United States District Court, E.D. North Carolina, Southern Division
TERRENCE W. BOYLE CHIEF UNITED STATES DISTRICT JUDGE.
matter is before the Court on the parties' cross-motions
for judgment on the pleadings. [DE 20, 27]. The motions have
been fully briefed and are ripe for disposition. A hearing on
this matter was held at Elizabeth City, North Carolina on
September 13, 2019. For the reasons discussed below,
plaintiffs motion for judgment on the pleadings [DE 20] is
GRANTED and defendant's motion [DE 27] is DENIED.
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 a period of disability and
disability insurance benefits and supplemental security
income. Plaintiff applied for benefits back in November 2011.
These initial applications were denied, and she received a
hearing in front of an Administrative Law Judge (ALJ) in
October 2013, who issued an unfavorable ruling. This ALJ
ruling was remanded by Magistrate Judge Kimberly Swank in
September 2016. A second hearing in front of the ALJ was held
in June 2017, leading to a second unfavorable decision in
November 2017. This decision 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 at step two that plaintiff had severe
impairments of bipolar/schizoaffective disorder, degenerative
disc disease, and osteoarthritis in the left shoulder and
both knees. The ALJ determined that she did not meet any
Listings at step three, and at step four, concluded she had
an RFC to perform light work with additional non-exertional
limitations and could not return to her past relevant work.
But at step five, the ALJ determined that there were jobs in
the national economy she could perform despite her
impairments and therefore she was not disabled.
argues that the ALJ erred in (1) ignoring Judge Swank's
instructions and repeating the same errors as the first
decision; (2) improperly discounting the opinions of the
medical professionals; and (3) failing to properly consider
the Listing at step three. The Court finds that, at least in
regard to plaintiffs second argument, the ALJ committed
improperly rejected the opinions of the medical professionals
who examined plaintiff and diagnosed her mental limitations,
and his decision is not supported by substantial evidence.
The ALJ gave little weight to the opinions of Dr. Linda
Graham, a treating psychiatrist who saw plaintiff multiple
times, and Dr. Antonio Puente, who performed a psychological
evaluation of the plaintiff. Dr. Linda Graham diagnosed
plaintiff with Bipolar II and Schizoaffective disorders. Dr.
Graham indicated plaintiff was "markedly limited"
in most areas of social interaction and adaption, including
the ability to accept instructions, respond appropriately to
criticism from supervisors, the ability to maintain socially
appropriate behavior, and the ability to respond to changes
in the work setting. Dr. Graham concluded plaintiff could not
return to full time employment. [Tr. 825]. Dr. Puente's
evaluation supports Dr. Graham's opinion. He administered
a Beck Depression Scale II test, and plaintiff tested as
being significantly impaired. [Tr. 791]. Dr. Puente concluded
she would "disintegrate underpressure." [Tr. 791],
Furthermore, Stephen Bower, MSW-LCSW, who was plaintiffs
treating therapist, confirmed the diagnosis for plaintiffs
Bipolar II Disorder and major depressive disorder, stating
that plaintiff "has not demonstrated an ability to
regulate her affect in more challenging occupational and
social settings." [Tr. 913].
deciding whether a claimant is disabled, 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). Here, the
ALJ repeatedly discounted the conclusions of Dr. Graham and
Dr. Puente on reed-thin justifications while citing to no
medical evidence in the record that undercut their findings.
For example, the ALJ seemed to discount Dr. Graham's
medical source statement, calling into question its
credibility, by speculating that Dr. Graham had only seen
plaintiff two or three times before issuing the statement.
[Tr. 951]. He also questioned Dr. Graham's note of
plaintiffs compliance with taking her medication using the
same justification already rejected by Judge Swank. [Tr.
951]. He refused to credit Dr. Puente's assessment on the
grounds that he lacked a "longitudinal treating
relationship" with the plaintiff and contended that Dr.
Puente's conclusions were unsupported by the medical
evidence. But the ALJ neither cited to nor detailed medical
evidence in the record that undercut Dr. Puente's
conclusions. It certainly was not the opinions of Dr. Graham
and Mr. Bower, which are consistent with Dr. Puente. An ALJ
cannot simply ignore medical evidence pointing to a finding
of disability. See Lewis v. Berryhill, 858 F.3d 858,
869 (4th Cir. 2017). On the basis of this significant defect,
the Court finds the ALJ's decision was not supported by
substantial evidence. Having found reversible error, there is
no need to consider plaintiffs remaining arguments.
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