Lim v. Berryhill

Background

Wayne Chun Lim sought disability insurance benefits under Title II of the Social Security Act, alleging disability beginning October 30, 2009. The Administrative Law Judge (ALJ) found that Lim remained insured through September 30, 2013; had one severe impairment, a history of headaches; and had nonsevere depression, bipolar disorder, and schizoaffective disorder. The ALJ found that Lim could perform work at all exertional levels with no concentrated exposure to hazards and could perform his past work as a consultant and sales manager. The Social Security Appeals Council declined further review.

The parties filed cross-motions for summary judgment, which ask the court to decide whether the agency’s decision should stand based on the administrative record.

Mental impairments and Listing 12.04

The court held that the ALJ’s finding that Lim’s mental impairments were not severe was not supported by substantial evidence. Substantial evidence means relevant evidence that a reasonable person could accept as adequate to support a conclusion. The ALJ relied on some mild Global Assessment of Functioning scores, reported improvement, and limited evidence of functional problems, but did not adequately address the record as a whole.

The omitted or underconsidered evidence included later scores showing moderate or serious symptoms, fluctuations in depression and anxiety, suicidal thoughts, and Lim’s December 2012 involuntary mental-health hold under California Welfare and Institutions Code section 5150. The court also found that the ALJ’s discussion of Lim’s ability to interact with others and concentrate, persist, or maintain pace was cursory and did not address contrary evidence, including Lim’s testimony about social isolation and difficulty consistently working on his dissertation.

The court did not find that Lim had established that he necessarily met Listing 12.04, which concerns depressive, bipolar, and related disorders. But because the ALJ’s severity and functional-limitations analysis was legally inadequate, the ALJ’s Listing determination also had to be reconsidered on remand. On this issue, the court granted in part and denied in part Lim’s motion and granted in part and denied in part the Commissioner’s motion.

Medical-source evidence

The court upheld the ALJ’s decision to give little weight to Robin Neville’s opinion. Neville was a licensed clinical social worker, and the opinion was issued four years after Lim’s date last insured. The court treated the opinion as evidence from an “other source,” rather than an acceptable medical source whose opinion could receive controlling weight, and found that the timing was a sufficient reason to discount it.

The court also rejected Lim’s argument that the ALJ improperly ignored opinions from treating nurse practitioner Jessica Yu and treating psychologist Diane Zacher. The court concluded that the treatment notes and questionnaire materials cited by Lim recorded observations or Lim’s self-assessment, rather than medical-source judgments about his functional abilities or restrictions. The court therefore denied Lim’s motion and granted the Commissioner’s motion on the medical-source-opinion issue.

Medical expert and vocational-expert issues

The court rejected Lim’s argument that the ALJ was required to obtain medical-expert testimony about his disability-onset date. The ALJ had found that Lim was not disabled before his date last insured, so the question of when disability began did not arise under the rule Lim cited. The court denied Lim’s motion and granted the Commissioner’s motion on this issue, while noting that the ALJ could revisit the need for medical-expert testimony if, on remand, she found Lim disabled but could not determine the onset date.

Lim also argued that the ALJ’s hypothetical questions to the vocational expert failed to include his functional limitations and his December 2012 mental-health hold. Because the ALJ’s assessment of Lim’s ability to work depended on the earlier, erroneous assessment of the severity of his impairments, the court directed the ALJ to reconsider Lim’s residual functional capacity and ability to perform past relevant work on remand.

Disposition

The court stated that when an ALJ denies benefits and the court identifies error, the usual remedy is a remand for further agency proceedings rather than an immediate award of benefits. The court ordered the ALJ to reassess the medical record as a whole and provide legally adequate reasons for finding Lim’s mental impairments severe or not severe.

The court granted in part and denied in part Lim’s motion for summary judgment, granted in part and denied in part the Commissioner’s cross-motion for summary judgment, and remanded the matter for further proceedings consistent with the order. The clerk was directed to enter judgment and close the file. Judge Virginia K. Demarchi signed the order.