United States District Court, E.D. North Carolina, Western Division
TERRENCE W. BOYLE CHIEF UNITED STATES DISTRICT JUDGE.
cause comes before the Court on cross-motions for judgment on
the pleadings. A hearing on the motions was held before the
undersigned on June 14, 2019, at Edenton, North Carolina. For
the reasons that follow, plaintiffs motion is granted and
this matter is remanded to the Commissioner for further
brought this action under 42 U.S.C. §§ 405(g) and
1383(c)(3) for review of the final decision of the
Commissioner denying her claim for disability and disability
insurance benefits (DIB) pursuant to Title II of the Social
Security Act. Plaintiff protectively applied for DIB on
September 9, 2013, and has alleged an amended onset date of
January 19, 2013. 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 Court.
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). 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. 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). 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 the inquiry ceases.
See 20 C.F.R. §§ 404.1520(a)(4),
the ALJ determined that plaintiff met the insured status
requirements through December 31, 2018, and that she had not
engaged in substantial gainful activity since her amended
alleged onset date. The ALJ found plaintiffs multilevel
cervical, thoracic, and lumber degenerative disc disease;
obesity; hypertension; carpal tunnel syndrome; major
depressive disorder; panic disorder; post-traumatic stress
disorder; and borderline personality disorder were severe
impairments at step two, but determined at step three that
plaintiff did not have an impairment or combination of
impairments which met or medically equaled a Listing. The ALJ
found plaintiff to have an RFC of a reduced range of
sedentary work with exertional and non-exertional
limitations. The ALJ found that at step four plaintiff could
not return to her past relevant work as a family and child
welfare case worker, but that at step five, in light of
plaintiffs age, education, work experience, and RFC, there
were jobs that existed in significant numbers in the national
economy which plaintiff could perform. Thus, a finding of not
disabled was directed.
Court finds that remand for the ALJ to properly evaluate the
opinion evidence in the record is necessary. 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. In formulating an RFC supported by
substantial evidence, an ALJ must always consider the medical
opinions in the case record together with the rest of the
relevant evidence received. 20 C.F.R. §§
404.1527(a)(2)(b), 416.927(a)(2)(b). A medical opinion is a
statement "from physicians and psychologists or other
acceptable medical sources that reflect judgments about the
nature and severity of [a claimant's] impairment(s),
including [the claimant's] symptoms, diagnosis and
prognosis, what [she] can still do despite impairment(s), and
[her] physical or mental restrictions." 20 C.F.R. §
404.1527(a)(2). Treating source opinions are entitled to
controlling weight if they are "well supported by
medically acceptable clinical and laboratory diagnostic
techniques and [are] not inconsistent with the other
substantial evidence in [the] case record." 20 C.F.R.
§§ 404.1527(d)(2), 416.927(d)(2); see also
Craig v. Chater, 76 F.3d 585, 590 (4th Cir. 1996).
Factors that ALJs consider in determining how much weight to
afford a medical opinion include (1) the examining
relationship, (2) the treatment relationship, (3) the
supportability of the opinion, (4) the consistency of the
opinion with the record as a whole, (5) the physician's
specialization, and (6) other relevant factors. 20 C.F.R.
the ALJ declined to give controlling or substantial weight to
two of plaintiffs treating physicians because one opinion was
in check-box format and the other was "vague and not
expressed in vocationally relevant terms." Tr. 28; 29.
Corvino provided an opinion using a form in which he
indicated that he had seen plaintiff once a month for nine
months and that plaintiff would be limited to lifting and
carrying ten pounds, standing and/or walking less than two
hours per day, and sitting less than six hours per day. Tr.
561-62. Contrary to the ALJ's conclusion, Dr.
Coplin's opinion was neither vague nor expressed in terms
irrelevant to a vocational analysis. Dr. Coplin's
opinions are in regard to plaintiffs ability to sit, stand,
lift and carry, and push and pull, which are directly
relevant to the inquiry into whether a claimant can perform
substantial gainful activity.
as plaintiff correctly argues, the use of a check-box form is
not, in and of itself, a basis for discounting the weight of
a treating opinion. Pate v. Berryhill, No.
5:16-CV-00864-D, 2018 WL 577998, at *8 (E.D. N.C. Jan. 10,
2018), report and recommendation adopted, No.
5:16-CV-864-D, 2018 WL 576833 (E.D. N.C. Jan. 26, 2018). Dr.
Arcedo's opinion as to plaintiffs abilities to perform
work activities specifically noted plaintiffs bilateral hand
weakness and severe carpal tunnel syndrome. Tr. 1021-22. Dr.
Arcedo's treatment notes and letter further discuss
objective findings regarding plaintiffs L5-S1 disc herniation
and abnormal electrodiagnostic testing in plaintiff supper
extremities. See Tr. 987.
ALJ's explanation for discounting the opinions of these
two treating physicians is inadequate and perfunctory. Such
rejection of treating source opinions is grounds for remand
where, as here, the ALJ failed to adequately explain where
any non-treating sources disputed the treating source
opinions or how the ...