United States District Court, E.D. North Carolina, Southern Division
SANDRA B. LAKEMAN, Plaintiff,
ANDREW SAUL Commissioner of Social Security,  Defendant.
TERRENCE W. BOYLE CHIEF UNITED STATES DISTRICT JUDGE
matter is before the Court on the parties' cross-motions
for judgment on the pleadings. [DE 41, 45]. The motions have
been fully briefed and are ripe for disposition. A hearing on
this matter was held at Edenton, North Carolina on August 30,
2019. For the reasons discussed below, plaintiffs motion for
judgment on the pleadings [DE 41] is GRANTED and
defendant's motion [DE 45] is DENIED.
brought this action under 42 U.S.C. §§ 405(g) for
review of the final decision of the Commissioner denying her
claim for Disability Insurance Benefits and Supplemental
Security Income. After initial denials of her application for
benefits, plaintiff was given a hearing in front of an
Administrative Law Judge (ALJ) on July 18, 2017. The ALJ
issued an unfavorable ruling, finding that plaintiff was not
disabled, which became the final decision of the Commissioner
when the Appeals Council denied plaintiffs request for
review. Plaintiff then 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 kind 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 the inquiry ceases. See 20 C.F.R. §§
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).
the ALJ determined that plaintiff had the RFC to perform a
limited range of light work activity and therefore could
perform her past relevant work as an assistant manager and
cashier of a convenience store. This finding is not supported
by substantial evidence, and upon consideration of the
record, the Court finds the most plaintiff could perform is
discredited the opinion of treating provider Dr. Girguis,
M.D., who found that plaintiff could not perform light work
due to her chronic back pain, as being inconsistent with the
record. Specifically, the ALJ states in a short paragraph
that Dr. Girguis's opinion was inconsistent with a record
showing generally conservative treatment of plaintiff by
providers that appeared to have been effective. [Tr. 30]. But
the record demonstrates that plaintiffs financial situation,
particularly her lack of insurance, was a determinant of the
level of treatment she had received in the past. The ALJ
never addressed this evidence. And the ALJ's conclusion
that the treatment was effective is undercut by evidence in
the record showing that plaintiff had an additional surgery
scheduled to deal with her L4-5 posterior annular fissure and
its associated effects. A denial of benefits is not supported
by substantial evidence if the ALJ has not analyzed all of
the evidence and sufficiently explained his conclusions.
See Gordon v. Schweiker, 725 F.2d 231, 236 (4th Cir.
1984). The ALJ failed to do so here. Additionally, the ALJ
erred by effectively requiring plaintiff to put forth
clinical and objective evidence of the intensity,
persistence, and limiting effects of her back pain. Plaintiff
established that she had degenerative disc disease, which is
capable of causing severe pain, and was entitled to rely on
subjective evidence. See Hines v. Barnhart, 453 F.3d
559, 565 (4th Cir. 2006).
decision of whether to reverse and remand for benefits or
reverse and remand for a new hearing is one that "lies
within the sound discretion of the district court."
Edwards v. Bowen, 672 F.Supp. 230, 237 (E.D. N.C.
1987); see also Evans v. Heckler, 734 F.2d 1012,
1015 (4th Cir. 1984). When "[o]n the state of the
record, [plaintiffs] entitlement to benefits is wholly
established," reversal for award of benefits rather than
remand is appropriate. Crider v. Harris, 624 F.2d
15, 17 (4th Cir. 1980). The Fourth Circuit has held that it
is appropriate for a federal court to "reverse without
remanding where the record does not contain substantial
evidence to support a decision denying coverage under the
correct legal standard and when reopening the record for more
evidence would serve no purpose." Breeden v.
Weinberger, 493 F.2d 1002, 1012 (4th Cir. 1974).
Court in its discretion finds that reversal and remand for an
award of benefits is appropriate in this instance. The record
plainly demonstrates that plaintiff was at most capable of
performing sedentary work, and given her age, education, and
experience, a finding of disabled is appropriate under
Medical-Vocational Guideline 201.14. Accordingly, there is
nothing to be gained ...