The opinion
IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF NEW JERSEY
CAMDEN VICINAGE
Plaintiff, Civil No. 20-5575 (RMB)
v. OPINION
COMMISSIONER, SOCIAL SECURITY |
ADMINISTRATION,
Defendant.
BUMB, United States District Judge:
This matter comes before the Court upon an appeal by Plaintiff J.G. from a denial of
social security disability benefits.
For the reasons set forth below, the Court vacates the decision of the Administrative
Law Judge (“ALJ”) and remands for proceedings consistent with this Opinion’s reasoning.
I. STANDARD OF REVIEW
When reviewing a final decision of an ALJ with regard to disability benefits, a court
must uphold the ALJ’s factual decisions if they are supported by “substantial evidence.”
Knepp v. Apfel, 204 F.3d 78, 83 (3d Cir. 2000); 42 U.S.C. §§ 405(g), 1383(c)(3).
“Substantial evidence” means “‘more than a mere scintilla. It means such relevant evidence
as a reasonable mind might accept as adequate to support a conclusion.’” Richardson v.
Perales, 402 U.S. 389, 401 (1971) (quoting Cons. Edison Co. v. NLRB, 305 U.S. 197, 229
(1938)); Plummer v. Apfel, 186 F.3d 422, 427 (3d Cir. 1999).
In addition to the “substantial evidence” inquiry, the court must also determine
whether the ALJ applied the correct legal standards. See Friedberg v. Schweiker, 721 F.2d
445, 447 (3d Cir. 1983); Sykes v. Apfel, 228 F.3d 259, 262 (3d Cir. 2000). The Court’s
review of legal issues is plenary. Sykes, 228 F.3d at 262 (citing Schaudeck v. Comm’r of Soc.
Sec., 181 F.3d 429, 431 (3d Cir. 1999)).
The Social Security Act defines “disability” as the inability “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 states,
[A]n 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,
regardless of whether such work exists in the immediate area in which
he lives, or whether a specific job vacancy exists for him, or whether he
would be hired if he applied for work.
42 U.S.C. § 1382c(a)(3)(B).
The Commissioner has promulgated a five-step, sequential analysis for evaluating a
claimant’s disability, as outlined in 20 C.F.R. § 404.1520(a)(4)(i-v). The analysis proceeds
as follows:
At step one, the ALJ determines whether the claimant is performing
“substantial gainful activity[.]” 20 C.F.R. §§ 404.1520(a)(4)(i),
416.920(a)(4)(i). If he is, he is not disabled. Id. Otherwise, the ALJ moves on
to step two.
At step two, the ALJ considers whether the claimant has any “severe
medically determinable physical or mental impairment” that meets certain
regulatory requirements. Id. §§ 404.1520(a)(4)(ii), 416.920(a)(4)(ii). A “severe
impairment” is one that “significantly limits [the claimant’s] physical or
mental ability to do basic work activities[.]” Id. §§ 404.1520(c), 416.920(c). If
the claimant lacks such an impairment, he is not disabled. Id. §§
404.1520(a)(4)(ii), 416.920(a)(4)(ii). If he has such an impairment, the ALJ
moves on to step three.
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At step three, the ALJ decides “whether the claimant’s impairments meet or
equal the requirements of an impairment listed in the regulations[.]” Smith,
631 F.3d at 634. If the claimant’s impairments do, he is disabled. 20 C.F.R. §§
404.1520(a)(4)(iii), 416.920(a)(4)(iii). If they do not, the ALJ moves on to step
four.
At step four, the ALJ assesses the claimant’s “residual functional capacity”
(“RFC”) and whether he can perform his “past relevant work.”2 *202 Id. §§
404.1520(a)(4)(iv), 416.920(a)(4)(iv). A claimant’s “[RFC] is the most [he] can
still do despite [his] limitations.” Id. §§ 404.1545(a)(1), 416.945(a)(1). If the
claimant can perform his past relevant work despite his limitations, he is not
disabled. Id. §§ 404.1520(a)(4)(iv), 416.920(a)(4)(iv). If he cannot, the ALJ
moves on to step five.
At step five, the ALJ examines whether the claimant “can make an
adjustment to other work[,]” considering his “[RFC,] ... age, education, and
work experience[.]” Id. §§ 404.1520(a)(4)(v), 416.920(a)(4)(v). That
examination typically involves “one or more hypothetical questions posed by
the ALJ to [a] vocational expert.” Podedworny v. Harris, 745 F.2d 210, 218
(3d Cir. 1984). If the claimant can make an adjustment to other work, he is
not disabled. 20 C.F.R. §§ 404.1520(a)(4)(v), 416.920(a)(4)(v). If he cannot,
he is disabled.
Hess v. Comm’r Soc. Sec., 931 F.3d 198, 201–02 (3d Cir. 2019).
II. FACTS
The Court recites only the facts that are necessary to its determination on appeal.
Plaintiff, who was 36 years old at the alleged onset date, claims disability, in part, due to
diagnoses of failed back syndrome, spinal stenosis, radiculopathy, migraine disorder,
sleep apnea, adjustment disorder, anxiety, depression, agoraphobia, attention deficit
disorder, and post-traumatic stress disorder. Plaintiff’s Brief at 1.
In support of his claim, Plaintiff provides, among other documents, his hearing
testimony, hospital reports documenting his back operation; hospital records from the
Philadelphia Veterans Affairs Medical Center; mental status examination records from
Theodore J. Brown, PhD.; consultative examination reports from William Anthony,
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M.D.; clinical psychological disability examination reports from Ronald Karpf, PhD.;
examination reports from neuropsychiatrist Bradford Bobrin, M.D.; educational records
from Riverside High School, Rowan University, and the University of the Sciences; and
medical assessments regarding his physical abilities from AtlanticCare Behavioral Health.
III. ALJ’S DETERMINATION
The ALJ found Plaintiff not disabled. The ALJ determined Plaintiff’s impairments
of failed back syndrome, radiculopathy, migraines, and chronic pain syndrome to be severe.
Tr. 13. However, the ALJ determined that Plaintiff’s medically determinable mental
impairments of adjustment disorder, major depressive disorder, post-traumatic stress
disorder (“PTSD”), and attention deficit disorder (“ADD”), “considered singly and in
combination, do not cause more than a minimal limitation in the claimant’s ability to
perform basic mental work activities and are therefore nonsevere.” Id. At Step Two and
Step Three of the sequential evaluation process, the ALJ concluded that Plaintiff’s severe
failed back syndrome, radiculopathy, migraines, and chronic pain syndrome were
“medically determinable impairments significantly limit[ing] the ability [of Plaintiff] to
perform basic work activities as required by SSR 85-28.” Tr. 13. Plaintiff’s mental
impairments, according to the ALJ, did not meet or medically equal one of the
Commissioner’s listed impairments in 20 C.F.R. Appendix 1, Subpart P. Tr. 13-17. In
determining Plaintiff’s residual functional capacity, the ALJ found that Plaintiff could
perform a range of light work with a sit or stand option and occasional postural movements.
Tr. 17-22. At Step Five, the ALJ concluded that Plaintiff could perform work that exists in
substantial numbers in the national economy, namely the positions of routing clerk, mail
clerk, or assembler of small products. Tr. 23-24. Accordingly, the ALJ found Plaintiff not
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to be disabled. Tr. 24.
In her decision, the ALJ heavily relied upon the fact that Plaintiff has attended
college and medical school over the past several years and that he has had some ability to
care for his young children. The ALJ frequently noted that Plaintiff has been able to attend
college, take the MCAT, attend medical school, and care for his children. Tr. 15, 16, 21, 21.
The ALJ assigned little weight to the opinions of consultative examiners Theodore
Brown, Ph.D. and Ronald Karpf, Ph.D. as their opinions, in her own words, “are dated and
outweighed by the evidence as a whole.” Tr. 14. Dr. Brown diagnosed Plaintiff with major
depression disorder, learning disorder, NOS [not otherwise specified], and pain disorder.
Tr. 13. Dr. Brown also reported that Plaintiff needed help with daily activities due to
physical limitations and that Plaintiff’s wife handled the cooking, cleaning, laundry, and
shopping for their household. Id. Dr. Karpf found Plaintiff to have adjustment disorder
with mixed anxiety and depressed mood, and agoraphobia, and noted Plaintiff’s problems
with absenteeism and tardiness. Tr. 14. In support of her finding that the consultative
examiner’s opinions are outweighed by the evidence as a whole, the ALJ cited Plaintiff’s
college and medical school attendance and caring for his children. Id.
The ALJ also accorded little weight to the statements provided by Plaintiff from
physicians indicating that he could not work or that he required accommodations due to
PTSD, depression, ADD, cognitive issues, and chronic pain. Tr. 14. The ALJ described
Dr. Bobrin’s statements as “overly restrictive” despite the doctor’s assessment that Plaintiff
had PTSD, ADD, and various moderate, marked, and extreme limitations in functioning.
Tr. 14. The ALJ noted that Dr. Bobrin had only been treating Plaintiff for a year and
determined that the doctor’s findings were “internally inconsistent,” in that the doctor’s
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notes indicate an “improvement in functioning with medications and [Plaintiff] was able to
attend medical school.” Id.
Little weight was also accorded to the opinions of State agency psychological
consultants Hugo Roman Rivera, Ph.D. and J. Tendler, M.D. as “they have no treating or
examining relationship with the claimant and their opinions are dated and outweighed by
the evidence as a whole.” Tr. 15. In support of this determination, the ALJ noted, again,
that Plaintiff has been able to attend college and medical school and care for his children.
As for the four “Paragraph B” criteria for mental impairments, the ALJ determined
that Plaintiff had only a “mild” limitation in each category. Tr. 15-16. In support of her
finding, the ALJ noted his college and medical school attendance in each of the four
“Paragraph B” areas, as well as his alleged ability to care for his children. Id.
In consideration of Plaintiff’s residual functional capacity, the ALJ again made
mention of Plaintiff’s schooling and childcare but described that “he needed help putting on
his socks and belt and it was painful to transition from sitting to standing.” Tr. 17. The
ALJ also acknowledged that Plaintiff received accommodations for school, such as
extended time for tests and assignments (Tr. 18), “did well on his MCAT’s,” and attended
school full-time. Tr. 20. The ALJ afforded little weight to the opinions of Plaintiff’s
Veterans Affairs records as “these varying opinions were offered in the context of
establishing disability for purposes of VA disability benefits,” all while using a different
standard of disability from Social Security. Id. Again, the ALJ afforded little weight to Dr.
Bobrin’s medical source statements as Plaintiff “has been able to maintain a full-time school
course load, attend college, take the MCAT’s, and attend medical school.” Tr. 21. The
ALJ concluded that “the record suggests that his symptoms are controlled by conservative
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measures alone.” Id.
As for the State agency opinion of Plaintiff’s physical abilities, the ALJ afforded little
weight as Harpreet Khurana, M.D. had no treating or examining relationship with Plaintiff.
Tr. 22. The ALJ did afford partial weight to the statements from Plaintiff’s mother-in-law
but noted that she does not “offer any specific functional limitations for consideration and
she is not an acceptable medical source.” Id.
IV. ANALYSIS
Among other arguments, Plaintiff argues that the ALJ erred in repeatedly relying on
Plaintiff’s school attendance and household activities while failing to adequately weigh the
testimony and evidence detailing Plaintiff’s failures in those areas. Plaintiff’s Brief at 16.
Plaintiff alleges that the ALJ dismissed Plaintiff’s conditions and rejected the opinion of
treating sources and instead used the school and family activity evidence as the sole proof of
Plaintiff’s abilities. Tr. 14.
The Commissioner argues that the ALJ fairly characterized Plaintiff’s activities of
daily living and appropriately weighed them as a factor, along with other probative
evidence, when assessing Plaintiff’s claim. While the Commissioner’s brief supplies a
detailed review of the record in support of the ALJ’s finding, the ALJ’s decision, however,
does not contain such helpful analysis. The Commissioner’s brief contains numerous
citations to the record that are missing from the ALJ’s decision, making review difficult for
this Court. Without such detailed analysis, it does appear therefore that the ALJ unduly
relied upon the fact that Plaintiff attended college and medical school. The Court is unclear
as to what evidence the ALJ considered and rejected, and why. Her decision must provide
further details and analysis addressing the foregoing arguments.
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Plaintiff also alleges that the ALJ erred in failing to find at Step Two the presence of
severe mental health impairments and failed to incorporate limitations consistent with
Plaintiff’s mental health impairments in determining his residual functional capacity.
Plaintiff’s Brief at 21. According to Plaintiff, the ALJ rejected the findings and conclusions
of Dr. Brown, Dr. Karpf, Plaintiff’s treating physician Dr. Bradford Bobrin, psychiatric
treatment notes, and Plaintiff’s own testimony “despite the opinions of two consultative
examiners, years of treating physician notes, and reports spanning multiple years.” Id. at
23. Additionally, despite the ALJ finding Plaintiff’s migraines and chronic pain to be severe
(Tr. 13), she did not incorporate these findings with respect to relevant limitations in the
residual functional capacity analysis. “Functional limitations caused by all impairments,
whether found to be severe or non-severe at step two, must be taken into consideration at
steps three, four, and five of the sequential evaluation.” Brown v. Astrue, 2010 WL
4455825, at *4 (E.D.Pa. Nov. 4, 2010). Surprisingly, the Commissioner’s brief makes no
mention of the ALJ’s finding that Plaintiff’s migraines and chronic pain syndrome were
severe in addressing Plaintiff’s argument that the ALJ failed to incorporate these findings
into her residual functional capacity analysis.
Plaintiff also argues that the ALJ erred in the evaluation of opinion evidence of
record. Plaintiff’s Brief at 25. Here, as before, Plaintiff argues that the ALJ discounted
documented medical opinion evidence because “the claimant has been able to attend college
and medical school since the alleged onset date. He cares for his 3 children.” Tr. 22. The
Court acknowledges that while these facts are probative, the ALJ’s decision fails to analyze
the numerous findings and medical opinions. Again, the Commissioner supports the ALJ’s
finding with numerous citations to the record not present in the ALJ’s decision, rendering
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an analysis of these points difficult for the Court.
The Court concludes that remand, as opposed to reversal, is appropriate. On
remand, the ALJ may revisit her evaluation of Dr. Bogrin’s examination and provide
further rationale for her discounting of the medical opinion evidence. To the extent that
contradictory medical evidence can be cited, the ALJ may do so and perhaps arrive at the
same conclusion. On the whole, the ALJ’s form rejection of Plaintiff’s claims based upon
his school attendance and childrearing abilities is threaded throughout the decision and may
rightfully determine the ALJ’s ultimate analysis. Her decision, however, must take into
account and adequately weigh the opinion evidence provided by Plaintiff and, more
specifically, set forth her findings so that an informed review, if necessary, can be
conducted. At this juncture, the ALJ must revisit her analysis consistent with the law and
record facts discussed herein. As such, the Court vacates the decision of the ALJ and
remands for proceedings consistent with the above analysis.
An accompanying Order will follow.
Date:8/31/2021 /s/ Renée Marie Bumb
RENÉE MARIE BUMB, U.S.D.J.
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