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Ghaul v. Berryhill

United States District Court, W.D. Virginia, Roanoke Division

August 9, 2017

CAROL K. GHAUL Plaintiff,
NANCY A. BERRYHILL, Acting Commissioner of Social Security Defendant.


          Hon. Glen E. Conrad United States District Judge

         The plaintiff, Carol K. Ghaul, filed this action challenging certain provisions of the final decision of the Commissioner of Social Security, denying her application for disability insurance benefits ("DIB") and establishing a period of disability for purposes of her application for supplemental security income benefits ("SSI") pursuant to the Social Security Act ("the Act"), as amended, 42 U.S.C. § 401 et seq., and 42 U.S.C. § 1381 et seq., respectively. Stated succinctly, plaintiff challenges the disability onset date established by the Commissioner. For the reasons that follow, the court will affirm the Commissioner's final decision.

         Standard of Review

         The Social Security Administration is authorized to award DIB and SSI benefits to persons who are deemed to be "disabled" from all forms of substantial gainful employment. Barnhart v. Thomas, 540 U.S. 20, 21 (2003). A claimant is considered "disabled, " and thus, potentially eligible to receive DIB and/or SSI benefits, if her "physical or mental impairment or impairments are of such severity that [she] is not only unable to do [her] previous work but cannot, considering [her] age, education, and work experience, engage in any other kind of substantial gainful work which exists in the national economy." 42 U.S.C. §§ 423(d)(2)(A), 1382c(a)(3)(B).

         Upon review, this court must affirm the disability determination of an Administrative Law Judge ("ALJ") if it is supported by substantial evidence and the ALJ applied the correct legal standards. Lewis v. Berryhill 858 F.3d 858, 865 (4th Cir. 2017). Stated briefly, substantial evidence has been characterized as such relevant evidence, considering the record as a whole, as might be found adequate to support a conclusion by a reasonable mind. Richardson v. Perales, 402 U.S. 389, 401 (1971).

         To determine whether a claimant is disabled for both DIB and SSI purposes, the ALJ applies a five-step sequential evaluation process, which assesses "whether the claimant: (1) is working; (2) has a severe impairment; (3) has an impairment that meets or equals the requirements of a listed impairment; (4) can return to [her] past relevant work; and if not, (5) whether [she] can perform other work." Nelson v. Berryhill No. 7:15-cv-573, 2017 U.S. Dist. LEXIS 27840, at *3 n.5 (W.D. Va. Feb. 28, 2017) (citing Johnson v. Barnhart 434 F.3d 650, 654 n.l (4th Cir. 2005) (per curiam)); see also 20 C.F.R. §§ 1520(a)(4); 416.920(a)(4). "The claimant bears the burden to make the requisite showing during the first four steps." Lewis, 858 F.3d at 861 (internal citation omitted). Notably, "[i]f the claimant fails to demonstrate she has a disability that meets or medically equals a listed impairment at step three, the ALJ must assess the claimant's residual functional capacity ('RFC') before proceeding to step four." Id. If the claimant meets her burden under the first four steps, then the burden shifts to the Commissioner at step five. Id. If the claimant is determined to be disabled, the ALJ must then establish the onset date of disability. Social Security Ruling ("SSR") 83-20, 1983 SSR LEXIS 25 at *2.

         Ultimately, the crucial factual determination is whether the claimant is disabled from all forms of substantial gainful employment. See 42 U.S.C. § 423(d)(2). There are four elements of proof that must be considered in making such a determination. These elements are summarized as follows: objective medical facts and clinical findings; the opinions and conclusions of treating physicians; subjective evidence of physical manifestations of impairments, as described through the claimant's testimony; and the claimant's education, vocational history, residual skills, and age. Vitek v. Finch, 438 F.2d 1157, 1159-60 (4th Cir. 1971); Underwood v. Ribicoff. 298 F.2d 850, 851 (4th Cir. 1962). Accordingly, when assessing whether substantial evidence supports a disability determination, the reviewing court "must consider whether the ALJ analyzed all the relevant evidence and whether the ALJ sufficiently explained his findings and rationale in crediting the evidence." Turner v. Astrue. No. 2:08cv0006, 2008 U.S. Dist. LEXIS 88453, at *39-40 (W.D. Va. Oct. 21, 2008) (citing Sterling Smokeless Coal Co. v. Akers. 131 F.3d 438, 439-40 (4th Cir. 1997)).

         Finally, the court emphasizes that the ALJ is uniquely tasked with resolving discrepancies in the record and making credibility determinations. See Felton-Miller v. Astrue, 459 Fed.App'x 226, 228 (4th Cir. 2011). Therefore, even when "conflicting evidence allows reasonable minds to differ, " this court must give great deference to the ALJ's assessment of recorded discrepancies and the credibility of the claimant's allegations as long as the ALJ's determination is supported somewhere in the record. See id (internal quotation marks omitted).

         Background & Procedural History

         Ms. Ghaul was born on December 24, 1967. (Tr. 64.) After earning her GED, she worked as a roof truss builder, saw operator, and pin drafter machine operator. (Tr. 73.) Aside from two temporary positions that each lasted about a month, Ms. Ghaul has remained unemployed since her employer's company shut down in 2008. (See Tr. 20, 47-48.) Ms. Ghaul filed for DIB on August 15, 2013 (Tr. 211), and SSI on September 6, 2013 (Tr. 213). In both applications, Ms. Ghaul alleged that she became disabled beginning February 10, 2012, due to pain in her neck, back, knees, and feet; arthritis in her back; depression; anxiety; and past suicide attempts. (Tr. 64, 88.) As to her application for DIB, the record reveals that Ms. Ghaul met the insured status requirements of the Act through March 31, .2015. See 42 U.S.C. § 423(a)(1)(A), (c)(1); 20 C.F.R. §§ 404.101(a), 404.131(a). Accordingly, Ms. Ghaul is only eligible for DIB if she has established that she became disabled from all forms of substantial gainful employment on or before March 31, 2015.

         Ms. Ghaul's applications were both denied initially and upon reconsideration. (Tr. 13.) Thereafter, Ms. Ghaul requested a hearing before an ALJ, which was subsequently held on October 7, 2015. (Tr. 13.) On December 15, 2015, the ALJ issued a partially favorable opinion concluding that Ms. Ghaul was able to perform a limited range of light work until a motorcycle accident rendered her disabled on August 25, 2015. (Tr. 30.) Consequently, Ms. Ghaul was found to be disabled for purposes of her claim for SSI benefits, beginning on August 25, 2015. (See Tr. 31.) Additionally, based on the conclusion that Ms. Ghaul failed to prove that she became disabled from all forms of substantial gainful employment on or before March 31, 2015, the ALJ completely denied Ms. Ghaul's DIB claim. (See Tr. 31.) The ALJ's partially favorable opinion was subsequently adopted as the final decision of the Commissioner by the Social Security Administration's Appeals Council. Having exhausted all available administrative remedies, Ms. Ghaul appeals to this court pursuant to 42 U.S.C. § 405(g).


         Stated succinctly, the ALJ found that Ms. Ghaul did not become disabled until experiencing physical injuries in a motorcycle crash, which occurred on August 25, 2015. The ALJ stated as follows:

In reaching this conclusion, I find that beginning August 25, 2015, [Ms. Ghaul's] allegations regarding her symptoms and limitations are generally credible. On this date, [Ghaul] was involved in a motorcycle crash as a passenger. She presented to the emergency room for complaints [of] pain. Imaging confirmed fractures in the right forearm, wrist, and ankle, as well as [factures in] several lumbar discs and the right side of the pelvis. [Ghaul] required multiple surgeries and was hospitalized until September 2, 2015. [Ghaul] was then sent for inpatient rehabilitation. When discharged on September 12, 2015, it was noted that though stable, [Ghaul] continued to experience posttraumatic and postoperative pain. [Ghaul] has continued to follow up with her orthopedist. While signs of healing have been noted, [Ms. Ghaul's] current complaints of pain and the need to rest are supported by the severe polytraumas incurred in the motorcycle accident. Given the nature of her injuries, it is likely that these limitations would continue for at least a year.

(Tr. 28.)

         Sequential Disability Evaluation

         The court believes that in determining that Ms. Ghaul was not disabled prior to August 25, 2015, the ALJ properly applied the sequential disability evaluation. With regard to the first step of the sequential evaluation process, the ALJ found that Ms. Ghaul has not engaged in substantial gainful activity since her alleged onset date of February 10, 2012. (Tr. 15.) At the second step, the ALJ decided that prior to the established onset date of August 25, 2015, Ms. Ghaul "had the following severe impairments: degenerative disc disease of the cervical and lumbar spines and medical meniscus tear status post repair." (Tr. 16.) Additionally, the ALJ classified Ms. Ghaul's "medically determinable mental impairments of depression and substance addiction"[1] as non-severe. (Tr. 16.) With regard to the third step, since her alleged onset date of February 10, 2012, none of Ms. Ghaul's impairments or a combination thereof met or was the medical equivalent of one of the listed impairments. (Tr. 16.) Before proceeding to the next step, the ALJ concluded that, prior to the established onset date, Ms. Ghaul had the RFC to perform light work. (See Tr. 18.) At the fourth step, the ALJ found that Ms. Ghaul could perform her past relevant work as a roof truss machine operator prior to the established onset date. (Tr. 28.) Since Ms. Ghaul was capable of performing her past relevant work, the ALJ concluded that Ms. Ghaul was not disabled prior to August 25, 2015.[2] (Tr. 29.) Accordingly, as she was unable to prove that she became disabled from all forms of substantial gainful employment on or before March 31, 2015 (i.e., the date she last enjoyed her requisite insured status), the ALJ denied Ms. GhauFs DIB claim. (See Tr. 31.) The ALJ found that Ms. Ghaul was not entitled to a period of disability for purposes of her SSI claim until August 25, 2015.

         Amongst the issues before the court, Ms. Ghaul contests the ALJ's step two and RFC determinations. Regarding the ALJ's step two analysis, Ms. Ghaul argues that the ALJ erred in classifying her depression as non-severe. Ms. Ghaul further contends that the ALJ's RFC is unsupported by substantial evidence because the ALJ erroneously failed to conduct a comprehensive function-by-function analysis and properly assess the credibility of Ms. Ghaul's subjective evidence. The court addresses these arguments in turn and concludes that the ALJ's findings are supported by substantial evidence in the record.

         Substantial evidence supports classifying Ms. GhauFs depression as non-severe

         Ms. Ghaul first contests the ALJ's finding that her depression was non-severe. Before reviewing the ALJ's step two analysis, however, the court first highlights that the record conspicuously omits evidence showing that Ms. Ghaul received any meaningful and continuous psychological treatment. More specifically, the medical records before the court only reference Ms. Ghaul's psychological treatment in three instances, including her receipt of "mental health support services" from The Phoenix Center (Tr. at 268; see also Tr. 24, 804, 816-27); Ms. Ghaul's weeklong hospitalization, which occurred subsequent to her debatable suicide attempt on March 27, 2012 (see Tr. 20-21, 327-369, 417-41); and Ms. Ghaul's four office visits to the Center for Emotional Care between July 19-October 30, 2013 (see Tr. 23-24, 785-97). As these instances are relevant to the ALJ's classification of Ms. Ghaul's depression as non-severe, the following summarizes the applicable medical records.

         First, with regard to the "mental health support services" that Ms. Ghaul received from The Phoenix Center, the ALJ noted: "[i]n a letter dated, November 3, 2013, Drs. Rochelle Potter and [Ashley] Callahan stated that [Ghaul] began receiving treatment at The Phoenix Center since December 26, 2012; however, no treatment notes were provided. An individual treatment plan from December 26, 2013, was later provide[d]. Again, however, no mental status examinations were included." (Tr. 24 (internal citations omitted).) Since the record excludes documentation of the treatment she received from The Phoenix Center, neither the ALJ nor this court could assess Ms. Ghaul's alleged treatment with this facility. However, based on Ms. Ghaul's response in her Disability Report Appeal Form, dated January 27, 2014 (see Tr. 267-72), it is unclear whether The Phoenix Center actually provided psychological treatment. Ms. Ghaul stated that she "receive[d] mental health support services" from The Phoenix Center, but she described these services to include coordinating her medical care, transporting her to her appointments, and "get[ting] [her] out of [her] house." (Tr. 269, 287.)

         With regard to her weeklong hospitalization, the court believes that the ALJ justifiably questioned the events leading up to Ms. Ghaul's hospitalization. When she applied for DIB and SSI benefits, Ms. Ghaul claimed that she attempted to commit suicide three times. One of those attempts allegedly resulted in her weeklong hospitalization, beginning March 27, 2012. (See Tr. 21, 251.) However, the ALJ recognized that while Ms. Ghaul's hospital records contain some conflicting evidence (see, e.g., Tr. 21, 349-50, 439), most of her hospital physicians documented that Ms. Ghaul adamantly denied ever attempting to commit suicide (see, e.g., Tr. 21, 352, 354-55, 366, 369, 417-18, 420, 423, 431, 438). More specifically, Ms. Ghaul's weeklong hospitalization initiated on March 27, 2012, when she was found unresponsive and lying next to prescription bottles. (See Tr. 417.) Ms. Ghaul justified her condition to one of her treating physicians by explaining that she took "her typical dose of Lortab and Flexeril, but she had been drinking as well and she does not think that she made a suicide attempt." (Tr. 417.) Her hospital records also evidenced that Ms. Ghaul was "found to be positive for cocaine and benzodiazepenes in the [Emergency Room]" (Tr. 338); that Ms. Ghaul claimed that she only "felt depressed 'a little bit'" (Tr. 21, 417, 420); and that Ms. Ghaul demanded to be discharged, refused patient care, and pushed a hospital staffer after she was not allowed to go into the hospital waiting room (see Tr. 21, 350).

         Finally, given the limited record before the court, it appears that Ms. Ghaul received her most significant and continuous psychological treatment when she visited the Center for Emotional Care four times between July 19-October 30, 2013. (See Tr. 23-24, 785-97.) Although the Center for Emotional Care listed Ms. Ghaul's diagnosis as "major depressive disorder, " her treatment provider, Molly B. Sharp, P.A., noted that throughout her four office visits, Ms. Ghaul was not suicidal or homicidal and had no reports of hallucinations or delusions. (See Tr. 786, 789, 793.) Rather, during each visit, Ms. Sharp noted that Ms. Ghaul had fair judgment, good attention, and . concentration; she was cooperative, alert, and thinking coherently and in a goal-oriented manner; and Ms. Ghaul's recent and remote memory was intact. (See Tr. 786, 789-90, 793, 796.) Additionally, Ms. Ghaul testified on October 7, 2015, that she believed that the limited counseling therapy she received was helpful (see Tr. 57), and she was on a waiting list to receive further mental health treatment and medication (see Tr. 20, 46).

         With Ms. Ghaul's above-mentioned psychological treatment in mind, the court turns to the ALJ's step two analysis to assess whether substantial evidence supports the ALJ's classification of Ms. Ghaul's depression as non-severe. The regulations state that an impairment "is not severe if it does not significantly limit [the claimant's] physical or mental ability to do basic work activities." 20 C.F.R. § 404.1521(a). With regard to the claimant's mental functioning, "basic work activities" include the claimant's capacity to "understand, carr[y] out, and remember[] simple instructions; us[e] judgment; respond[] appropriately to supervision, co-workers and usual work situations; and deal[] with changes in a routine work setting." Id. ยง 404.152l(b)(2)-(6). Although "[t]his is not a difficult hurdle for the applicant to clear, " the court "must affirm the ALJ's severity finding if she applied the correct legal ...

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