Cortez v. Colvin

          ORDER REGARDING PLAINTIFF'S SOCIAL SECURITY COMPLAINT

         I. INTRODUCTION

         Plaintiff, Israel Cortez ("Plaintiff"), seeks judicial review of a final decision by the Commissioner of Social Security ("Commissioner" or "Defendant") denying his application for Supplemental Security Income ("SSI") benefits and Disability Insurance Benefits ("DIB") pursuant to Titles II and XVI of the Social Security Act. The matter is currently before the Court on the parties' briefs, which were submitted without oral argument to the Honorable Erica P. Grosjean, United States Magistrate Judge.^[1] Upon a review of the administrative record, the Court finds the ALJ's decision is not supported by substantial evidence and the case is remanded to the agency for further proceedings.

         II. BACKGROUND AND PRIOR PROCEEDINGS

         Plaintiff filed applications for DIB and SSI in October 2012, alleging a disability onset date of February 28, 2003. AR 210-213; 214-223.^[2] Both applications were denied initially in June 2013, and on reconsideration in August 2013. AR 131; 135; 143; 149. A hearing was conducted before Administrative Law Judge Trevor Skarda ("ALJ") on May 6, 2014. AR 38-70. On July 16, 2014, the ALJ issued a decision finding that Plaintiff was not disabled. AR 25-33. The Appeals Council denied Plaintiff's appeal, rendering the order the final decision of the Commissioner. AR 1-5.

         Plaintiff now challenges that decision, arguing that: (1) the ALJ failed to give legally sufficient reasoning in rejecting the treating opining of Dr. Jorge Urbina, M.D., and (2) the ALJ did not provide legally sufficient reasons for finding Plaintiff not fully credible. (Doc. 19, pgs. 6-14). Plaintiff argues that the Court should reverse and remand with instructions to award benefits. In the alternative, Plaintiff contends the case should be remanded for further administrative proceedings. (Doc. 19, pg. 16). In opposition, Defendant argues: (1) that the ALJ properly evaluated the medical evidence of record, giving greater weight to Dr. Chandler's opinion than to Dr. Urbina's opinion; and (2) the ALJ properly evaluated Plaintiff's subjective symptom testimony. (Doc. 24, pgs. 6-10).

         A. Plaintiff's Testimony

         The hearing was held in Stockton, California. AR 38. Plaintiff and a vocational expert, Stephen Schmidt, testified. AR 38. Plaintiff was 56 years old at the time of the hearing. AR 46. He earned a GED in 2000 while incarcerated. AR 46. At the time of the hearing, Plaintiff was enrolled in Modesto Junior College and was receiving special accommodations, i.e. private room for testing. AR 46-47. However, he was unable to maintain being enrolled in four classes. AR 47-48.

         Plaintiff reported having a history of drug and alcohol use but stopped "using" and "drinking" about 10 years ago. AR 52-53. He attributes the outset of his mental health condition to suffering from verbal, physical, and sexual abuse as a child. AR 55. He has lost over 100 jobs as a result of being uneasy, angry, and unfocused due to his mental health condition. AR 54. He testified he would become violent and angry in a work environment, even while on medication and undergoing counseling. AR 58-59.

         B. Medical Record

         i. Gardner Family Care Corp.

         Plaintiff participated in mental health services at Gardner Family Care Corp. (GFCC) from December 2009 to December 2010. AR 373. Treatment plans dated March 2010 and June 2010 describe Plaintiff as presenting with depressed mood, anger problems, weight gain, hypersomnia, history of suicidal ideations as a teenager, and hopelessness. AR 379-380. In July 2010, Plaintiff's chief complaint was being scared all the time and angry. AR 374. However, the psychiatric evaluation describes his mood only as sad. AR 376. Plaintiff reported using medically prescribed marijuana daily since September 2009 to ease his pain from Hepatitis C treatment. AR 375; 377.

         ii. Stanislaus Behavioral Health

         During a psychiatric consultation at Stanislaus Behavioral Health in November 2012, Plaintiff reported he slept most of the time, had no energy, and felt hopeless and helpless for years. AR 369. He also reported feeling angry and anxious depending on the situation. AR 369. SSRI's and therapy/anger management were recommended. AR 370.

         In April, 2013, Plaintiff denied suicidal intent but reported feeling like he wanted to die. AR 395. Plaintiff also reported hearing voices and smoked marijuana to calm himself down. AR 396. Rachel Acosta, M.F.T., described Plaintiff as appearing paranoid and becoming confused and irrational when attempting to talk about his thoughts. AR 396. Acosta also described Plaintiff as sincere, hopeful, and pleasant. AR 396. During a mental status examination, Plaintiff had decreased motor activity that was tense and teary, decreased speech, poor concentration, poor judgement, and poor impulse control. AR 398. However, Plaintiff was oriented to person, time and place, had directed flow of thought, normal memory, and average intellect. AR 398.

         In June 2013, Plaintiff was not taking medication and complained of depression with suicidal ideation, anger issues, paranoia, auditory hallucinations, and thoughts of violence. AR 390. Medication was prescribed. AR 391. In July 2013, Plaintiff claimed the medication was helping and did not produce any side effects. AR 388; 394. He complained of paranoia but denied auditory hallucinations. AR 388. At a check-up in September 2013, Plaintiff was still taking medication and denied both auditory hallucinations and paranoia. AR 406.

         In January 2014, Plaintiff had his initial visit with Dr. Urbina. AR 405. Dr. Urbina reports that Plaintiff claimed to be taking medication but the pharmacy confirmed Plaintiff had not picked up the medication prescribed to him three months earlier. AR 405. Plaintiff complained of depressed mood, lack of motivation, and some level of frustration. AR 405. At a February 2014 follow-up visit, Plaintiff reported he was compliant with medication. AR 404. Dr. Urbina did not report any complaints and described Plaintiff's mood as "better." AR 404. In March 2014, Plaintiff claimed to be compliant with medication. AR 403. Dr. Urbina did not report any complaints and described Plaintiff's mood as euthymic. AR 403.

         Additionally, Dr. Urbina completed a medical opinion questionnaire in February 2014, while Plaintiff was on medication. AR 407; 404. Dr. Urbina states that Plaintiff has frequent anger outbursts resulting in violent behaviors and impaired ability to maintain concentration and attention. AR 407. Dr. Urbina diagnosed Plaintiff as suffering from chronic major depressive disorder and post-traumatic stress disorder. He opined that exposing Plaintiff ...