K.J. v. Saul

Background

K.J. applied for supplemental security income under Title XVI and disability benefits under Title II of the Social Security Act. She alleged that she became disabled on October 15, 2014. After the application was denied initially and on reconsideration, an administrative law judge held a hearing and denied the application. The Appeals Council denied review, making the administrative law judge’s decision the Commissioner’s final decision. K.J. then sought review in federal court.

K.J.’s claimed impairments included the effects of a traumatic brain injury, cognitive problems, memory and attention deficits, migraines, right-leg and right-knee problems, and foot drop. The administrative law judge found that K.J. had not engaged in substantial gainful activity since the alleged onset date and had several severe impairments. The judge found that none met or equaled a listed impairment.

The administrative law judge assessed K.J. as able to perform light work with restrictions, including walking and standing for a total of four hours in an eight-hour workday, certain postural limits, simple and routine tasks, being off task about five percent of the workday, no fast-paced production-line work, occasional changes in the work setting, and reminders twice a week to stay on task. Based on vocational-expert testimony, the administrative law judge found that K.J. could perform jobs including cashier, storage facility rental clerk, and mail clerk, and therefore was not disabled.

Medical opinions

The court held that the administrative law judge failed to give legally sufficient reasons for discounting the opinions of two examining professionals.

Dr. Samuelson performed a psychological examination and found memory and attention problems, disinhibited speech, difficulty answering questions, distractibility, and difficulty staying on topic. She opined that K.J. had marked difficulty with many work-related functions and could not work for a sustained period in a normal work setting, except possibly in a structured setting with trained professionals. The administrative law judge gave this opinion little weight, reasoning that it conflicted with Dr. Samuelson’s examination findings, other normal mental-status examinations, and K.J.’s education, work history, and move from Florida to California.

The court found that none of these reasons met the requirement for specific and legitimate reasons supported by substantial evidence. The administrative law judge listed some normal findings without explaining how they contradicted Dr. Samuelson’s findings of impaired memory and attention. The other mental-status examinations also did not adequately address several of Dr. Samuelson’s findings. The court further found that K.J.’s education and work history occurred before the alleged onset date and did not necessarily contradict the claimed limitations. The administrative law judge also did not explain how moving to California was inconsistent with Dr. Samuelson’s opinion.

Dr. Duffy performed a neuropsychological evaluation and found deficits in memory, attention, concentration, abstraction, planning, and problem-solving. He identified substantial impediments to employment and stated that K.J. was not a good candidate for full-time independent employment. He also said that any work would need to involve a slower pace, less demanding tasks, routine, and supervisors and coworkers who understood and allowed for K.J.’s mistakes.

The court agreed that whether K.J. could work or qualify for benefits was ultimately a question for the Commissioner. But the court held that the administrative law judge could not simply ignore those statements because they provided context for Dr. Duffy’s other opinions. The administrative law judge gave the limitations some weight but did not explain why they were not given full weight or how the residual functional capacity assessment addressed them. The court found that this error required a remand.

Migraines

The court rejected K.J.’s challenge to the treatment of her migraines. The administrative law judge found that migraines were a severe impairment but concluded that they improved with medication and did not require additional restrictions in the residual functional capacity assessment.

The court found the migraine evidence ambiguous. K.J. testified that her migraines had become constant and worse, while medical records showed periods when treatment helped and other periods when a doctor expressed concern that the migraines were difficult to control. The record also included treatment for a migraine lasting several days in January 2019. However, no doctor identified specific work-related limitations caused by the migraines, and the later records did not establish that similarly long-lasting migraines would continue. The court therefore held that the administrative law judge’s decision on migraines was supported by substantial evidence.

K.J.’s symptom testimony

The court also held that the administrative law judge did not provide sufficiently specific, clear, and convincing reasons for discounting K.J.’s testimony about the severity and effects of her symptoms.

The administrative law judge relied on K.J.’s daily activities and education and work history, varying reports about alcohol use, and medical findings that allegedly conflicted with her testimony. The court found that the administrative law judge did not identify which activities contradicted which parts of K.J.’s testimony. The court also found that the record described important limitations accompanying those activities, including short chores, the need for breaks, limited shopping and driving, difficulty walking, memory problems in social interactions, and difficulty managing medications and finances.

The court further found that K.J.’s alcohol-use reports were not inconsistent because they described different periods or were made at different times. Finally, the administrative law judge did not explain how the cited medical findings contradicted K.J.’s testimony, particularly when the administrative law judge had already recognized some physical limitations. The court concluded that all of the stated reasons for discounting K.J.’s testimony were inadequate.

Disposition

Judge Joseph C. Spero granted K.J.’s motion for summary judgment, denied the Commissioner’s motion for summary judgment, and remanded the case for further administrative proceedings consistent with the order. The parties agreed that, if the case were remanded, it should be remanded for further proceedings. The order did not award benefits or make a final determination that K.J. was disabled.