Vy v. Saul

Background

Stephanie Hien Vy sought judicial review under Title II of the Social Security Act after an administrative law judge denied her application for disability insurance benefits. Vy alleged disability beginning January 1, 2015, based principally on low back pain, right shoulder pain, and anxiety. The administrative law judge found severe impairments including lumbar degenerative disc disease, right shoulder tendinosis, depression, anxiety, somatoform disorder, and breast cancer status after lumpectomy and radiation.

The administrative law judge determined that Vy could perform a limited range of light work. The residual functional capacity, or RFC, allowed her to stand and walk for a total of two to four hours and sit for six hours in an eight-hour workday, with additional postural and task limitations. The administrative law judge concluded at the final step of the disability analysis that Vy could perform jobs such as small product assembler, collator, and cleaner or polisher.

Both parties moved for summary judgment. Vy argued that the administrative law judge failed to call a medical advisor about the disability onset date, improperly rejected treating physician Dr. Abhishek Gowda’s functional assessment, improperly rejected Vy’s testimony about her symptoms, failed to include all limitations in the RFC, and omitted limitations from the hypothetical questions posed to the vocational expert.

Court’s Analysis

The court rejected the argument that the administrative law judge was required to call a medical advisor to establish the onset date. The court explained that a medical advisor is required when the administrative law judge must infer the onset of a disabling impairment from unclear medical evidence. Here, the court said, the issue was whether Vy’s low back pain was disabling, not when it became disabling. The court therefore found no error on this issue.

The court held that the administrative law judge did not give specific and legitimate reasons, supported by substantial evidence, for rejecting portions of Dr. Gowda’s opinion. The administrative law judge gave Dr. Gowda’s opinion only some weight and relied on Dr. Pon’s opinion, but the court noted that Dr. Gowda had treated Vy regularly for more than a year while Dr. Pon examined her once. The court also stated that the administrative law judge did not identify specific conflicting facts or clinical evidence. The court observed that the physicians’ examinations showed similar findings, including low back pain radiating down the left leg and a positive left straight-leg-raise test.

The court also held that the administrative law judge inadequately evaluated Vy’s testimony about the intensity, persistence, and limiting effects of her symptoms. The administrative law judge did not identify which portions of her testimony were being rejected. The court further found that the explanation did not provide sufficiently clear and convincing reasons, because it relied on general references to the medical evidence and a note describing Vy’s pain as out of proportion to physical findings, while the record also showed chronic pain, positive testing, emergency-room visits, and extensive pain treatment.

Regarding the RFC, the court stated that the administrative law judge was not required to consider Vy’s education level in determining her RFC and that the restriction to simple, routine tasks adequately addressed the identified limitations in concentration, persistence, and pace. But because the administrative law judge improperly evaluated Dr. Gowda’s opinion, the court concluded that the RFC did not account for all relevant medical evidence and restrictions.

The court rejected Vy’s argument that the vocational expert’s hypothetical questions failed to account for her education. The questions referred to an individual with Vy’s education level, and the vocational expert had heard testimony about that education. However, the court directed the administrative law judge on remand to address Dr. Gowda’s opinion that Vy would be absent from work three times per month. The vocational expert had testified that no jobs would be available to a person with that limitation.

Disposition

The court GRANTED Plaintiff’s motion for summary judgment, DENIED Defendant’s motion for summary judgment, and REMANDED the case for further proceedings consistent with the opinion. A separate judgment was to issue. The opinion does not state that benefits were awarded.