The opinion
IN THE UNITED STATES DISTRICT COURT
FOR THE EASTERN DISTRICT OF NORTH CAROLINA
NORTHERN DIVISION
No. 2:20-CV-9-BO
THEODORE ROOSEVELT HUDSON, )
Plaintiff,
V. ORDER
ANDREW SAUL,
Commissioner of Social Security, )
Defendant.
This cause comes before the Court on plaintiff's motion for judgment on the pleadings [DE
19] and defendant's motion for judgment on the pleadings [DE 25]. A hearing was held on the
motions before the undersigned on June 17, 2021, at Edenton, North Carolina. For the reasons
that follow, plaintiffs motion is granted, and this matter is remanded to the Commissioner for
further proceedings.
BACKGROUND
Plaintiff brought this action under 42 U.S.C. § 405(g) for review of the final decision of
the Commissioner denying his application for disability and disability insurance benefits under
Title II of the Social Security Act. Plaintiff filed an application for a period of disability and
disability insurance benefits on February 11, 2016, alleging a disability onset date of January 1,
2011. Plaintiff later amended his alleged onset of disability date to January 1, 2014. After initial
denials, an administrative law judge (ALJ) held a hearing on November 14, 2018, and subsequently
found that plaintiff was not disabled. The ALJ’s decision became the final decision of the
Commissioner when the Appeals Council denied plaintiff's request for review. Plaintiff then
sought review of the Commissioner’s decision in this Court.
DISCUSSION
Under the Social Security Act, 42 U.S.C. § 405(g), this Court’s review of the
Commissioner’s decision is limited to determining whether the decision, as a whole, is supported
by substantial evidence and whether the Commissioner employed the correct legal standard.
Richardson v. Perales, 402 U.S. 389, 401 (1971). Substantial evidence is “such relevant evidence
as areasonable mind might accept as adequate to support a conclusion.” Johnson v. Barnhart, 434
F.3d 650, 653 (4th Cir. 2005) (per curiam) (internal quotation and citation omitted).
An individual is considered disabled if he or she is unable “to engage in any substantial
gainful activity by reason of any medically determinable physical or mental impairment which can
be expected to result in death or which has lasted or can be expected to last for a continuous period
of not less than twelve months.” 42 U.S.C. § 1382c(a)(3)(A). The Act further provides that an
individual “shall be determined to be under a disability only if 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 work experience, engage in any other kind of substantial
gainful work which exists in the national economy.” 42 U.S.C. § 1382c(a)(3)(B).
Regulations issued by the Commissioner establish a five-step sequential evaluation process
to be followed in a disability case. 20 C.F.R. §§ 404.1520(a)(4), 416.920(a)(4). The claimant bears
the burden of proof at steps one through four, but the burden shifts to the Commissioner at step
five. See Bowen vy. Yuckert, 482 U.S. 137, 146 n.5 (1987). If a decision regarding disatility can
be made at any step of the process the inquiry ceases. See 20 C.F.R. §§ 404.1520(a)(4),
416.920(a)(4).
At step one, if the Social Security Administration determines that the claimant is currently
engaged in substantial gainful activity, the claim is denied. If not, then step two asks whether the
claimant has a severe impairment or combination of impairments. If the claimant has a severe
impairment, it is compared at step three to those in the Listing of Impairments (“Listing”) in 20
C.F.R. Part 404, Subpart P, App. 1. If the claimant’s impairment meets or medically equals a
Listing, disability is conclusively presumed. If not, at step four, the claimant’s residual functional
capacity (RFC) is assessed to determine if the claimant can perform his past relevant work. If the
claimant cannot perform past relevant work, then the burden shifts to the Commissioner at step
five to show that the claimant, based on his age, education, work experience, and RFC, can perform
other substantial gainful work. If the claimant cannot perform other work, then he is found to be
disabled. See 20 C.F.R. § 416.920(a)(4).
At step one, the ALJ found that plaintiff had not engaged in substantial gainful activity
since his alleged onset date of January 1, 2014. The ALJ found that plaintiff's migraine headaches
were a severe impairment at step two, but that his impairments did not meet or equal a Listing.
The ALJ also found that plaintiff's irritable bowel syndrome, post-traumatic stress disorder, and
attention deficit disorder and attention hyperactivity disorder were non-severe impediments. The
ALJ determined that plaintiff had the residual functional capacity to perform a full range of work
at all exertional levels with some non-exertional limitations and at steps four and five found that
plaintiff was able to perform past relevant work as a corrections officer and fast food worker.
Upon review of the record and decision, the Court concludes that remand is appropriate
because the ALJ failed to evaluate and assign appropriate weight to medical opinions in the case.
The ALJ must carefully weigh the opinions of the medical sources on file through considering
several factors, including length of the treatment relationship, supportability, consistency, and
specialization. See 20 C.F.R. § 404.1527(c)(2). The ALJ must consider all medical opinion given
in the case, assess the weight given to each opinion, and explain any conflict between a medical
opinion and the ALJ’s RFC. /d. at § 404.1527(b). Furthermore, under the treating physician rule,
“the opinion of a claimant’s treating physician [must] be given great weight and may be
disregarded only if there is persuasive contradictory evidence.” Arakas v. Comm’r, Soc. Sec.
Admin., 983 F.3d 83, 107 (4th Cir. 2020) (quoting Coffman v. Bowen, 829 F.2d 514, 417 (4th Cir.
1987)). A treating physician’s opinion is controlling “unless it is unsupported by medically
acceptable clinical and laboratory diagnostic techniques or if it is inconsistent with other
substantial evidence of record.” Stephens v. Astrue, 533 F. Supp. 2d 598, 600 (E.D.N.C. 2008)
(citing 20 C.F.R. § 404.1527(d); Craig v. Chater, 76 F.3d 585, 590 (4th Cir. 1996)). The treating
physician rule is applicable to cases filed before March 27, 2017. See Brown v. Comm’r Soc. Sec.
Admin., 873 F. 3d 251, 255 (4th Cir. 2017).
Dr. Neil Pugach, the treating physician, diagnosed and treated plaintiff for chronic
posttraumatic migrainous headaches from August 15, 2012 to May 9, 2018. Dr. Pugach noted
fatigue, irritable bowel syndrome and memory loss. The ALJ gave no weight to Dr. Pugach’s
opinion regarding the side effects of erectile dysfunction from medications treating posttraumatic
headaches. Dr. Williams C. Bowens, a psychiatrist and neurologist who was also a treating
physician, diagnosed plaintiff with posttraumatic stress syndrome, attention deficit, and traumatic
brain injury and treated him from at least December 4, 2014 to July 17, 2018. Dr. Bowen noted
that plaintiff had difficulties focusing, concentrating, as well as inability to complete tasks or
accomplish objectives and goals. However, the ALJ omitted any discussion regarding the weight
assigned to Dr. Bowen’s opinions. The ALJ found that plaintiff has multiple non-exertional
limitations, but the ALJ does not address plaintiff's ability to perform the mental activities required
by the RFC. Based on the full medical evidence, it is clear that the ALJ failed to adequately account
for plaintiff's memory loss, inability to focus and concentrate, difficulty in completing tasks,
fatigue, frequent bathroom visits, and difficulty being around others.
The Court in its discretion finds that remand is appropriate. Remand is appropriate where,
as in this case, an ALJ fails to discuss relevant evidence that weighs against the decision and fails
to properly weigh medical opinions. This case is remanded so that the ALJ can give careful
consideration to plaintiffs non-exertional limits and the availability of jobs in the economy under
step five.
CONCLUSION
Accordingly, plaintiff's motion for judgment on the pleadings [DE 19] is GRANTED and
defendant’s motion for judgment on the pleadings [DE 25] is DENIED. The Commissioner’s
decision is REMANDED for further proceedings consistent with the foregoing.
SO ORDERED, this day of July, 2021,
Tee W. BOYLE uA, J
UNITED STATES DISTRICT JUDGE