United States District Court, E.D. California
ORDER AFFIRMING AGENCY'S DENIAL OF BENEFITS AND ORDERING JUDGMENT FOR COMMISSIONER (Doc. 17)
SANDRA M. SNYDER, Magistrate Judge.
Plaintiff Juana Hernandez, by her attorney, Jacqueline A. Forslund, seeks judicial review of a final decision of the Commissioner of Social Security ("Commissioner") denying her application for disability insurance benefits pursuant to Title II and for supplemental security income ("SSI") pursuant to Title XVI of the Social Security Act (42 U.S.C. § 301 et seq. ) (the "Act"). The matter is currently before the Court on the parties' cross-briefs, which were submitted, without oral argument, to the Honorable Sandra M. Snyder, United States Magistrate Judge. Following a review of the complete record and applicable law, this Court finds the decision of the Administrative Law Judge ("ALJ") to be supported by substantial evidence in the record as a whole and based on proper legal standards.
A. Procedural History
In 2006, Plaintiff first applied for disability insurance benefits and supplemental security income, which were denied in 2009. On June 21, 2010, Plaintiff again applied for disability insurance benefits and supplemental security income. Plaintiff initially alleged onset of disability date of October 24, 2006, but amended it at the hearing to July 1, 2009. The Commissioner initially denied the claims on November 8, 2010, and upon reconsideration again denied the claims on April 13, 2011. On April 22, 2011, Plaintiff filed a timely request for a hearing.
On April 25, 2012, and represented by counsel, Plaintiff appeared and testified with the assistance of a Spanish interpreter at a hearing presided over by John Cusker, Administrative Law Judge ("the ALJ"). See 20 C.F.R. 404.929 et seq. An impartial vocational expert, Thomas C. Dachlet ("the VE"), also appeared and testified.
On June 12, 2012, the ALJ denied Plaintiff's application. The Appeals Council denied review on November 7, 2013. The ALJ's decision thus became the Commissioner's final decision. See 42 U.S.C. § 405(h). On September 8, 2014, Plaintiff filed a complaint seeking this Court's review pursuant to 42 U.S.C. §§ 405(g), 1383(c)(3).
B. Plaintiff's Testimony
At the administrative hearing, Plaintiff was 55 years old. She had attended a few years of school in Mexico, and did not speak, read, or write in English. She had worked for fifteen years at a packing house sorting fruit until October 2006. Prior to that, she had worked in the fields.
Plaintiff was being treated for arthritis, anxiety, and depression. Since her date of disability of July 1, 2009, Plaintiff had not worked because she couldn't stand for long periods of time or use her hands as required by her job. Plaintiff could stand for about half an hour and sit for about an hour. She had to keep moving because of her back pain. She could not bend, stoop, or squat. She had trouble using her hands. She could not write or grip things that were heavy, and she could use her hands for about ten minutes before needing to rest them. Plaintiff also complained of daily headaches lasting one to two hours, constant knee pain, constant back pain, constant neck pain, and weight gain which exacerbated her pain.
Plaintiff felt that being depressed and anxious interfered with her ability to work because she couldn't remain calm and did not like to be around people. Plaintiff usually wanted to be enclosed in the dark. She also had problems focusing and concentrating while watching TV.
Plaintiff lived alone without anyone to help her. She dressed and bathed herself, did her own laundry and shopping, and took out the trash. She was unable to vacuum because it hurt her hands. She had trouble cleaning around the house and it took her longer than usual. She cooked for herself, although she was unable to cook full traditional meals as she had done previously. She took the bus independently to the store. Plaintiff's hobbies included reading or watching TV. Plaintiff also testified that her relatives visited and her daughter called her regularly. She occasionally attended church services.
C. Relevant Medical Record
1. Physical Impairments
Plaintiff received primary care at Madera Community Hospital. The record contains notes from Family Nurse Practitioner Eunice Hall from about 2009 to 2012. Ms. Hall's notes indicate that Plaintiff complained of headaches, pain in her knees, left arm, shoulders, joints, and hands, weakened grip and tender wrists, which caused her to suddenly drop things, anxiety and depression, and various other ailments such as fatigue and dry mouth. Ms. Hall diagnosed Plaintiff with headaches, carpal tunnel syndrome ("CTS"), arthritis, osteoarthritis, bursitis, depression, and hypertension. Ms. Hall prescribed Vicodin, Tramadol, Inderal, and Benazepril, and advised Plaintiff regarding nutrition, weight loss, and avoiding migraine triggers. Ms. Hall noted that Plaintiff's headaches were controlled with medication. With her CTS diagnosis, Ms. Hall prescribed Neurontin for neuropathic pain and referred Plaintiff to a neurologist for CTS. However, this medication was not effective for Plaintiff's hand and wrist symptoms, and Plaintiff did not see a neurologist. In March 2012, Ms. Hall completed a questionnaire from the Office of Disability Adjudication and Review, which listed Plaintiff's impairments as arthritis to her wrists, hands, and joints, associated pain, depressive disorder, headaches, and hypertension. In April 2012, Ms. Hall wrote a letter stating that Plaintiff had chronic pain to both hands because of arthritis.
Plaintiff also received regular pain management care from Henry Ho Kang, M.D., Ph.D beginning in 2007 and continuing into 2012. She saw Dr. Kang for management of pain in her lower back, neck, shoulders, and knees. Dr. Kang diagnosed Plaintiff with tendonitis/bursitis, osteoarthritis, rotator cuff syndrome of shoulder, lumbar disc disorder, lumbosacral spondylosis without myelopathy, discogenic disease of the cervical spine, and cervical spondylosis without myelopathy. At various times, Dr. Kang administered injections to Plaintiff's lower back, left shoulder, and neck.
In October 2010, Tahir Hassan, M.D. performed an internal medicine evaluation of Plaintiff at DSS's request. In his report, Dr. Hassan diagnosed Plaintiff with arthritis, pain in her left shoulder, backpain, hypertension, hyperlipidemia, and depression. AR 471. He wrote that she did not use an assistive device for walking and that she was independent in activities of daily life. He also wrote that Plaintiff was negative for headaches and joint pain. AR 469. Dr. Hassan's examination revealed normal findings, including in motor system, gait, cervical spine extension, and elbow and wrist extension and flexion. He found that Plaintiff was somewhat limited in lumbar spine flexion and left shoulder flexion and abduction. Based on his examination, Dr. Hassan opined that Plaintiff was limited to lifting 50 pounds occasionally and 25 pounds frequently. She could stand or walk for about four hours in an eight hour workday and sit for about six hours in an eight-hour workday. She should avoid overhead work because of left shoulder pain, and could only climb, balance, stoop, crawl, and crouch frequently due to back pain. Plaintiff had had visual limitations of precision work due to vision problems. Dr. Hassan opined that Plaintiff had no communicative and environmental limitations. AR 471.
In November 2010, David Chan, M.D. completed a physical residual functional capacity assessment. He diagnosed her with left shoulder pain, lumbar degenerative disc disease, and hypertension. AR 473. Dr. Chan similarly opined that Plaintiff was limited to lifting 50 pounds occasionally and 25 pounds frequently. He similarly opined that Plaintiff could sit for about six hours in an eight-hour workday, was limited in reaching in all directions, and did not have any communicative and environmental limitations. However, his assessment differs from Dr. Hassan's, because Dr. Chan opined that Plaintiff could stand or walk for about six hours in an eight-hour workday, as opposed to four. AR 477. While Dr. Hassan said Plaintiff could not perform overhead work due to left shoulder pain, Dr. Chan stated that Plaintiff was limited to overhead reaching with the upper left extremity to "frequently, " which is defined as one-third to two-thirds of an eight-hour workday. Dr. Chan assessed no vision problems.
In January 2011, Arthur Paredes, M.D. examined Plaintiff for lower back pain sustained after a fall. Dr. Paredes diagnosed Plaintiff with localized secondary osteoarthritis of the lumbar vertebrae and backache. AR 678.
2. Mental Impairments
Plaintiff began seeing Evangeline Murillo, M.D., psychiatrist, in February 2008 and continued to see her with some regularity through 2011. At least as of January 2009, Dr. Murillo had diagnosed Plaintiff with major depressive disorder and general anxiety disorder. She prescribed Seroquel and Paxil. AR 508. The records indicate that Plaintiff took Seroquil and Paxil as prescribed by Dr. Murillo through November 2010. Dr. Murillo also prescribed Benadryl to help her sleep. In April 2011, Dr. Murillo prescribed pain killers. AR 600. In July 2011, Dr. Murillo discontinued Paxil in favor of Prozac, keeping all other medications the same. The last prescription date in the record is December 2011.
In October 2010, Harvey Bilik, Psy.D, completed a psychiatric review technique form. He diagnosed Plaintiff with a non-severe affective disorder. Regarding functional limitations, Dr. Bilik marked that Plaintiff had mild restriction of activities of daily living, mild difficulties in maintaining social functioning, and mild difficulties in maintaining concentration, persistence, or pace. Dr. Bilik noted no episodes of decompensation. Dr. Bilik noted in his functional analysis that Plaintiff lived alone and was able to care for her own needs including chores, cooking, paying bills, using public transportation, and attending church. He also noted that Plaintiff "appears well-stabilized currently" under Dr. Murillo's care. AR 455-464.
In November 2010, Dr. Murillo completed a short-form evaluation for mental disorders. She diagnosed Plaintiff with depression which was recurrent and moderate. She also diagnosed Plaintiff with panic attacks and generalized anxiety. Regarding cognitive functioning and thought process, Dr. Murillo indicated that Plaintiff had moderately to severely impaired concentration, moderately impaired memory, and moderately impaired judgment. Dr. Murillo opined that Plaintiff could not usefully perform or sustain the following activities: 1) understand, remember, and carry out complex instructions; 2) maintain concentration, attention, and persistence; 3) perform activities within a schedule and maintain regular attendance; 4) complete a normal workday and workweek without interruptions from psychologically based symptoms; and 5) respond appropriately to changes in a work setting.
In April 2011, H. Biala, M.D. reviewed Plaintiff's record and found that there was no evidence of worsening depression since 2009. AR 524-526. Dr. Biala noted that Plaintiff had missed her appointments in October and November 2010. He also noted that the progress notes consistently showed that Plaintiff had an intact memory, despite Dr. Murillo's November 2011 assessment that Plaintiff had moderate memory impairment. Dr. Biala recommended adopting the not severe RFC finding.
D. Vocational Expert Testimony
At the administrative hearing, the VE classified Plaintiff's past work as packer (DOT # 920.687-134, medium, unskilled, SVP 2). The ALJ asked the VE to assume a hypothetical person who was able to lift 50 pounds occasionally and 25 pounds frequently, stand or walk with normal breaks for about six hours in an eight-hour workday, sit for about six hours in an eight-hour workday, push and pull without limitation, climb ladders, ropes, and scaffolds occasionally, reach overhead frequently; and had no communicative or environmental limitations but was limited to simple repetitive tasks. The VE opined that such an individual could perform Plaintiff's past work.
The ALJ then directed the VE to assume a second hypothetical person but who could climb, balance, stoop, crawl, and crouch frequently, but could not do overhead work or precision work. The VE testified that ...