T.H. v. Kijakazi

Background

T.H. sought judicial review of the Commissioner of the Social Security Administration’s final decision denying her applications for disability insurance benefits under Title II and supplemental security income under Title XVI of the Social Security Act. She applied for disability insurance benefits on February 23, 2017, and supplemental security income on March 16, 2017. After the applications were denied initially and on reconsideration, an administrative law judge held a hearing on June 7, 2019, and issued an unfavorable decision on July 2, 2019. The Appeals Council denied review on April 3, 2020, making the administrative law judge’s decision final.

The administrative law judge found that T.H. had severe impairments including obesity, degenerative disc disease of the cervical and lumbar spine, hypertension, and degenerative joint disease of the left shoulder with possible bicipital tendonitis. The judge determined that T.H. had the residual functional capacity—the most she could still do despite her impairments—to perform a limited range of light work. The judge concluded that she could not perform her past relevant work but could perform jobs such as counter clerk, marker II, and marker, and therefore was not disabled.

Issues and Analysis

T.H. argued that the administrative law judge improperly weighed the medical evidence, rejected her testimony without adequate explanation, failed to include all supported limitations in the residual-functional-capacity assessment, and relied on incomplete questions to the vocational expert.

The court held that the administrative law judge did not adequately explain the weight given to the opinion of examining physician Soheila Benrazavi. The judge gave that opinion “great weight,” citing the examination, clinical observations, record review, and consistency with the record. The court found those explanations conclusory and insufficient to explain why Dr. Benrazavi’s opinion was given more weight than other medical sources.

The court also held that the administrative law judge did not properly address the opinion of physical therapist Laura Dejesus. Although the judge mentioned some improvement in T.H.’s shoulder, the judge did not expressly reject or explain the treatment of the physical therapist’s identified shoulder limitations. The court concluded that this was error.

The court further held that the administrative law judge failed to give specific, clear, and convincing reasons for rejecting T.H.’s testimony about the severity of her symptoms. The judge stated only that the testimony was “not entirely consistent with the medical evidence and other evidence in the record.” The court found that this general statement did not identify which testimony was rejected or what evidence undermined it. The judge summarized T.H.’s daily activities but did not explain whether those activities contradicted her testimony.

Because the residual-functional-capacity determination was based partly on the medical evidence that needed to be reconsidered, the court also remanded that issue. The court likewise found that the vocational expert’s questions were based on the challenged medical and other evidence and therefore did not adequately account for all of T.H.’s limitations.

Disposition

The court granted T.H.’s motion for summary judgment, denied the Commissioner’s cross-motion for summary judgment, and remanded for further proceedings consistent with the order. The court determined that further administrative proceedings could remedy the identified defects and did not award benefits in this order. Judge Laurel Beeler signed the order as a United States Magistrate Judge.