Robert B. v. Saul

Background

Robert B. sought disability insurance benefits under Title II of the Social Security Act. He originally alleged that he became disabled on October 14, 2015, but later amended the alleged onset date to May 1, 2017. The Social Security Administration denied the application initially and on reconsideration. After a hearing, an administrative law judge (ALJ) issued an unfavorable decision on April 16, 2019. The Appeals Council denied further review, making the ALJ’s decision the Commissioner’s final decision.

Robert B. had multiple sclerosis, a cognitive disorder related to multiple sclerosis, and degenerative disc disease. The medical record included magnetic resonance imaging scans and neuropsychological testing. The opinion describes evidence of problems with attention, information-processing speed, working memory, executive functioning, balance, and walking. Testing by neuropsychologist Dr. Kerri J. Lamberty in 2015 and 2017 showed cognitive decline. Dr. Lamberty stated that Robert B. could not return to his former work as an attorney and later completed a functional-ability form stating that his mental impairments prevented him from working.

The ALJ’s decision

The ALJ found that Robert B. had not engaged in substantial gainful activity since May 1, 2017. At step two of the disability analysis, the ALJ found severe impairments consisting of multiple sclerosis, a multiple-sclerosis-related cognitive disorder, and degenerative disc disease. At step three, the ALJ found that none of the impairments met or medically equaled a listed impairment.

The ALJ determined that Robert B. retained the residual functional capacity (RFC), meaning his remaining ability to work despite his impairments, to perform light work with physical restrictions and no exposure to certain hazards. The ALJ also limited him to simple, routine tasks. At step four, the ALJ found that Robert B. could not perform his past work as an attorney. At step five, relying on vocational-expert testimony, the ALJ found that he could perform jobs such as deburrer, trimmer, and stuffer. The ALJ therefore found him not disabled.

The ALJ gave great weight to Dr. Lamberty’s opinion that Robert B. could not return to his former work as an attorney, but gave no weight to her opinion that he could not work for any period. The ALJ characterized the latter opinion as conclusory, inconsistent with the evidence, and addressing an issue reserved to the Commissioner.

Court’s analysis

The court reviewed whether the Commissioner’s decision was supported by substantial evidence on the record as a whole and was free from legal error. Because Robert B.’s claim was filed before March 27, 2017, the court applied the prior rules concerning treating-source opinions. Under those rules, a well-supported treating-source opinion that is not inconsistent with the record generally receives controlling weight. Even when it does not receive controlling weight, the opinion must be evaluated under factors including the treatment relationship, supporting evidence, consistency with the record, and the source’s specialization. The ALJ must give specific reasons that allow later reviewers to understand the weight assigned.

The court agreed that whether a claimant can work is an issue reserved to the Commissioner. But it explained that this did not permit the ALJ to disregard the underlying medical findings about Robert B.’s functional limitations. The court found that the ALJ did not properly evaluate those limitations under the required two-step analysis.

The court also determined that the error was not harmless. It found that Dr. Lamberty’s opinion was supported by objective testing, clinical observations, and MRI results. The court described the record as showing cognitive decline between the 2015 and 2017 neuropsychological testing, along with evidence of multiple-sclerosis progression, including a new brain lesion shown on a 2018 MRI. The court further noted that consultative examiner Dr. Robert Schuler’s findings were largely consistent with Dr. Lamberty’s findings, although he assessed less severe limitations.

The court concluded that the ALJ’s stated reasons—that Dr. Lamberty’s opinion was conclusory and inconsistent with the evidence—were not supported by the record. It also identified an unexplained inconsistency in the ALJ’s decision: the ALJ accepted Dr. Lamberty’s opinion that Robert B. could not work as an attorney because of cognitive deficits while rejecting her opinion that those deficits prevented all work.

Disposition

The court held that the ALJ’s rejection of Dr. Lamberty’s 2017 opinion violated applicable legal standards. It concluded that the RFC determination and the disability findings at steps three, four, and five were not supported by substantial evidence. The court reversed the finding that Robert B. was not disabled and remanded the matter for further proceedings. On remand, the Commissioner must reconsider steps three, four, and five and apply the proper standards in deciding whether Dr. Lamberty’s opinion deserves controlling or deferential weight.

The court granted Robert B.’s motion for summary judgment, denied the Commissioner’s motion for summary judgment, reversed the Commissioner’s decision, and remanded for further proceedings consistent with the opinion and order. The court expressly did not decide whether Robert B. is ultimately disabled.