Court: District Court, D. Massachusetts; September 26, 2014; Federal District Court
Plaintiff Harry Hagan, suffering from depression, anxiety, sleep disturbances, and fluid accumulation in the brain, seeks a review of the denial of his Social Security Disability (SSD) and Supplemental Security Income (SSI) applications. Hagan argues that the Administrative Law Judge (ALJ) mismanaged the evaluation of medical opinion evidence regarding his residual functional capacity (RFC) and incorrectly assessed his credibility. The Commissioner of the Social Security Administration has requested affirmation of the denial. The Court has denied the Commissioner’s motion and granted Hagan’s request for reversal and remand.
Hagan, aged 47 at the time of the ALJ's decision on September 23, 2011, has a background in carpentry and claims disability starting April 14, 2009. His medical history includes a seizure disorder diagnosed by neurologist Dr. Alan Bell, who noted findings from an EEG and MRI indicating epilepsy and chronic hydrocephalus. Hagan's mental health history reveals ongoing treatment for anxiety and depression. He has been prescribed various medications over the years, including Diazepam, Lexapro, and Effexor, with varying degrees of symptom management and some reported side effects, such as weight gain and sexual dysfunction. His Global Assessment of Functioning (GAF) scores have fluctuated between 54 and 58. Throughout his treatment, Hagan has reported improvements in his symptoms, although he continues to experience challenges such as insomnia and lack of ambition.
On June 17, 2011, Dr. Li completed a Psychiatric/Psychological Impairment Questionnaire, diagnosing Hagan with major depressive disorder and assigning a GAF score between 54 and 58. Dr. Li found Hagan markedly limited in several areas, such as remembering locations, understanding instructions, maintaining attention, and interacting with the public, while moderately limiting his ability to carry out simple instructions and respond to supervision. Hagan was noted to handle low stress levels.
Between July 2011 and July 2012, Hagan continued treatment with Dr. Li, whose diagnosis and GAF score for Hagan remained consistent, though his symptoms exhibited variability. Hagan reported fluctuating conditions, feeling slightly better on August 5, 2011, but experiencing ongoing anxiety and depression. Adjustments to his medication were made over time.
Additionally, a consultative examination by psychologist Richard Ober on June 18, 2010, revealed Hagan’s self-reported issues, including emotional difficulties and memory problems. Ober diagnosed Hagan with major depression and assigned a GAF score of 60, noting Hagan's cooperation and reasonable affect during the assessment. Hagan displayed capabilities in managing daily activities, using public transport, and maintaining concentration during the interview.
On June 24, 2010, Dr. S. Fischer conducted a psychiatric review, confirming Hagan's major depression diagnosis and identifying moderate limitations in social functioning and concentration, with mild limitations in daily activities. Dr. Fischer concluded that Hagan could manage simple and complex tasks in a work environment and adapt to routine stressors.
The ALJ's hearing included testimony from a vocational expert (VE) who evaluated a hypothetical individual with Hagan's age, education, and work history, but with specific non-exertional limitations. These limitations included an inability to provide or decipher written instructions, a restriction to simple tasks, challenges in dealing with co-workers, the need for low-to-average stress environments, and only casual contact with the public. The VE indicated that such an individual could potentially work as a cleaner, auto detailer, or merchandise maker, but would be unemployable if missing two or more workdays per month, as maintaining on-task performance of 90% is necessary for employment.
Hagan testified about his health issues, including fluid in his brain, depression, and joint pain. He described fluctuating energy levels, significant difficulty concentrating, low motivation, and poor memory, which affects his daily activities, including medication adherence. Hagan spends considerable time lying down due to depression and experiences pain when walking or standing. He can perform light cooking and minor household tasks but lacks computer skills. He requires breaks if employed and engages in limited social activities.
The legal framework for Hagan's claim for Social Security Disability (SSD) and Supplemental Security Income (SSI) requires him to demonstrate an inability to engage in substantial gainful activity due to a severe impairment lasting at least 12 months. The ALJ follows a five-step evaluation process that determines disability status, which includes assessing current work activity, the severity of impairments, meeting listed impairments, residual functional capacity to perform past work, and ability to do any other work. The application can be denied or granted at any step based on the findings.
Residual functional capacity (RFC) refers to the maximum ability of a claimant to perform work-related activities despite their limitations. A claimant's impairments and symptoms, including pain, can impose physical and mental restrictions affecting their employability. If a claimant can perform any job that exists in significant numbers within the national economy, they may adjust to other work. The burden of proof lies with the claimant for steps one through four of the evaluation process, while the Social Security Administration (SSA) must provide evidence of available jobs at step five.
The Court's review of an Administrative Law Judge (ALJ)'s decision is limited to instances of legal error or lack of substantial evidence supporting the ALJ's factual findings. Substantial evidence is defined as relevant evidence sufficient for a reasonable mind to accept as adequate to support a conclusion, meaning the ALJ's decision must be upheld even if alternative conclusions could be justified, as long as substantial evidence supports the decision.
In procedural history, Hagan applied for Social Security Disability (SSD) on May 13, 2009, and Supplemental Security Income (SSI) on January 5, 2010, citing a disability onset date of January 1, 2007. His claims were initially denied on November 19, 2009, and again upon reconsideration on June 24, 2010. After requesting an administrative hearing, Hagan amended his onset date to April 14, 2009, during a hearing held on August 16, 2011, by ALJ Paul S. Carter. The ALJ issued a decision on September 23, 2011, determining:
1. Hagan had not engaged in substantial gainful activity since April 14, 2009 (step one).
2. His impairments of depression, anxiety, and fluid on the brain were severe (step two).
3. He did not meet the statutory definition of a disability under the relevant listings (step three).
4. Hagan had the RFC to perform a full range of work at all exertional levels with specific non-exertional limitations, including the ability to understand signs but not provide written instructions, moderate effects of depression and anxiety on concentration and task management, and restrictions around coworker interactions (step four).
Although Hagan was unable to return to his past work as a carpenter, the ALJ concluded he could perform jobs available in significant numbers in the national economy, leading to a finding of "not disabled" under the Act (step five). The Appeals Council denied Hagan's request for review on December 20, 2012, rendering the ALJ's decision final and subject to review under 42 U.S.C. 405(g).
Hagan contends that the Administrative Law Judge (ALJ) improperly assigned minimal weight to the opinion of his treating psychiatrist, Dr. Li. A treating source is defined as a healthcare provider who has consistently treated a patient. Such an opinion can receive controlling weight when it is well-supported by clinical evidence and consistent with the overall case record. However, the ALJ is not required to automatically accept a treating physician's opinion and must consider several factors if the opinion does not receive controlling weight, including the length and nature of the treatment relationship, supporting evidence, consistency with the overall record, the source's specialization, and other relevant factors.
Dr. Li treated Hagan from January 2010 to July 2012, documenting at least twenty-one visits by the time he issued his opinion on June 17, 2011. The ALJ assigned “little weight” to Dr. Li’s assessment, citing inconsistencies with treatment records that showed Hagan’s improvement with medication. Specifically, Dr. Li noted varying degrees of limitations in Hagan's abilities, which the ALJ found inconsistent with records indicating moderate improvement. However, the court found that the ALJ erred in dismissing Dr. Li’s opinion, highlighting that Dr. Li had treated Hagan for about a year at the time of his opinion, focused on Hagan’s depression, and provided clinical findings that supported his assessment. Additionally, Dr. Li is a Board-certified psychiatrist, which further substantiates the need for greater weight to be assigned to his opinion. The ALJ’s rationale that Hagan’s condition was moderate and responsive to treatment was acknowledged, but the court determined that this did not adequately justify the minimal weight given to Dr. Li’s opinion.
Hagan's Global Assessment of Functioning (GAF) score improved from 54 to 58, indicating some progress, but he continued to experience recurrent symptoms of depression and anxiety despite ongoing treatment. By November 9, 2011, he reported significant anxiety, and by March 27, 2012, he exhibited low energy and low motivation, signs of major depression, after years of treatment. Dr. Li's observations aligned with those of neurologist Dr. Bell, but the Administrative Law Judge (ALJ) did not adequately justify the decision to assign little weight to Dr. Li’s opinion. Dr. Ober, a consulting psychiatrist, did not provide functional limitation opinions after only one examination of Hagan, while Dr. Fischer's findings were based solely on a review of records that did not include Dr. Li’s psychiatric treatment details at the time of his assessment. The court noted the variability in weight given to non-examining physicians' conclusions, especially regarding mental impairments, and concluded that the ALJ's reliance on Dr. Fischer, who had never met Hagan, was improper. Consequently, the court reversed or remanded the decision regarding Hagan’s case and denied the government's motion to affirm the Commissioner’s decision. It is also noted that GAF scores are no longer used in the latest DSM for assessing functioning due to their questionable reliability. Dr. Li's last examination of Hagan was on June 17, 2011, after which Hagan ceased treatment due to lack of insurance. Additionally, ischemic changes in cerebral small vessels may indicate a higher risk for stroke or dementia.
