Paulette N. v. Saul

Background

Paulette N. applied for disability insurance benefits, alleging disability beginning January 18, 2017. After two hearings at which Paulette N. and vocational experts testified, the Administrative Law Judge (ALJ) found that she had severe physical impairments, including lumbar degenerative disc disease, cervical spondylosis and stenosis, intermittent asthma or reactive airway disease, and a right-shoulder condition following surgery. The ALJ found that her plantar warts and mental impairments were not severe.

The ALJ determined that Paulette N. had the residual functional capacity (RFC)—the most she could do despite her limitations—to perform medium work with specified restrictions. The ALJ found that she could perform her former job as a public information officer as that job is generally performed and could alternatively perform several other jobs. The ALJ therefore found her not disabled. Paulette N. and the Acting Commissioner of Social Security filed cross-motions for summary judgment.

Mental impairments

The court rejected Paulette N.’s challenge to the ALJ’s evaluation of the medical opinions about her mental impairments. Consultative psychologist Dr. Martin diagnosed several conditions and found moderate limitations in five work-related areas. Non-examining state-agency psychiatrist Dr. Berkowitz found only mild or no limitations. The ALJ gave Dr. Berkowitz’s opinion great weight and Dr. Martin’s opinion little weight.

The court held that the ALJ gave specific and legitimate reasons for favoring Dr. Berkowitz’s opinion: Dr. Martin’s mental-status examination was normal, and Paulette N. did not seek mental-health treatment until May 2019, more than two years after the alleged onset of her work-limiting anxiety. The court also upheld the ALJ’s finding that Paulette N.’s mental impairments were not severe because that finding relied on the properly credited assessment of mild limitations.

Subjective testimony

The court held that the ALJ gave specific, clear, and convincing reasons for discounting Paulette N.’s testimony about her mental impairments, asthma, and plantar warts. The reasons included the normal mental-status examination and delayed mental-health treatment, an inconsistency between her testimony about repeated emergency-room treatment for asthma and the medical record, and the limited plantar-wart treatment records together with her report that she walked a lot.

The court found the reasons insufficient as to her shoulder and back pain. Regarding the shoulder, the ALJ relied on an allegedly normal examination from October 2016 and the absence of specialized treatment afterward. The court found that later examinations showed reduced movement or tenderness, that Paulette N. had reported increased pain to her primary-care physician, and that she had received pain medication and a referral to an orthopedic surgeon. The ALJ had not adequately explained why the lack of further specialized treatment undermined her testimony.

Regarding the back, the ALJ relied on a consultative examiner’s statement that Paulette N. could sit for up to two hours, generally normal examinations with occasional tenderness, and a note describing her lower-back pain as stable on medication. The court found these reasons inadequate because the ALJ had rejected the sitting limitation for a different reason, did not identify what testimony the examination findings contradicted, and relied on the isolated “stable” description despite other records describing severe and continuing back pain.

Lay witness testimony

Paulette N.’s daughter submitted a third-party function report describing limitations consistent with Paulette N.’s testimony. The court held that the ALJ erred by failing to discuss the daughter’s testimony or provide reasons for rejecting it. Because the court found errors in evaluating Paulette N.’s testimony, it could not treat the ALJ’s failure to address the daughter’s testimony as harmless. On remand, the ALJ must properly evaluate both witnesses’ testimony.

RFC and work findings

Because the RFC and the ALJ’s findings at steps four and five depended on the evaluation of Paulette N.’s testimony, the court remanded for further assessment of the RFC and whether she could perform her past relevant work or adjust to other work. The court stated that additional issues remained and that the record did not clearly require a finding that Paulette N. was disabled if the evidence were properly evaluated.

Disposition

The court granted in part and denied in part Paulette N.’s motion for summary judgment and granted in part and denied in part the Commissioner’s cross-motion for summary judgment. It remanded the action for further proceedings.