Bernola v. Commissioner of Social Security

Citations: 127 F. Supp. 3d 857; 2015 U.S. Dist. LEXIS 119921; 2015 WL 5254997Docket: Case No. 3:14CV1405

Court: District Court, N.D. Ohio; September 9, 2015; Federal District Court

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Kasey A. Bernola appeals the Commissioner’s denial of her applications for Social Security Disability (SSD) and Supplemental Security Income (SSI) benefits, claiming inability to work since August 2008 due to multiple disabling conditions, including mental health disorders and physical issues. The Social Security Administration (SSA) initially determined Bernola lacked sufficient work history for SSD benefits, a decision she did not appeal. Her SSI application was denied both initially and upon reconsideration. Following a request for a hearing, an Administrative Law Judge (ALJ) conducted an evaluation using a five-step sequential analysis to determine disability status. This analysis requires the claimant to prove they haven't engaged in substantial gainful activity, suffer from a severe impairment, and either meet or equal listed impairments or demonstrate inability to perform past or other work based on residual functional capacity (RFC). The burden of proof lies with the claimant for the first four steps, shifting to the Commissioner at the fifth step.

The ALJ considered two RFC reports from Bernola's treating physician, who indicated significant limitations in multiple categories and assessed Bernola as "unemployable." The physician diagnosed her with various mental health issues and described her prognosis as "guarded," concluding she would be unable to perform any job due to her combined physical and mental limitations. The court adopted the Magistrate Judge’s Report and Recommendation in full, affirming the ALJ's decision.

Bernola was determined by a physician to be incapable of securing and maintaining full-time employment in a competitive environment. However, the Administrative Law Judge (ALJ) found that while Bernola had multiple severe physical and mental impairments, these did not meet or medically equal any listed impairments per the applicable regulations. The ALJ concluded that Bernola had the residual functional capacity to perform light work and identified jobs available in significant numbers that she could undertake, leading to the determination that she had not been disabled under the Social Security Administration (SSA) guidelines since her application date. The SSA Appeals Council denied Bernola’s request for review, making the ALJ’s decision final. Bernola now seeks judicial review under 42 U.S.C. 405(g) and 1383(c), raising two legal issues: whether the ALJ erred by not giving sufficient weight to the primary health source and whether the evaluation of the treating mental health source was procedurally deficient. 

The standard of review for the Magistrate Judge's Report and Recommendation (R. R.) involves a de novo determination of the contested portions, with the requirement to assess whether substantial evidence supports the ALJ’s findings and whether proper legal standards were applied. Substantial evidence is defined as more than a scintilla but less than a preponderance, sufficient for a reasonable mind to accept as adequate support for a conclusion. In reviewing the record, the overall context must be considered. Bernola objects to the Magistrate Judge’s findings, arguing that the ALJ's decision violated the "treating physician" rule and that procedural errors misrepresented her capabilities. Under this rule, the ALJ is generally required to give more weight to treating physicians' opinions, provided they are well-supported by objective medical evidence and consistent with other substantial evidence.

An ALJ must evaluate the weight of a treating physician's opinion, even if it does not receive controlling weight, by applying specific regulatory factors and providing 'good reasons' for any discounting of that opinion. These reasons must be supported by the record and clearly articulated for future reviewers. Failure to adequately explain the weight assigned may warrant remand, even if substantial evidence supports the Commissioner's decision. In this case, Bernola claims the ALJ inadequately weighed her treating physician's records, which document her fluctuating symptoms and functionality. She argues the ALJ focused excessively on short periods of stability due to high medication dosages, overlooking the return of severe symptoms at lower doses. Conversely, the Commissioner asserts that the ALJ reasonably assessed the medical evidence, citing inconsistencies between the physician's opinions and objective test results, Bernola's daily activities, and the physician’s own notes. The Commissioner contends that Bernola's disagreement with the ALJ's evaluation of the evidence does not justify reversal. The ALJ did consider Bernola's comprehensive treatment history from January 2010 through August 2012 and found substantial evidence indicating her condition had stabilized, including improvements noted by her treating physician, such as reduced hallucinations and tolerable medication effects. The physician's assessment that Bernola would be 'off-task' no more than five percent of the workday was deemed consistent with the overall evidence.

The ALJ assigned "great weight" to a treating physician's statement regarding Bernola's capabilities but found subsequent statements inconsistent with earlier assessments and the physician's own treatment notes. Bernola contends that both the ALJ and the R. R overvalued this statement and argues procedural errors regarding the ALJ's adherence to Social Security Rulings (SSR) 96-2p, 96-6p, and 20 C.F.R. 416.927, claiming a lack of substantial evidence to support the ALJ's conclusions. The ALJ evaluated medical opinions using relevant factors and determined that non-examining sources could be given weight if they had access to a comprehensive record. The ALJ found the opinions consistent with Bernola's treatment history, and Bernola's disagreements with the ALJ's evaluations do not constitute valid grounds for reversal. Ultimately, the ALJ's determination, supported by substantial evidence and lawful application of the regulations, is affirmed.

Bernola's objections to the Magistrate Judge's Report and Recommendation have been overruled, and the Report is adopted as the court's order. Previously, Bernola applied for benefits in 2008 without success. She has received treatment for mental health issues both before and after her application, with her condition's severity fluctuating due to medication adjustments by her physician. The Report outlines specific Residual Functional Capacity (RFC) categories that assess her abilities, such as carrying out detailed instructions and interacting appropriately with coworkers. Bernola's argument that only post-application medical records should be considered is rejected, emphasizing that she cannot selectively exclude parts of her medical history. The regulations state that all relevant evidence, including complete medical records, must be considered in disability claims.