David A. v. Commissioner of Social Security

Background

David A. applied for Supplemental Security Income benefits in November 2019, alleging disability beginning July 1, 2018. The Social Security Administration denied the application initially and on reconsideration. After a hearing at which David A. testified with an attorney, Administrative Law Judge Selwayn Walters denied the application on March 26, 2021. The Appeals Council declined review, making the administrative law judge’s decision the Commissioner’s final decision.

The administrative law judge found that David A. had a severe seizure disorder. The judge determined that he had the residual functional capacity—the ability to work despite his impairments—to perform work at all exertional levels, subject to restrictions involving ladders, ropes, scaffolds, unprotected heights, moving mechanical parts, heavy machinery, and motor vehicles. The judge found that David A. had no past relevant work but could perform jobs existing in significant numbers in the national economy.

Issues and Analysis

David A. challenged the administrative law judge’s treatment of the medical-opinion evidence and the finding at the second step of the disability evaluation that his depressive disorder and post-traumatic stress disorder were not severe.

The court held that the administrative law judge improperly evaluated the opinion of Dr. Samuel Bhuiyan, who had treated David A. since September 2018. Dr. Bhuiyan diagnosed a seizure disorder and assessed moderate limitations in several areas, including daily activities, dealing with ordinary work stress, regular attendance, following instructions, staying on task, and social functioning. He also stated that David A.’s conditions would prevent full-time, competitive, ongoing work.

The court found that the administrative law judge failed to consider the consistency between Dr. Bhuiyan’s opinion and the opinion of consultative psychiatric examiner Dr. Alexandra Gordon-Fitzsimons. Dr. Gordon-Fitzsimons assessed moderate limitations in interacting with others and regulating emotions, controlling behavior, and maintaining well-being, along with other limitations. The court stated that the administrative law judge analyzed the two opinions separately instead of considering their agreement, and did not include limitations addressing social functioning and self-regulation in the residual functional capacity assessment.

The court also found that the administrative law judge selectively relied on treatment records describing normal or unremarkable mental-status examinations while failing to address records describing depression, impaired attention and concentration, slowed thinking, possible memory deficits, post-traumatic stress disorder, and generalized anxiety disorder. The court further held that the administrative law judge should not have treated Dr. Bhuiyan’s handwritten response as an indication that David A. exaggerated symptoms or was malingering. Because another part of Dr. Bhuiyan’s form was unclear, the administrative law judge also should have contacted him for clarification.

Although state-agency consultants concluded that David A. did not have a severe psychiatric impairment, the court held that those opinions were not substantial evidence sufficient to support the decision in light of the errors involving the treating and examining physicians’ opinions.

The court concluded that these errors also undermined the second-step finding that David A.’s depressive disorder and post-traumatic stress disorder were not severe. The court therefore required reconsideration of the medical-opinion evidence and further development of the record.

Disposition

Magistrate Judge Gary R. Jones granted David A.’s motion for judgment on the pleadings, denied the Commissioner’s motion for judgment on the pleadings, and remanded the case for further administrative proceedings consistent with the decision. The clerk was directed to enter final judgment and close the file.