Plaintiff is a 49 year old immigrant from Cuba with HS education, some training as a nursing assistant and past relevant work as a caretaker and event worker. The Plaintiff applied for SSI benefits alleging disability since January of 2005 based on limitations related to her stroke, hypertension, major depressive disorder, anxiety disorder, and multiple myeloma. The Plaintiff was able to read, write, and speak English at some point, but had difficulties communicating in English at the time of the SSI application because of the cognitive limitations she acquired after the stroke. The Plaintiff was not engaged in substantial gainful activity since the time of the SSI application in 2010.
After the SSA initial and reconsideration denial the Plaintiff timely filed her request for an administrative hearing. The ALJ denied the Plaintiff’s SSI application at step IV. The ALJ determined that the Plaintiff was unable to perform her past relevant work as a personal care aid (semiskilled, medium-duty job) because she retained RFC only for a reduced range of light work limited to simple routine, and repetitive tasks. The ALJ held, however, that the Plaintiff was able to perform her past job as an “event worker. “
The ALJ disregarded the opinions of the Plaintiff’s treating physicians as inconsistent both internally and as compared to the record as a whole. In assigning the Plaintiff’s RFC, the ALJ determined the Plaintiff’s statements regarding the persistence, severity, and limiting effects of her impairments were inconsistent with the medical evidence, because she (1) had not been hospitalized or required emergency-room treatment at any time relevant to the ALJ's decision, (2) had not reported any side effects from medication to her treating or examining sources, and (3) was independent in self-care. The ALJ observed that the Plaintiff was cooperative and interacted appropriately with her counsel, court staff, and the ALJ. The Plaintiff was able to follow the hearing “without perceptible difficulties and to provide meaningful testimony.”
The District Court affirmed the ALJ’s denial.
On appeal, the Circuit Court of Appeals for the 11th Circuit held that substantial evidence did not support (1) the ALJ's decision to accord little weight to the opinions of the Plaintiff’s treating physician and psychiatrist relative to those of the consulting sources; (2) the reasons underlying the ALJ's decision to discount the Plaintiff’s testimony about the persistence and severity of her symptoms; and (3) the ALJ's RFC determination. Moreover, the ALJ erred in considering the Plaintiff's “event-worker” job to be her past relevant work.
The Appeals Court reject the reasons given by the ALJ for crediting the opinions of the SSA consulting physicians over those of the Plaintiff’s treating physician and her psychiatrist.
The ALJ stated the treating physician's opinion about the Plaintiff’s limitations contradicted the treating physician’s own contemporaneous treatment notes. The Appeals Court found this statement conclusory, because the ALJ did not identify any specific contradictions.
The Appeals Court further found that the ALJ’s characterization of the treating physician’s opinion as inconsistent with the record as a whole was based on one discrete portion of the record. Contrary to the SSA regulations, the ALJ ignored the parts of the medical record that supported the treating physician’s opinion and failed to reconcile those parts with the opinions of the SSA consultants. The Appeals Court noted that the findings of the SSA consultant cited by the ALJ did not contradict the opinion of the Plaintiff’s treating physician. The SSA consultant concluded that (1) the Plaintiff had no impairment to her ambulation or dexterity; (2) she could tandem and heel-to-toe walk; (3) her joints were normal; and (4) she had 5/5 strength in her arms, and 4+/5 and 1+/5 strength in her lower extremities. The Court held that none of these conclusions directly contradicted the Plaintiff’s inability to lift 10 pounds or to walk or sit for more than an hour in a workday or any other limitations fond by her treating physician.
The ALJ accorded little weight to the Plaintiff’s treating psychiatrist’s opinion that she had little to no ability to perform most mental work-related functioning. According to the ALJ, the opinion was inconsistent with (1) the psychiatrist’s treatment notes, and (2) the Plaintiff's actual functioning. In explaining the first reason, the ALJ emphasized that the psychiatrist's treatment notes showed that the Plaintiff was cooperative, had good eye contact, and had no delusions or compulsions. The Appeals Court emphasized that “these findings, however, do not contradict the ultimate conclusion, concerning the Plaintiff’s inability to function in a work setting.”
In reviewing the Plaintiff’s functioning, the Appeals Court noted that the Plaintiff’s report about being independent in self-care, her ability to cook and clean her home on occasion, and oversee her daughter’s homework did not constitute substantial evidence in support of the ALJ’s decision to give little weight to the opinion of the treating psychiatrist. The Appeals Court affirmed the previously annunciated rule that the Plaintiff’s “ability to perform everyday activities for a short duration is not necessarily inconsistent with …her overall inability to function in a work setting.” Perez v. Comm'r of Soc. Sec., No. 14-14671, 2015 WL 5042654, at *11 (citing Lewis v Callahan, 125 F.3d 1436, 1441 (11th Cir.1997).
The Appeals Court also agreed with the Plaintiff’s argument that the ALJ erred when he considered her work as an event worker to be “past relevant work” within the meaning of the Social Security Act. The Plaintiff earned $421.75 in 2004 and $391.19 in 2005 in this position. The Plaintiff’s work could not be considered substantial gainful activity because her wages fell well below the applicable SGA threshold for the relevant time period ($810 per month for 2004 and $830 per month for 2005).