSR 96-6p5 (stating that the ALJ must treat the findings of
State agency medical consultants as expert opinion evidence of non-examining
sources). While the ALJ is not bound by the findings of non-examining
physicians, the ALJ may not ignore these opinions and must explain the weight
given to them in his decision. SSR 96-6p.
5 SSR 96-6p has been rescinded and replaced by SSR 17-2p effective March 27,
2017. However, because Plaintiff’s applications predated March 27, 2017, SSR 96-6p
was still in effect on the date of the ALJ’s decision.
B. Relevant Evidence of Record
1. Satyen P. Madkaiker, M.D.
Dr. Madkaiker has treated Plaintiff since October 2, 2008. (Tr. 317.) On
April 12, 2011, Dr. Madkaiker wrote a note, stating that considering Plaintiff’s
chronic condition, he would “need treatment for several more years.” (Tr. 298.)
On December 5, 2012, Dr. Madkaiker completed a Medical Source
Statement of Ability to Do Work-Related Activities (Mental) (“MSS”). (Tr. 348-
51.) In the MSS, Dr. Madkaiker opined, inter alia, that Plaintiff was extremely
limited in the ability to understand, remember, and carry out complex instructions,
and to make judgments on complex work-related decisions; he was markedly
limited in the ability to make judgments on simple work-related decisions and the
ability to interact appropriately with the public; and he was moderately limited in
the ability to interact appropriately with supervisors and co-workers, and the
ability to respond appropriately to usual work situations and to changes in a
routine work setting. (Tr. 348-49.) Dr. Madkaiker explained:
[Patient] has many [years] of chronic symptoms ‒ [with] multiple
hospitalizations [and] only moderate improvement [with] various
medication interventions over the years. . . . Also, as far as [work] ‒
[patient] tried in the past to be successful [at] the most basic of jobs,
although never successful due to chronic symptoms of psychosis,
[depression, and] anxiety.
. . .
[Patient and] family have had [three] major deaths in the family,
which have exacerbated [patient’s] symptoms. [Patient] cannot drive
more than a block or two [and] has difficulty going out of the house
[and] being around people outside the family. [Illegible] of
psychosis, [depression, and] anxiety.
. . .
[Patient] has paranoid schizophrenia [with] several [negative and]
positive symptoms. Although his delusions [and] hallucinations have
been controlled, he continues to have severe apathy, lack of drive
[and] inability to function in a social/[work] setting.
(Id.) Dr. Madkaiker also opined that Plaintiff was unable to manage benefits in
his own best interest and explained that Plaintiff’s mother assisted with his
finances and everyday affairs, including medication management. (Tr. 351.)
2. Richard E. Nay, Ph.D.
On November 20, 2017, Dr. Nay performed a psychological evaluation of
Plaintiff in order to assess his suitability for Social Security benefits. (Tr. 1014-
21.) Dr. Nay’s opinions were based on a clinical interview, behavioral
observations, Mini Mental State Examination (MMSE), selected subtests of the
Repeatable Battery for the Assessment of Neuropsychological Status (RBANS),
the DSM-V Cross Cutting Symptom Measure (CCSM), and review of Dr.
Madkaiker’s February 6, 2012 MSS and February 22, 2012 letter, and Ms.
Cowart’s December 26, 2013 correspondence. (Tr. 1014.)
Under Behavioral Observations, Dr. Nay stated, in relevant part:
Mr. Martinez . . . was accompanied to the evaluation by his mother,
Myriam Muniz, who drove him to the evaluation. Mr. Martinez
appeared quite anxious upon meeting the examiner, and requested
that his mother be able to accompany him into the evaluation proper,
which was allowed given his obvious level of hesitation and anxiety
about the evaluation. He presented with a flat affect, and exhibited
poor eye contact, frequently averting his vision. His overall
demeanor was noted to be very intense and serious, and he was
observed to fidget frequently in his chair. His immediate answers to
questions were often short and terse, and he often looked
at/deferred to his mother for assisting him in answering interview
questions. As Mr. Martinez was noted to be a poor historian for
specific information and dates, his mother answered many questions
for him. . . . Mr. Martinez appeared to exhibit an adequate test-
taking effort, and current test data is considered to be a valid
estimate of current cognitive functioning.
(Tr. 1014-15.)
As part of the Relevant Background Information, Dr. Nay noted, inter alia:
[Mr. Martinez] first sought psychiatric help in approximately 1988,
and was placed in a psychiatric hospital for approximately one week
in Titusville. At this time, he stated “I was hearing voices that told
me bad things about myself . . . I thought the world was going to
end.” From this point forward, Mr. Martinez began seeing a
psychiatrist on a monthly basis for medication management. He
stated he also experienced two subsequent psychiatric
hospitalizations in Jacksonville, secondary to symptoms of
schizophrenia, in 2013 and 2014. Mr. Martinez reports that he has
been seeing psychiatrist Dr. Satyan Madkaiker every three months
since 2014. Prior to Dr. Madkaiker, he had seen two other
psychiatrists over a period of many years, but was unable to
remember their names.
(Tr. 1015.)
With respect to his work history:
Mr. Martinez stated he last worked in 2007, adding that he had to
quit work because of his psychiatric symptoms. In this regard, he
added “I felt shaky, panicky . . . I didn’t feel good . . . I had bad
thoughts and paranoia.” At the time he quit working in 2007, he had
been employed as a part-time bagger at a Publix supermarket (26
hours per week) for 18 years. Mr. Martinez has not worked at all
since 2007.
(Tr. 1017.)
As to his daily activities, Plaintiff explained he spent his time watching
television, reading, playing solitaire, and doing crosswords.6 (Id.) Further:
He stated he leaves home only 2-3 times per week usually to take
his mother shopping. He stated[,] “I leave home for doctors[’]
appointments also, but for no other reasons.” Mr. Martinez does no
cooking. He stated he engages in limited cleaning, adding “I do
minimal sweeping once in a while . . . Sometimes I help my mother
clean.” Mr. Martinez stated he rarely goes shopping, and almost
always with a family member if he does go to a store. He stated he
does have a current driver’s license, but only drives close to his
home, as frequently as two times per week. In this regard, he
stated[,] “I don’t feel comfortable driving any further.” . . . He does
not use any form of public transportation, and added “I’m not sure I
could get on a bus alone . . . I get lost.”
(Id.) Then, “[w]hen asked specifically why he feels he is unable to be gainfully
employed at the present time, Mr. Martinez replied[,] ‘[I]f anyone else was around
I would get really nervous . . . I’m afraid it would all happen again, and I would
[e]nd up in a psychiatric hospital.’” (Id.)
Next, Dr. Nay summarized the results of the various tests as follows:
[T]he results of the MMSE indicated a total MMSE score of 28/30,
which by itself is not indicative of significant cognitive impairment.
Test results did indicate that Mr. Martinez . . . was unaware what
county he was in with respect to orientation to place. Also, and
significantly, he was completely unable to perform a simple serial
sevens task, adding “math has always been very hard for me.” . . .
It is important to remember that the MMSE is only a very gross
indicator of overall mental status . . . . Thus, a more discriminating
instrument was employed in this regard, the RBANS.
. . .
[T]he results of the RBANS indicated that all three measured areas
of cognitive functioning, including short-term/immediate memory,
attention/concentration, and delayed memory/recall, all fall into the
very low range of cognitive functioning, suggesting severe
impairment in all three areas. The results of the delayed memory
6 The medical records reflect that Plaintiff spent his time watching television,
listening to music, and coloring. (See, e.g., Tr. 843, 845, 852.)
index scores suggest that Mr. Martinez does not benefit from
repeated administrations of the same stimuli, indicating he would
require frequent, ongoing repetitions of any new material to be
learned. These findings certainly corroborate Mr. Martinez’[s] self-
report of having significant difficulties with memory and retention of
information.
. . . The following CCSM domains received a score of either
“moderate” or “severe”: [d]epression, feelings of irritation, anxiety,
somatic complaints, and difficulties with memory.
(Tr. 1018-19.)
Under Summary and Diagnostic Impressions, Dr. Nay cited some of Dr.
Madkaiker’s records and Ms. Cowart’s statements regarding Plaintiff’s
functioning, and then stated, in relevant part:
In light of all of this information, which is quite consistent, this
examiner concurs that the most appropriate diagnosis for this man is
schizoaffective disorder, depressed type, chronic. He also suffers
with various anxiety-based symptoms, and yet may not qualify for a
full diagnosis of any one particular anxiety disorder. Hence, the
more general diagnosis of anxiety disorder NOS is most appropriate.
Mr. Martinez is extremely dependent on his mother and other family
members, and his sense of security can become easily threatened if
he attempts to venture away from his home. He has an extremely
poor stress coping response, and his feelings of depression and
anxiety can quickly become exacerbated to the point of severe
depression and even panic attacks, in response to even minimal
stressors. It is important to note that the above statements are true
even though this man takes multiple psychotropic medications and
has done so for many years. Overall, his symptoms of psychosis,
including delusional thinking and hallucinations, appear[] to be fairly
well controlled with medications at this point, but could quickly
deteriorate if he forgot to take medications or there was any change
in his medication regimen. In addition to all of the aforementioned
psychiatric issues and psychosocial limitations noted, Mr. Martinez
also experiences significant, even severe impairments in short-
term/immediate memory, attention/concentration, and delayed
memory/recall. Consistent with findings of the attached medical
records, Mr. Martinez would require constant reminders and cues in
order to complete even the simplest of tasks. Indeed, his very
limited work history suggests that he was unable to continue
performing a very simple, routine job (i.e., []bagger), as his
psychiatric symptoms and poor stress coping response made any
type of work impossible for this man. Based on all of the above
information, including interview information, behavioral observations,
current testing, and a complete review of attached medical records,
it is the opinion of this examiner that Mr. Martinez is totally disabled
from a psychological perspective, and is unable to perform in any job
setting on a five[-]day [] week, eight[-]hour[-]day basis. While the
current medical records reviewed [] go back to 2012-13, it is this
examiner’s opinion this man was sufficiently disabled to preclude
any work from the time he was forced to quit his job with Publix in
2007 up until the present. It is possible that some of the cognitive
dysfunction noted could be secondary to side effects of his multiple
psychotropic medications, but it is extremely important to note that
Mr. Martinez relies on these medications to maintain any sort of
psychological stability in his life.
Based on all of the above information, the following DSM-IV
diagnostic impressions are offered:
Axis I: Schizoaffective Disorder, Depressed Type, Chronic
Anxiety Disorder NOS (Generalized Anxiety and Panic)
Axis II: Dependent Personality Disorder
Axis III: Type II Diabetes, High Cholesterol
Axis IV: Current stressors: Financial, Ongoing Psychiatric
Symptoms
Axis V: Current GAF: 45 [H]ighest GAF over past year: 45
(Tr. 1020.)
On December 15, 2017, Dr. Nay completed a Mental MSS regarding
Plaintiff’s functioning. (Tr. 1022-25.) He reiterated Plaintiff’s diagnoses and
identified the following symptoms: anhedonia; decreased energy; inappropriate
affect; feelings of guilt or worthlessness; poverty of content of speech;
generalized persistent anxiety; mood disturbance; difficulty thinking or
concentrating; psychomotor agitation; motor tension; autonomic hyperactivity;
pathological dependence; persistent disturbances of mood or affect;
apprehensive expectation; paranoid thinking; emotional withdrawal or isolation;
easy distractibility; memory impairment; oddities of thought, perception, speech,
or behavior; perceptual or thinking disturbances at times; hallucinations or
delusions at times; pathologically inappropriate suspiciousness at times; and
recurrent severe panic attacks at times. (Tr. 1022-23.)
Then, Dr. Nay opined, inter alia, that Plaintiff would be unable to perform
the following tasks/functions on a regular, reliable, and sustained basis:
remember work-like procedures; maintain attention for a two-hour segment;
maintain regular attendance and be punctual; complete a normal workday and
workweek without interruptions from psychologically based symptoms; respond
appropriately to changes in a routine work setting; deal with normal work stress;
understand, remember, or carry out detailed instructions; deal with the stress of
semi-skilled and skilled work; and interact appropriately with the general public.
(Tr. 1023-24.)
Dr. Nay also repeated some of the opinions expressed in his November
20, 2017 report. (Tr. 1024-25.) Specifically, he stated that “the severity of
symptoms observed at present existed at least as far back as 2007.” (Tr. 1025.)
3. State Agency Non-Examining Consultants
On March 14, 2012, based on a review of the records available as of that
date, B. Lee Hudson, Ph.D., a State agency non-examining consultant,
completed a Psychiatric Review Technique, opining, in relevant part, that Plaintiff
had a mild limitation in activities of daily living and a moderate limitation in social
functioning and concentration, persistence, or pace. (Tr. 85-86.) The same day,
Dr. Hudson completed a Mental RFC Assessment, opining, in relevant part that
Plaintiff was moderately limited in the ability to: understand, remember, and carry
out detailed instructions; maintain attention and concentration for extended
periods; work in coordination with or in proximity to others without being
distracted by them; interact appropriately with the general public; get along with
coworkers or peers without distracting them; and respond appropriately to
changes in the work setting. (Tr. 88-89.) Dr. Hudson explained that Plaintiff
retained “the ability to learn and perform simple, straightforward work tasks,
function adequately in many types of brief, conventional employment-related
social situations, and respond effectively to most routine changes that frequently
occur in basic occupational settings.” (Tr. 89-90.)
On May 30, 2012, another State agency non-examining consultant, Minal
Krishnamurthy, M.D., completed a Physical RFC Assessment of Plaintiff’s
abilities. (Tr. 111-12.) Dr. Krishnamurthy opined, inter alia, that Plaintiff could lift
and/or carry fifty pounds occasionally and twenty-five pounds frequently, and he
could sit for about six hours and stand and/or walk for about six hours in an eight-
hour workday. (Id.)
On June 13, 2012, Robert F. Schilling, Ph.D., P.A., a State agency non-
examining consultant, completed a Psychiatric Review Technique, opining, in
relevant part, that Plaintiff had a mild limitation in activities of daily living and a
moderate limitation in social functioning and concentration, persistence, or pace.
(Tr. 110.)
On December 8, 2015, Richard Willens, Psy.D., a State agency non-
examining consultant, completed a Psychiatric Review Technique, opining, in
relevant part, that Plaintiff had a mild limitation in activities of daily living and a
moderate limitation in social functioning and concentration, persistence, or pace.
(Tr. 524-25.) The same day, Dr. Willens completed a Mental RFC Assessment,
opining, in relevant part, that Plaintiff was moderately limited in the ability to:
carry out detailed instructions; maintain attention and concentration for extended
periods; work in coordination with or in proximity to others without being
distracted by them; interact appropriately with the general public; get along with
coworkers or peers without distracting them; respond appropriately to changes in
the work setting; and complete a normal workday and workweek without
interruptions from psychologically based symptoms and perform at a consistent
pace without an unreasonable number and length of rest periods. (Tr. 527-28.)
In summary, Dr. Willens stated:
Claimant can understand, retain, and carry out simple instructions.
Claimant can consistently and usefully [sic] perform routine tasks on
a sustained basis, with minimal (normal) supervision. Claimant has
reduced ability to cooperate effectively with [the] public and co-
workers in completing simple tasks and transactions and would
perform best in [a] setting with modest social demands. Claimant
can adjust to the mental demands of most new task settings.
(Tr. 528.)
On February 11, 2016, Renee McPhersonSalandy, Ph.D., a State agency
non-examining consultant, completed a Psychiatric Review Technique, opining,
in relevant part, that Plaintiff had a mild limitation in activities of daily living and a
moderate limitation in social functioning and concentration, persistence, or pace.
(Tr. 537.) The same day, Dr. McPhersonSalandy completed a Mental RFC
Assessment, opining, in relevant part that Plaintiff was moderately limited in the
ability to: carry out detailed instructions; maintain attention and concentration for
extended periods; work in coordination with or in proximity to others without
being distracted by them; interact appropriately with the general public; accept
instructions and respond appropriately to criticism from supervisors; get along
with coworkers or peers without distracting them; respond appropriately to
changes in the work setting; and complete a normal workday and workweek
without interruptions from psychologically based symptoms and perform at a
consistent pace without an unreasonable number and length of rest periods. (Tr.
539-40.) Dr. McPhersonSalandy adopted Dr. Willens’s summary, stating:
Claimant can understand, retain, and carry out simple instructions.
Claimant can consistently and usefully [sic] perform routine tasks on
a sustained basis, with minimal (normal) supervision. Claimant has
reduced ability to cooperate effectively with [the] public and co-
workers in completing simple tasks and transactions and would
perform best in [a] setting with modest social demands. Claimant
can adjust to the mental demands of most new task settings.
(Tr. 540.)
4. Carmen Cowart
On December 26, 2013, Plaintiff’s aunt, Carmen Cowart, authored a letter
regarding Plaintiff’s abilities. (Tr. 283-84.) She stated that “for many years,”
Plaintiff and his mother had been “very dependent on [her] to handle most of their
affairs.” (Tr. 283.) She also stated, in relevant part:
Michael has lived with his mother all of his life and becomes
very uncomfortable when he is not with her.
. . . [H]e has and continues to be extremely paranoid, often
hiding himself in corners of his room. He frequently hears voices
and sees things others do not see even though he has and
continues to be on medication. Throughout the years, my
[n]ephew’s medication regimen has been changed frequently in the
hopes that he could become stable and not require hospitalization.
He has been Baker-Acted in the past for his delusional thinking with
extreme highs and lows.
Michael seldom leaves his home and, if he does, much [sic]
be accompanied by his mother, sister or myself because he has
panic attacks and is not able to do even the smallest of tasks without
supervision. He is unable to handle any types of change in routine
and becomes distraught with increased anxiety and depression
when faced with anything new. He began to frequently leave his
position as bagger at Publix, retreating to hide in the back of the
store away from his fellow employees and customers while
experience [sic] panic attacks. He would become lost when driving
the three blocks to Publix from his home. This is the same route he
drove for many years while employed with Publix. He becomes very
anxious and confused when in traffic not only when driving but also
when riding as a passenger. He was and continues to be unable to
interact appropriately with the public.
He often does not sleep for 3-4 days at a time, frequently
pacing and unable [sic] to focus or maintain concentration. His
[m]other administers and monitors his medication regularly to assure
his compliance. Michael is unable to make decisions or complete
tasks. He is very slow in his thinking. When he worked, his mother
would go with him to the bank to cash his payroll check and help him
monitor his money . . . .
The only time Michael goes to any family functions is when I
come to get him and his mother. When Michael is with the family, he
either sits alone or watches television. He seldom makes
conversation or interacts with the other family members. He
becomes very anxious outside of his home and familiar surroundings
even when he has been to the particular site other times. . . .
He is unable to remember his doctor’s appointments and must
be reminded frequently to ready himself and attend in a timely
manner. There are times when he becomes anxious[,] has extreme
panic attacks and is unable to follow through on attending scheduled
appointments. Many times since he was a young boy, I have had to
come to his home or call him to help calm him down when he was
having extreme paranoia with delusional thoughts.
(Id.)
On November 23, 2015, Ms. Cowart authored another letter, stating in
relevant part:
I provide all transportation and I am contacted at any time Michael
Martinez has needs or when his mother needs help with Michael’s
care for many years. In the last four years, I can see his condition
progress [sic] and so has my involvement. Michael lives with his
mother, one brother and one sister[,] and Michael cannot be left
unattended at any time. He has a fear of being left alone and can
experience an anxiety or frantic [sic] attack at any given time which
requires someone to be with him all the time. I see Michael at least
every other day unless I’m needed sooner.
So far, in the 1st, 2nd and 3rd quarter of this year (2015), I have taken
him to the hospital 2 times for evaluation and I have seen him have
5 setbacks so far this year (January, February, March, May, and
July). Each setback involves the 1st night of maybe 2 hours sleep;
[the] 2nd and 3rd night will be with no sleep. He gets anxious, can’t
stay still, moves things from one place to another place, easily get[s]
confused and nervous. I’ve seen this take place each time. He tells
me he hears voices and the voices won’t leave him alone.
For example, on March 26, 2015, Michael had his mother call me,
which he does often, and when I spoke to Michael, he said “you
need to do something because I’m going to have a heart attack.
They’re driving me up the wall screaming.” . . . I drove to the house.
His eyes were extra wide open, like an owl’s eyes, and said he’s
going out of his mind and having a heart attack. His mother said he
hasn’t done any hygiene in 2 or 3 days and he hasn’t slept in 2 or 3
days ([n]o one is able to sleep when Michael has anxieties and gets
shaky). I could immediately see he was having a setback because
I’ve seen it before with Michael. I repeatedly tell [sic] him to calm
down and then drove him to the hospital. He was sitting in the back
with his mother, sister and brother (none of them can drive). They
had him evaluated and gave him some sedative to calm him down
and asked him if he would stay and they would keep an eye on him
but he refused.
He was released and then 2 days later, I came by to check on
Michael and he was hostile and frustrated and all over the house
walking back and forth, turning lights off and on, open[ing] and
closing doors. I then drove him back to the hospital and his
Lorazepam was increased for anxiety and they told me and his
mother to continue with the increase and make sure to call his doctor
the next day and let him know. I called the doctor and let him know
and [took] him to the doctor in early April. The doctor kept the
Lorazepam at the double dose and increased Seroquel to 400 mg
and I then drove him and his family home.
On July 27, 2015, I had to call the doctor and let him know Michael is
not getting any better. He was shaking and couldn’t sit down still
and pacing [sic] on the floor. . . . [H]e was still hearing voices.
Michael said not as bad but still hearing voices and still gets a little
upset. Michael told the doctor he noticed he gets frustrated fast.
The doctor then increased the Seroquel and Invega med[ications].
The med[ications] appear to help him sleep longer and [he] is calmer
so far.
(Tr. 716.)
Ms. Cowart also testified at the August 16, 2018 hearing before the ALJ.
(Tr. 481-89.) She repeated her prior written statements and explained that her
sister (Plaintiff’s mother) was in a wheelchair due to a crippling disease, which
further necessitated Ms. Cowart’s involvement because she became the only
driver in the family. (Tr. 482-84, 486-88.)
C. The ALJ’s September 13, 2018 Decision
At step two of the sequential evaluation process,7 the ALJ found that
Plaintiff had the following severe impairments: obesity, schizoaffective disorder,
generalized anxiety disorder (“GAD”), type two diabetes mellitus (“DM”), and
hypertension. (Tr. 455.) Then, at step three, the ALJ found that Plaintiff did not
have an impairment or combination of impairments that met or medically equaled
the severity of one of the listed impairments in 20 C.F.R. Part 404, Subpart P,
Appendix 1. (Tr. 456.) The ALJ determined that Plaintiff had only mild limitations
in the ability to concentrate, persist, or maintain pace, and moderate limitations in
understanding, remembering, or applying information, in interacting with others,
and in adapting or managing oneself. (Tr. 456-57.)
When determining that Plaintiff was moderately limited in interacting with
others, the ALJ acknowledged that he had “a close supportive relationship with
his family.” (Tr. 456.) Then, in determining that the evidence did not establish
the presence of the “paragraph C” criteria of listings 12.04 and 12.06, the ALJ
stated:
Per the evidence and hearing testimony, the record does not
establish the claimant having minimal capacity to adapt to changes
in his environment or to demands that are not already part of his
daily life. He does not live in a highly structured environment (e.g.,
group home or institutional facility); he is independent in personal
care, toileting, feeding, etc.; he is able to read, write and
communicate; he has a driver’s license and is able to drive short
7 The Commissioner employs a five-step process in determining disability. See
20 C.F.R. §§ 404.1520(a)(4), 416.920(a)(4).
distances without assistance.8 Furthermore, although the claimant’s
medical history is remarkable for mental hospitalization, inpatient
treatment was not of an extended duration.
(Tr. 457.)
Further, before proceeding to step four, the ALJ found that Plaintiff had the
residual functional capacity (“RFC”) to perform medium work with the following
limitations:
Specifically, the claimant is limited to performing simple tasks with
little variation that take a short period to learn (up to and including 30
days), consistent with unskilled work (i.e., jobs with a Specific
Vocational Preparation (SVP) level of 1 or 2). The claimant is able
to deal with the changes in a routine work setting; he is limited to
work settings that do not require production-paced work; he is able
to relate adequately to supervisors; he is limited to only occasional
interaction with co-workers; and he must avoid contact with the
public.
(Id.)
In making this finding, the ALJ discussed Plaintiff’s diagnoses; his “regular
[and] continuous” treatment with his psychiatrist, Dr. Madkaiker; his “continued[,]
regular follow-up care with his primary care provider (PCP)” at the University of
Florida Family Practice (“UF”); the testimony from the two hearings; the third-
party statements by Plaintiff’s mother and aunt; and the opinion evidence from
the treating, examining, and non-examining sources. (Tr. 457-66.) After
8 The record indicates that Plaintiff could drive only a few blocks and when he
did, he was accompanied by family members. (See Tr. 25-27 (noting that Plaintiff could
drive his sister to the same Publix where he used to work, which was a two-minute
drive); Tr. 28 (stating that Plaintiff does not drive in unfamiliar areas, because when he
did, he got lost); Tr. 277.)
considering Plaintiff’s and the third-parties’ statements concerning the intensity,
persistence, and limiting effects of Plaintiff’s symptoms, the ALJ found that these
statements were Anot entirely consistent with the medical evidence and other
evidence in the record,@ and were, therefore, accorded “little weight.” (Tr. 459.)
The ALJ explained:
For instance, despite the claimant’s above-reported limitations, the
claimant (and Ms. Cowart) indicated his prescribed medications work
well in controlling his mental symptoms and stabilizing his mood. In
addition, the evidence and hearing testimony reflects the claimant is
able to drive short distances to familiar places; he is able to count
change and read; he is able to appropriately interact with others
when he is not stress[ed] and on appropriate prescribed
psych[otropic] medications; and he sleeps well while on medication.
. . .
Furthermore, the record fails to convey objective medical evidence
or positive clinical findings to suggest the claimant’s impairments
reach a level of severity to support a conclusion of “disabled” under
the Regulations. Treating and examining medical sources have
similarly recorded some mild to moderate findings regarding the
claimant’s impairments, as well as largely unremarkable medical
examinations otherwise, with no acute deficits in overall physical or
mental functioning. As discussed below, the treatment record
regularly denotes good control of (mental and physical) symptoms
with appropriate, ongoing medical treatment, continued follow-up
care with mental health providers, and compliance (Exhibits 5F and
7F-10F, 14F and 15F).
(Tr. 459-60.)
The ALJ then discussed Plaintiff’s treating and examining records (see Tr.
460-64), which he summarized as follows:
Overall, the above-summarized treatment records, evaluations and
objective findings remain consistent with other medical entries
received from the claimant’s treating/examining medical sources of
record since the approximate alleged onset date. This includes
similar assessments and diagnoses; some mild/moderate findings
concerning the claimant’s impairments; improvements noted with
appropriate, conventional treatment and compliance; consistent
medical directives to follow a conservative plan (i.e., exercise,
healthy diet, medication compliance, continue follow-up care, etc.);
and no substantial changes in [the] prescribed treatment regimen,
except for some occasional adjustments in medications (Exhibits 1F-
5F, 7F, 8F and 10F-17F).
(Tr. 464.)
The ALJ also addressed the medical opinion evidence. (Tr. 464-66.) As to
Dr. Madkaiker’s opinions, the ALJ stated:
I find Dr. Madkaiker’s medical source statements indicating the
claimant to have “marked” limitations in [the] ability to make simple
work-related decisions inconsistent with the evidence of record as a
whole, including his own treatment notes that routinely show the
claimant’s mental symptoms as “controlled.” Dr. Madkaiker’s
treatment notes also frequently describe the claimant as “doing well”
and “functioning well” (see[,] e.g., Exhibits 5F, 15F and 17F).
Notwithstanding, most of Dr. Madkaiker’s medical source statements
are supportive of the claimant’s above [RFC] assessment, which
accommodate the claimant’s limitations in performing certain mental
work activities. Consequently, I accord Dr. Madkaiker’s medical
opinion some weight to the extent consistent with the instant
decision; and I accord great weight to his routine treatment records
in determining the claimant’s [RFC].
(Tr. 465.)
The ALJ then addressed Dr. Nay’s examining opinions as follows:
[S]ubsequent to his 2017 evaluation, Dr. Nay noted the claimant as
“extremely dependent on family members, and his sense of security
can become easily threated [sic] if he attempts to venture away from
his home.” The claimant has poor stress coping response; and
depression and anxiety are easily exacerbated in response to even
minimal stressors. Dr. Nay further found that overall, the claimant’s
symptoms of psychosis appear fairly well controlled with
medications, but could quickly deteriorate if he forgets to take
medications or if there is any change in his medication regimen. The
claimant also experiences significant impairments in short-
term/immediate memory, attention/concentration, and delayed
memory/recall. As applied to a vocational setting, Dr. Nay
concluded the claimant would require constant reminders and cues
in order to complete simple tasks; and that the claimant’s very
limited work history suggests he was unable to continue performing
a very simple, routine job (i.e., []bagger), as his psychiatric
symptoms and poor stress coping response made any type of work
impossible. Based on all evidence reviewed, evaluation findings,
behavioral observations and current testing, Dr. Nay opined the
claimant is “totally disabled” from a psychological perspective[] and
is unable to perform in any job setting on a full-time basis (Exhibit
16F).
Here, I find Dr. Nay’s above evaluation and medical opinion
unsupported by the medical evidence as a whole. Specifically, as
discussed above, the claimant’s routine PCP treatment records and
contemporaneous progress notes from his psychiatrist, Dr.
Madkaiker, reflect no more than moderate mental
symptoms/difficulties. Therefore, I accord Dr. Nay’s medical opinion
little weight.
(Id.)
The ALJ also considered the findings by the State agency non-examining
consultants, Dr. Schilling and Dr. Krishnamurthy, who reviewed the file in June
and May of 2012, respectively, and found Plaintiff not disabled. (Tr. 466.) The
ALJ weighed these opinions as follows:
Here, I find Dr. Schilling’s psychological assessment an accurate
summary of the medical evidence as a whole, and therefore accord
his medical opinion significant probative weight in determining the
claimant’s relevant mental limitations.
. . . Here, I find Dr. Krishnamurthy’s medical assessment an
accurate summary of the file as a whole, and accord his medical
opinion substantial weight to the extent consistent with the instant
decision.
(Id.) Then, the ALJ stated:
In sum, the State agency physical and psychological assessments,
in addition to the claimant’s and third party[’s] statements/testimony
and medical records presented, fail to establish that the claimant is
disabled. Although he may experience some significant limitations
resulting from his impairments, he has not established that these
symptoms are of such intensity and frequency that he is unable to
work. Thus, the limitations that do exist are accommodated within
the [RFC] assessment.
(Id.)
At step four, the ALJ determined that Plaintiff was unable to perform any
past relevant work. (Tr. 467.) At step five, considering Plaintiff’s age,9
education,10 work experience, and RFC, as well as the testimony of the
vocational expert (“VE”), the ALJ determined that there were jobs existing in
significant numbers in the national economy that Plaintiff could perform, such as
the jobs of hand packager, laundry worker, and cleaner II. (Tr. 467-68.) As
noted in the ALJ’s decision, all of these representative occupations are medium
duty, unskilled jobs with an SVP of 2. (Tr. 468.)
D. Analysis
The Court agrees with Plaintiff that the ALJ’s RFC assessment is not
supported by substantial evidence. First, the ALJ improperly evaluated the
opinion evidence. The ALJ gave significant or substantial weight to the opinions
of two State agency non-examining consultants, Dr. Schilling and Dr.
9 Plaintiff was born in 1967. (Tr. 467.)
10 Plaintiff completed high school but was in special education classes. (Tr. 467,
845, 852.)
Krishnamurthy, who reviewed the record in June and May of 2012,
respectively.11 The ALJ explained that these consultants’ assessments were “an
accurate summary of the medical evidence [or the file] as a whole.” (Tr. 466.)
However, these assessments were clearly outdated as they did not take into
account, inter alia, the treatment records for the remainder of 2012 and through
2018, Dr. Madkaiker’s December 5, 2012 MSS, Dr. Nay’s November 2017
consultative report and MSS, or Ms. Cowart’s statements from either 2013 or
2015. Given that the assessments by Dr. Schilling and Dr. Krishnamurthy were
clearly based on an incomplete record, the ALJ’s statement that these
assessments represented “an accurate summary of the medical evidence [or the
file] as a whole,” is not supported by substantial evidence.
Further, the ALJ’s evaluation of the treating and examining opinions is not
supported by substantial evidence. As an initial matter, it appears that the ALJ
essentially ignored the consistency between Dr. Madkaiker’s opinions, Dr. Nay’s
opinions and findings, and the third-party statements by Ms. Cowart. When
discounting Dr. Madkaiker’s opinions as inconsistent with his own treatment
notes, the ALJ stated that the treatment notes showed Plaintiff had no more than
11 Although the ALJ referenced only the assessments completed by Dr. Schilling
and Dr. Krishnamurthy, there were three other State agency consultants who issued
opinions in this case, one of which predated Dr. Krishnamurthy’s assessment and the
other two assessments were issued in December 2015 and February 2016,
respectively. Interestingly, the ALJ did not discuss these more recent assessments.
Also, while the ALJ referenced an assessment by “P.S. Krishnamurthy, M.D.” in his
decision (Tr. 466), the record includes an assessment by “Minal Krishnamurthy, M.D.”
(Tr. 111-12).
moderate difficulties, his symptoms were controlled, and he was doing well. (Tr.
460, 465.)
However, despite reporting “moderate improvement as a result of [his]
medications” (Tr. 318), Plaintiff was still depressed, anxious, with poor to fair
insight and judgment; and, at times, had hallucinations, impaired memory, slow
speech with low volume, was confused, labile, distracted, lethargic, and slightly
disheveled, requiring continuous treatment and support from his family. (See,
e.g., Tr. 319-43, 346, 825, 827, 829, 831, 833-34, 848, 851, 855, 998, 1000,
1002, 1004, 1006, 1008, 1010, 1032-33; see also Tr. 288 (noting that in August
of 2010, Plaintiff was partially cooperative, disorganized, had poor insight and
judgment, paranoia, auditory hallucinations, impaired concentration, and thought
blocking); Tr. 852 (reporting auditory hallucinations and racing thoughts as of
May 8, 2014); Tr. 841 (noting that as of January 7, 2015, Plaintiff was hearing
voices and was not sleeping well); Tr. 836-37 (noting that as of March 25, 2015,
Plaintiff’s insight and judgment were poor, his anxiety was out of control, he
experienced thought blocking, hallucinations, paranoid delusions, rapid mood
swings, less energy and motivation, panic symptoms, and increased agitation
and hypervigilance, despite taking his medications as prescribed); Tr. 829 (noting
that as of July 27, 2015, Plaintiff was anxious, could not stay still, was repeating
himself, and felt “nobody ha[d] been helpful to him,” despite taking his
medications as prescribed); Tr. 917 (noting hallucinations, behavioral problems,
confusion, and anxiety/nervousness as of November 18, 2015); Tr. 1030 (noting
that as of April 10, 2018, Plaintiff was anxious, depressed, easily distracted,
slightly disheveled, with slow speech, and fair energy and motivation, among
other symptoms).)
Significantly, although the ALJ gave great weight to Dr. Madkaiker’s
“routine treatment records” (Tr. 465), those records reflect that Plaintiff was
accompanied by a family member anywhere he went, including at his doctor’s
visits. (See Tr. 825, 827, 831, 833-34, 836-37, 839, 841-44, 846, 848, 852, 855,
998, 1000, 1002, 1004, 1006, 1030; see also Tr. 1008 (“He has had to travel with
his mother. He gets very anxious around people.”); Tr. 1010 (“He needs to be
accompanied by his family.”).)12 Moreover, Plaintiff’s mother, aunt, and/or sister
were not merely providing transportation; rather, they were actively participating
in the decision-making process regarding his treatment, while also relaying his
symptoms and medical history given that Plaintiff was “a poor historian” and
could not even recall the name of his psychiatrist at one point. (Tr. 287, 379,
400, 719, 805, 920.)
The ALJ’s decision seems to acknowledge Plaintiff’s reliance on his family
members. (See, e.g., Tr. 458 (stating Plaintiff “never goes anywhere alone[,]
12 The treatment records from the PCP also show that Plaintiff was accompanied
by one or more family members during his appointments. (See, e.g., Tr. 301, 307, 313,
354, 360, 365, 367, 371, 379, 391, 397, 400, 404, 441, 865, 880, 891, 916, 920, 938;
but see Tr. 383, 389, 395, 403, 409 & 440 (failing to mention whether a family member
was present).) Further, the record, as a whole, consistently shows that Plaintiff could
not “go or do anything alone.” (Tr. 277; see also Tr. 25 (stating “my mom’s always with
me and helping me”); Tr. 14, 19-20, 23, 35.)
including doctor[’s] appointments, food shopping, church[,] etc.”); Tr. 459 (“Ms.
Cowart similarly indicated the claimant requires assistance with ‘everything’; he
cannot go anywhere without his family; he is unable to handle any type of change
in routine; he is unable to interact appropriately with the public; and ‘he cannot
adjust to anything’ without close relatives (i.e., mother, sister or aunt) [being]
present. . . . Ms. Cowart testified she or the claimant’s mother/sister take[] the
claimant everywhere[,] including [to] doctor[’s] appointments and shopping . . .
and she even had to assist him in going to the bathroom at the doctor’s [office]
because he could not find the light switch and just waited silently in the bathroom
until she could come help him . . . .”); Tr. 460, 461 & 462 (noting that Plaintiff was
accompanied by his mother and/or aunt to his doctor’s appointments); Tr. 462
(noting that Plaintiff “has had to travel with his mother”); Tr. 463 (noting that
Plaintiff “needs to be accompanied by his family”); Tr. 465 (noting Dr. Nay’s
observation that Plaintiff was “extremely dependent on family members, and his
sense of security [could] become easily [threatened] if he attempt[ed] to venture
away from his home”).)
Further, the ALJ’s decision seems to reflect the active role that Plaintiff’s
relatives played in his treatment. (See Tr. 460-61 (“The mother and aunt
reported the claimant ‘had to have [his] psych[otropic] med[ications] adjusted due
to too many setbacks of recent’; the claimant had ‘not taken med[ications] that
morning [due to] fasting for labs; [and] he was very nervous coming in.’”); Tr. 461
(noting that “the claimant’s ‘mother and aunt [we]re agreeable to [liver testing]
and imaging,’” and that the “‘mother and aunt prefer[red] to consult with [the]
psych[iatrist] and [inquire about] possible med[ication] interactions prior to
starting [the treatment] . . .’”).)
Despite noting all these records, the ALJ did not explain why he apparently
rejected Plaintiff’s need to have a family member present practically at all times
and, instead, concluded that Plaintiff did “not live in a highly structured
environment” because he was not in a “group home or institutional facility.” (Tr.
457.) It appears that in weighing the evidence and assessing Plaintiff’s
limitations, the ALJ simply ignored the reality of Plaintiff’s structured environment.
Although Plaintiff was technically not in a group home or at an institutional facility,
he was constantly surrounded by his mother, sister, and/or aunt, whose presence
alleviated his mental symptoms and helped him cope when outside the confines
of his home. (See, e.g., Tr. 367 (stating that Plaintiff’s mother was
accompanying him to his appointment and he “seem[ed to be] calmed by her
responses and interruption”); see also Tr. 459 (reciting Ms. Cowart’s statement
that Plaintiff’s medications “help him stay calm so long as he is in [the] presence
of close family”) (emphasis added).)
Also, it appears that the ALJ assumed that Plaintiff’s functioning with the
support of his relatives was his baseline level of functioning. This assumption
seems to have influenced the ALJ’s decision as a whole. Assuming the ALJ
believed that Plaintiff’s medications alone sufficiently controlled his symptoms,
the record seems to paint a different picture. Specifically, it indicates that during
the relevant period, Plaintiff did not work at all,13 and was, thus, able to control
his environment, stressors, and activities; and also that he relied on his relatives
for practically everything that he needed to function ‒ from medication and
appointment reminders, to transportation, meals, emotional support, and
constant presence anytime he needed to leave the house. (See Tr. 277.)
Despite staying at home, away from stressors, and taking all of his
medications as prescribed, Plaintiff nevertheless encountered “setbacks”
requiring medication adjustments and/or hospitalization. (See, e.g., Tr. 802-05
(noting a visit to the emergency room on March 28, 2015 for worsening
symptoms, such as depression, anxiety, lack of sleep, suicidal thoughts, and
auditory hallucinations, after starting medications a few days earlier); Tr. 813-17
(noting a visit to the emergency room on March 26, 2015 for worsening mental
symptoms after adjustment of his medication the day before); Tr. 285-87
(showing a psychiatric admission from August 6 to August 12, 2010 for acute
exacerbation of Plaintiff’s schizophrenia, paranoid type, and noting “extensive
outpatient and inpatient psychiatric care in the past”); Tr. 400 (noting another
mental health hospitalization in 2008).) In other words, Plaintiff’s “setbacks”
occurred while he was taking several psychotropic medications, which he had
been doing regularly and consistently since approximately 1989 (see Tr. 28-29);
while he was not working; and while he relied on his family members for
13 Plaintiff’s testified that his work as a bagger at Publix, which was the only job
he had held, aggravated his symptoms. (See Tr. 11-13, 31-32.)
practically everything that he needed to function. (See Tr. 277.)
In addition, the above-cited records lend support to Dr. Nay’s opinion that
Plaintiff had poor coping skills and was extremely dependent on his family
members, which the ALJ discounted as inconsistent with the treatment records of
Dr. Madkaiker and the PCP. Also, the tests administered by Dr. Nay, which
showed, inter alia, significant difficulties with memory and retention of
information, seem to undermine the ALJ’s statement that there was no objective
medical evidence to support Plaintiff’s claim of disability. Notably, Dr. Nay’s
opinions, which were the most recent examining opinions in the record and were
rendered years after the State agency non-examining consultants’ assessments,
were based on the results of the MMSE, the RBANS, the CCSM, a review of
pertinent records, and Dr. Nay’s own observations and clinical interview of
Plaintiff. The ALJ seemed to ignore the relevancy and consistency of Dr. Nay’s
opinions with the other medical and non-medical opinions in the file. In sum, the
ALJ’s reasons for discounting the treating and examining sources’ opinions were
not supported by substantial evidence in the record. In light of this conclusion,
the Court will not separately address the third-party statements in the record, but
on remand, the ALJ should re-consider all medical and non-medical opinions in
conducting the five-step sequential evaluation process.
Accordingly, it is ORDERED:
1. The Commissioner’s decision is REVERSED and REMANDED
pursuant to sentence four of 42 U.S.C. § 405(g), with instructions to the ALJ to
conduct the five-step sequential evaluation process in light of all the evidence,
including the opinion evidence from treating, examining, and non-examining
sources, as well as the third-party statements, and conduct any further
proceedings deemed appropriate.
2. The Clerk of Court is directed to enter judgment accordingly,
terminate any pending motions, and close the file.
3. In the event that benefits are awarded on remand, any § 406(b) or §
1383(d)(2) fee application shall be filed within the parameters set forth by the
Order entered in /n re: Procedures for Applying for Attorney’s Fees Under 42
U.S.C. §§ 406(b) & 1383(d)(2), Case No.: 6:12-mc-124-Orl-22 (M.D. Fla. Nov.
13, 2012). This Order does not extend the time limits for filing a motion for
attorney’s fees under the Equal Access to Justice Act, 28 U.S.C. § 2412.
DONE AND ORDERED at Jacksonville, Florida, on March 10, 2020.
UNITED STATES MAGISTRATE JUDGE
Copies to:
Counsel of Record
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