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Lo v. Berryhill

United States District Court, E.D. California

July 27, 2017

MOLLY LO, Plaintiff,
NANCY A. BERRYHILL[1], Acting Commissioner of Social Security, Defendant.



         Molly Lo asserts she is entitled to disability insurance benefits and supplemental security income under Titles II and XVI of the Social Security Act. Plaintiff argues the administrative law judge erred in evaluating the record and seeks judicial review of the decision to deny her applications for benefits. Because the ALJ erred in evaluating the medical record, the matter is REMANDED for further proceedings pursuant to sentence four of 42 U.S.C. § 405(g).


         Plaintiff filed her applications for benefits on April 25, 2012, alleging disability beginning on January 1, 2012. (Doc. 9-3 at 20) The Social Security Administration denied Plaintiff's applications at both the initial level and upon reconsideration. (See generally Doc. 9-4) After requesting a hearing, Plaintiff testified before an ALJ on July 24, 2014. (Doc. 9-3 at 36) The ALJ determined Plaintiff was not disabled and issued an order denying benefits on September 16, 2014. (Id. at 17-29) The Appeals Council denied Plaintiff's request for review of the decision on August 25, 2015. (Id. at 2-4) Therefore, the ALJ's determination became the final decision of the Commissioner of Social Security (“Commissioner”).


         District courts have a limited scope of judicial review for disability claims after a decision by the Commissioner to deny benefits under the Social Security Act. When reviewing findings of fact, such as whether a claimant was disabled, the Court must determine whether the Commissioner's decision is supported by substantial evidence or is based on legal error. 42 U.S.C. § 405(g). The ALJ's determination that the claimant is not disabled must be upheld by the Court if the proper legal standards were applied and the findings are supported by substantial evidence. See Sanchez v. Sec'y of Health & Human Serv., 812 F.2d 509, 510 (9th Cir. 1987).

         Substantial evidence is “more than a mere scintilla. It means such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” Richardson v. Perales, 402 U.S. 389, 401 (1971) (quoting Consol. Edison Co. v. NLRB, 305 U.S. 197 (1938)). The record as a whole must be considered, because “[t]he court must consider both evidence that supports and evidence that detracts from the ALJ's conclusion.” Jones v. Heckler, 760 F.2d 993, 995 (9th Cir. 1985).


         To qualify for benefits under the Social Security Act, Plaintiff must establish he is unable to engage in substantial gainful activity due to a medically determinable physical or mental impairment that has lasted or can be expected to last for a continuous period of not less than 12 months. 42 U.S.C. § 1382c(a)(3)(A). An individual shall be considered to have a disability only if:

his physical or mental impairment or impairments are of such severity that he is not only unable to do his previous work, but cannot, considering his age, education, and work experience, engage in any other kind of substantial gainful work which exists in the national economy, regardless of whether such work exists in the immediate area in which he lives, or whether a specific job vacancy exists for him, or whether he would be hired if he applied for work.

42 U.S.C. § 1382c(a)(3)(B). The burden of proof is on a claimant to establish disability. Terry v. Sullivan, 903 F.2d 1273, 1275 (9th Cir. 1990). If a claimant establishes a prima facie case of disability, the burden shifts to the Commissioner to prove the claimant is able to engage in other substantial gainful employment. Maounois v. Heckler, 738 F.2d 1032, 1034 (9th Cir. 1984).


         To achieve uniform decisions, the Commissioner established a sequential five-step process for evaluating a claimant's alleged disability. 20 C.F.R. §§ 404.1520, 416.920(a)-(f). The process requires the ALJ to determine whether Plaintiff (1) engaged in substantial gainful activity during the period of alleged disability, (2) had medically determinable severe impairments (3) that met or equaled one of the listed impairments set forth in 20 C.F.R. § 404, Subpart P, Appendix 1; and whether Plaintiff (4) had the residual functional capacity (“RFC”) to perform to past relevant work or (5) the ability to perform other work existing in significant numbers at the state and national level. Id. The ALJ must consider testimonial and objective medical evidence. 20 C.F.R. §§ 404.1527, 416.927.

         A. Relevant Medical Evidence[2]

         In May 2011, Plaintiff went to the Kings Winery Medical Clinic, complaining of pain and “feeling down.” (Doc. 9-10 at 35) Plaintiff reported she “was feeling depressed about 5 years and it got worse gradually, ” and had feelings of hopelessness and worthlessness. (Id. at 34) Plaintiff said she “became withdrawn” and “had no motivation to do things.” (Id.) Plaintiff reported hearing voices and feeling suicidal, though she did not have suicidal ideations at the appointment. (Id.) Further, Plaintiff said she “had difficulty [with] concentration and remembering things.” (Id.) During the examination, she appeared sad and tearful. (Id.) Plaintiff was diagnosed with major depressive disorder and received prescriptions for Prozac and Zyprexa. (Id.)

         Treatment notes from Kings Winery indicate that at a follow-up appointment in August 2011, Plaintiff reported she “took medications regularly, however she was still feeling depressed.” (Doc. 9-10 at 33) As a result, the doctor increased the dosage of her prescription for Prozac. (Id.) Plaintiff's medications were altered again in October 2011, when she reported that she took the medication “regularly, ” but “was feeling hopeless, worthless…[and] tired.” (Id. at 29) The following month, Plaintiff reported that “she was still having insomnia.” (Id. at 27) However, her mood was normal, she had a pleasant demeanor, and she did not have any hallucinations. (Id.)

         Plaintiff had a comprehensive assessment for services from Fresno County Department of Behavioral Health on January 12, 2012. (Doc. 9-10 at 5-14) Plaintiff reported she had “frequent nightmares about unknown people who will hurt [her], ” heard voices, and “saw black shadows.” (Id. at 5) Plaintiff stated she had “problems staying asleep and [awoke] easily due to the frequent nightmares.” (Id. at 9) She reported she was on psychotropic medications that were prescribed by a psychiatrist from Kings Winery Clinic. (Id. at 8) In addition, Plaintiff said she had “poor memory and concentration.” (Id. at 12) Doan Truong, a social worker, observed that Plaintiff appeared “[d]epressed, irritable, … and worried, ” and “[s]he cried several times during the interview.” (Id. at 9, 12) Mr. Truong believed Plaintiff had fair immediate and short term memory, poor insight, poor judgment, and fair abstraction. (Id. at 10) Mr. Truong recommended Plaintiff be admitted to the County's Prevention Early Intervention program, through which Plaintiff began meeting with a social worker. (See Id. at 13, 19)

         Dr. Helen Patterson completed a mental residual functional capacity assessment for Plaintiff's current abilities on July 14, 2012. (Doc. 9-4 at 41-43) Dr. Patterson opined Plaintiff was “[n]ot significantly limited” with the ability to understand, remember, and carry out “very short and simple instructions, ” but was “[m]oderately limited” with detailed instructions. (Id. at 41-42) She believed that Plaintiff had moderate limitations with maintaining attention and concentration, completing a normal workday and workweek, interacting appropriately with the public, and getting along with coworkers or peers. (Id. at 42)

         On August 7, 2012, Plaintiff was admitted to the hospital on a 5150 hold, “as a danger to self and danger to others.” (Doc. 9-11 at 31, 32) Plaintiff said “she [was] very depressed and suicidal and that she [needed] protection… in order to keep herself safe.” (Id. at 33) Dr. Dwight Sievert observed that Plaintiff was “oriented and able to accurately name the day, date and hospital.” (Id. at 34) In addition, Dr. Sievert opined Plaintiff's “[i]nsight, judgment and impulse appear[ed] to be reasonably well preserved with the exception of impulse control in the area of self harm.” (Id.) Plaintiff was discharged on ...

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