United States District Court, E.D. California
FINAL JUDGMENT AND ORDER REGARDING PLAINTIFF'S
SOCIAL SECURITY COMPLAINT
matter is before the Court on Plaintiff's complaint for
judicial review of an unfavorable decision of the
Commissioner of the Social Security Administration regarding
his applications for supplemental security income and
disability insurance benefits. The parties have consented to
entry of final judgment by the United States Magistrate Judge
under the provisions of 28 U.S.C. § 636(c) with any
appeal to the Court of Appeals for the Ninth Circuit.
hearing on November 16, 2017, the Court heard from the
parties and, having reviewed the record, administrative
transcript, the briefs of the parties, and the applicable
law, finds as follows:
reasons announced by the Court on the record at the
conclusion of the parties' oral argument on November 16,
2017, the Court finds that the decision of the Commissioner
of Social Security should be reversed and the case should be
remanded for further proceedings.
September 12, 2013, Licensed Marriage and Family Therapist
(LMFT) Sahai-Bains diagnosed Ms. Lane with Bipolar Disorder
I, with the most recent episode of mania, moderate, and
referred Ms. Lane for group services and to Dr. Obata for
psychiatric follow-up. (AR 505)
October 25, 2013, Psychiatrist Christine Obata, M.D.
evaluated Ms. Lane. (AR 490-491) Dr. Obata assessed Ms. Lane
as “Likely Bipolar Disorder Type I, ” and
“[c]urrently appears to be in a hypomanic
episode.” (AR 491) Dr. Obata also assessed that Ms.
Lane “requires more intensive mental health services
than can be provided through primary care” and
recommended that Plaintiff continue the psychotherapy at
Fresno County Mental Health and to establish care with a
psychiatrist for psychotropic medication management visits.
December 20, 2013, Ms. Lane was again treated by psychiatrist
Dr. Obata, who assessed “Depression NOS [more likely];
rule out Bipolar Disorder.” (AR 485) Dr. Obata noted
that Ms. Lane was “uncontrollably tearful during most
of interview, ” prescribed an antidepressant and
recommended continuing psychotherapy at Fresno County Mental
29, 2014, psychiatrist Shawn Hersevoort, M.D. evaluated Ms.
Lane at the request of Dr. Sheh, M.D. to assist with
treatment planning. (AR 467) Dr. Hersevoort observed that Ms.
Lane suffers from major depression, generalized anxiety
disorder, and partially-resolved Post-Traumatic Stress
Disorder (PTSD). Dr. Hersevoort further observed that Ms.
Lane “by strict criteria likely fits into the Bipolar
NOS category, ” but has never been hospitalized for her
symptoms and “scored a 7 on the [Mood Disorder
Questionnaire], which is the minimum score for considering
bipolar.” Dr. Hersevoort noted to “consider an
adjunctive mood stabilizer at a later date to help with
bipolar NOS.” (AR 473)
November 20, 2014, there was a subsequent psychiatric visit
with Dr. Hersevoort, where he observed and opined that Ms.
Lane is “suffering from a combination of cluster B
personality disorder (most likely borderline) as well as a
bipolar 2 illness.” (AR 448) Ms. Lane was treated by
Dr. Hersevoort again on December 4, 2014, who observed that
Ms. Lane was experiencing severe mood, anxiety and somatic
symptoms. (AR 443) Dr. Hersevoort noted that Ms. Lane had a
“complex history and presentation with likely
borderline personality disorder, possible bipolar (1 vs 2),
ADHD, PTSD.” In the diagnosis (Patient Active Problem
List) section of the medical record, Dr. Hersevoort recorded
the following mental conditions:
Cluster B personality disorder (likely)
ADHD (attention deficit hyperactivity disorder)
Bipolar disorder, unspecified
two of the five-step sequential disability analysis, the ALJ
found Ms. Lane had severe impairments of “brittle
diabetes mellitus with peripheral neuropathy, depressive
disorder, borderline intellectual functioning, and ADHD. (AR
13). Although Ms. Lane had claimed she also suffered from
bipolar disorder, the ALJ failed to discuss this disorder in
any way in step 2 and did not refer to the above mentioned
doctor's diagnoses at this step. Moreover, when the ALJ
formulated Ms. Lane's residual functioning capacity
(“RFC”) assessment, the ALJ failed to address the
opinions of treating doctors Obata and Hersevoort. This was
legal error. See Lester v. Chater, 81 F.3d 821,
830-31 (9th Cir. 1995), as amended (Apr. 9, 1996)
(providing that the ALJ must give “clear and
convincing” reasons for rejecting the uncontradicted
opinion of an examining physician, Pitzer v.
Sullivan, 908 F.2d 502, 506 (9th Cir.1990), and
“specific and legitimate” reasons that are
supported by substantial evidence in the record for rejecting
a contradicted opinion, Andrews v. Shalala, 53 F.3d
1035, 1043 (9th Cir. 1995)).
only mentioned bipolar disorder in the context of
discrediting Ms. Lane's credibility. The ALJ noted that
Ms. Lane was seen in September 2013 by LMFT Sahai-Bains, who
diagnosed bipolar disorder. (AR 18) In the same paragraph,
the ALJ went on to express an opinion that Ms. Lane was
exaggerating her symptoms in order to receive disability
benefits. While this discussion includes references to
medical records by Drs. Obata and Hersevoort, they are not
mentioned by name or their diagnoses, and the ALJ does not
provide specific reasons for discounting their opinions.
Although the Commissioner argues that these page references
are sufficient to satisfy the ALJ's burden, the Court
ALJ's decision does cite to “Exhibit 6F, ”
which consists of 69 pages of medical records from Community
Medical Centers, a medical group consisting of several
doctors (including Obata and Hersevoort) that provided to
treatment to Ms. Lane. (AR 432-499) The Court reviewed the
all of instances where the ALJ cited to a specific page of
Exhibit 6F, and none the citations were to the records of
doctors Obata and Hersevoort.
Court thus remands the case for additional development
regarding the medical opinions of doctors Obata and
Hersevoort and possible work-related limitations resulting
from the conditions. On remand, the ALJ shall consider their
opinions and either accept them or provide specific and
legitimate reasons supported by substantial evidence for
failing to do so.
the Court GRANTS Plaintiffs appeal from the administrative
decision of the Commissioner of Social Security and the case
is remanded to the Social Security Administration. The Clerk
of the Court is DIRECTED to enter judgment in favor of
Plaintiff and ...