United States District Court, E.D. North Carolina, Southern Division
MARIA E. OLIVA, Plaintiff,
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.
TERRENCE W. BOYLE, UNITED STATES DISTRICT JUDGE.
cause comes before the Court on cross-motions for judgment on
the pleadings. A hearing was held on these matters before the
undersigned on March 15, 2017, in Raleigh, North Carolina.
For the reasons discussed below, this matter is remanded to
the Acting Commissioner for further proceedings.
brought this action under 42 U.S.C. §§ 405(g) and
1383(c)(3) for review of the final decision of the
Commissioner denying his claim for disability and disability
insurance benefits ("DIB") and supplemental
security income ("SSI") pursuant to Titles II and
XVI of the Social Security Act. Plaintiff protectively filed
her applications on January 26, 2012, alleging disability
beginning January 1, 2010. After initial denials, a hearing
was held before an Administrative Law Judge (ALJ) who issued
an unfavorable ruling. The decision of the ALJ became the
final decision of the Commissioner when the Appeals Council
denied plaintiffs request for review. Plaintiff then timely
sought review of the Commissioner's decision in this
the Social Security Act, 42 U.S.C. §§ 405(g), and
1383(c)(3), 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 a
reasonable 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
individual is considered disabled if he 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 line of substantial gainful work which exists in
the national economy." 42 U.S.C. § 1382c(a)(3)(B).
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 v. Yuckert, 482 U.S. 137, 146 n.5 (1987).
If a decision regarding disability can be made at any step of
the process, however, the inquiry ceases. See 20
C.F.R. §§ 404.1520(a)(4), 416.920(a)(4).
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. Pt. 404,
Subpt. 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 so, the claim is denied. 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).
one, the ALJ determined that plaintiff met the insured status
requirements and had not engaged in substantial gainful
activity since her alleged onset date. Plaintiffs back
disorder, obesity, migraines, sleep disorder, and chronic
obstructive pulmonary disease were considered severe
impairments at step two, but were not found alone or in
combination to meet or equal a listing at step three. The ALJ
concluded that plaintiff had the RFC to perform sedentary
work with additional exertional limitations. The ALJ then
found that plaintiff was able to return to her past relevant
work. In the alternative, at step five, the ALJ considered
plaintiffs age, education, work experience, and RFC, along
with the testimony of the vocational expert ("VE"),
to determine that plaintiff was capable of making a
successful adjustment to other work that exists in
significant numbers in the national economy. Accordingly, the
ALJ found that plaintiff had not been under a disability as
defined in the Act.
ALJ's decision in this instance is not supported by
substantial evidence. An ALJ makes an RFC assessment based on
all of the relevant medical and other evidence. 20 C.F.R.
§ 404.1545(a). An RFC should reflect the most that a
claimant can do, despite the claimant's limitations.
Id. An RFC finding should also reflect the
claimant's ability to perform sustained work-related
activities in a work setting on regular and continuing basis,
meaning eight-hours per day, five days per week. SSR 96-8p;
Hines v. Bamhart, 453 F.3d 559, 562 (4th Cir. 2006).
The ALJ found that plaintiff was limited to a restricted
range of sedentary work activities, with limitations to only
occasionally climb stairs; that she must be allowed to use a
handheld device for prolonged ambulation; she must avoid
irritants; and that plaintiff is limited to simple, routine
tasks in a low stress job. Tr. 33.
Fourth Circuit has found that in Social Security disability
cases, "[t]he record should include a discussion of
which evidence the ALJ found credible and why, and specific
application of the pertinent legal requirements to the record
evidence." Radford v. Colvin, 734 F.3d 288, 295
(4th Cir. 2013) (citing Hines v. Bowen, 872 F.2d 56,
59 (4th Cir. 1989)). "If the reviewing court has no way
of evaluating the basis for the ALJ's decision, then
'the proper course, except in rare circumstances, is to
remand to the agency for additional investigation or
explanation.'" Radford at 295 (citing
Florida Power & Light Co. v. Lorion, 470 U.S.
729, 744 (1985)).
must "explain how any material inconsistencies or
ambiguities in the evidence in the case record were
considered and resolved." SSR 96-8p. If an opinion from
a treating source is well-supported by and consistent with
the objective medical evidence in the record, it may be
entitled to controlling weight. 20 C.F.R. §§
404.1527(c), 416.927(c). Where an opinion is inconsistent
with other evidence in the record, the ALJ need not give that
opinion any significant weight. Id; see also Craig v.
Chater, 76 F.3d at 585, 590 (4th Cir. 1996) ("[I]f
a physician's opinion is not supported by clinical
evidence or if it is inconsistent with other substantial
evidence, it should be accorded significantly less
weight."). However, ALJ's decision to do so must be
accompanied by "a narrative discussion" that
discusses "how the evidence supports each conclusion,
" such that the ALJ's decision is sufficiently
specific to make it clear to a reviewing district court
"why the opinion was not adopted." See SSR
regulations require that the ALJ consider the combined effect
of all of claimant's impairments, "without regard to
whether any such impairment if considered separately"
would be sufficiently severe. 42 U.S.C. § 423(d)(2)(c).
The Fourth Circuit has accordingly held that in determining
whether an individual's impairments are of sufficient
severity to prohibit basic work related activities, an ALJ
must consider the ...