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Cooper v. Acting Commissioner of Social Security Administration

United States District Court, M.D. Florida, Jacksonville Division

March 27, 2017




         THIS CAUSE is before the Court on Plaintiff's appeal of an administrative decision denying her application for a period of disability and Disability Insurance Benefits. Plaintiff alleges she became disabled on November 30, 2011. (Tr. 22.) Plaintiff's claims were denied initially and on reconsideration. (Tr. 130-34, 142-46.) A hearing was held before the assigned Administrative Law Judge (“ALJ”) on January 10, 2014, at which Plaintiff was represented by an attorney. (Tr. 42-94.) The ALJ found Plaintiff not disabled from November 30, 2011, the alleged onset date, through March 15, 2014, the date of the decision. (Tr. 22-33.) Plaintiff is appealing the Commissioner's decision that she was not disabled from November 30, 2011 through March 15, 2014. Plaintiff has exhausted her available administrative remedies and the case is properly before the Court. The undersigned has reviewed the record, the briefs, and the applicable law. For the reasons stated herein, the Commissioner's decision is REVERSED AND REMANDED.

         I. Standard of Review

         The scope of this Court's review is limited to determining whether the Commissioner applied the correct legal standards, McRoberts v. Bowen, 841 F.2d 1077, 1080 (11th Cir. 1988), and whether the Commissioner's findings are supported by substantial evidence, Richardson v. Perales, 402 U.S. 389, 390 (1971). “Substantial evidence is more than a scintilla and is such relevant evidence as a reasonable person would accept as adequate to support a conclusion.” Crawford v. Comm'r of Soc. Sec., 363 F.3d 1155, 1158 (11th Cir. 2004). Where the Commissioner's decision is supported by substantial evidence, the district court will affirm, even if the reviewer would have reached a contrary result as finder of fact, and even if the reviewer finds that the evidence preponderates against the Commissioner's decision. Edwards v. Sullivan, 937 F.2d 580, 584 n.3 (11th Cir. 1991); Barnes v. Sullivan, 932 F.2d 1356, 1358 (11th Cir. 1991). The district court must view the evidence as a whole, taking into account evidence favorable as well as unfavorable to the decision. Foote v. Chater, 67 F.3d 1553, 1560 (11th Cir. 1995); accord Lowery v. Sullivan, 979 F.2d 835, 837 (11th Cir. 1992) (stating the court must scrutinize the entire record to determine the reasonableness of the Commissioner's factual findings).

         II. Discussion

         Plaintiff raises two general issues on appeal. Plaintiff argues that the ALJ erred in failing to develop the record despite evidentiary gaps and missing records from Plaintiff's primary care physician, Judella Haddad, M.D., and Plaintiff's treating providers for her mental health impairments, Drs. Lockey and Latteny. Plaintiff also contends that the Appeals Council failed to properly analyze the new evidence submitted by her. Specifically, Plaintiff submitted a clinic note dated January 5, 2015 (the “Clinic Note”), interpreting an April 4, 2014 echocardiogram and opining that Plaintiff is a New York Heart Association class III, denoting severe limitations. (Tr. 13-17.) Plaintiff also attempted to fax medical records from Drs. Haddad and Latteny to the Appeals Council, but they never made it into the record. (Tr. 12.)

         Defendant contends that Plaintiff failed to meet her burden of proving disability and that the ALJ did not err in failing to develop the record. Defendant also argues that the Appeals Council did not err in reviewing the new evidence because the Clinic Note was not chronologically relevant, as the Appeals Council determined, and because the alleged missing records were never faxed to the Appeals Council.

         A. The ALJ's Decision and Appeals Council Review

         The ALJ found that Plaintiff had severe impairments, including congestive heart failure, Chronic Obstructive Pulmonary Disease, osteoarthritis, hypertension, obesity, diabetes mellitus, and Gastroesophageal Reflux Disease. (Tr. 24.) However, the ALJ found that Plaintiff had non-severe impairments, including small singer's vocal cord nodule, Reinkes edema, 20/40 vision, affective disorder, and anxiety related disorders. (Id.) The ALJ discussed a May 2012 Psychological Evaluation Report from Allison Keiter, Psy.D. in assessing Plaintiff's mental impairments as non-severe. (Tr. 24-25, 524-28.) In the report, Dr. Keiter opined, inter alia, that Plaintiff can follow and understand simple directions and instructions, and is able to maintain concentration and attention, but may have occasional difficulties maintaining a regular schedule. (Tr. 25, 527.) In concluding that Plaintiff's mental impairments were non-severe, the ALJ afforded Dr. Keiter's opinions “no significant weight, ” explaining that the “examination records and the longitudinal treatment records do not corroborate the conclusion of occasional difficulties maintaining a regular schedule, ” and because Plaintiff “routinely denied experiencing any mental health symptoms, ” subsequent to the examination. (Tr. 25.) The ALJ determined that “claimant does not have an impairment or combination of impairments that meets or medically equals the severity of one of the listed impairments in 20 CFR Part 404, Subpart P, Appendix 1 (20 CFR 404.1520(d), 404.1525, 404.1526).” (Tr. 27.)

         The ALJ then determined that Plaintiff had the residual functional capacity (“RFC”) to perform light work with limitations. (Id.) As part of this determination, the ALJ discounted Plaintiff's credibility, noting that she received only minimal treatment for her alleged disabling impairments. (Tr. 31.) The ALJ afforded weight to one record medical opinion - the opinion of non-examining state agency medical consultant, David Guttman, M.D. (Id.) The ALJ afforded Dr. Guttman's opinions regarding Plaintiff's suggested limitations “great weight, ” explaining that the opinions are well supported by the record. (Id.)

         Continuing on with the evaluation, the ALJ determined that Plaintiff could perform her past relevant work as a sales agent, underwriter, and receptionist. (Tr. 32.) The ALJ ultimately concluded that Plaintiff was not disabled. (Id.)

         At the hearing before the ALJ, Plaintiff informed the ALJ that her file did not include recent treatment records from the doctors who treated her subsequent to her onset date, but prior to the ALJ's decision. (Tr. 63-68.) Plaintiff explained that she would have obtained the records prior to the hearing and brought them to the hearing if she was aware that her attorney did not have the records. (Tr. 68.)

         Plaintiff's attorney apparently did not undertake to represent Plaintiff on Appeal, and Plaintiff herself timely requested review of the decision on May 15, 2014 (Tr. 18.) Although the record is limited in this regard, it does appear that Plaintiff's attorney notified the agency on March 3, 2015 that certain records (presumably not in the record) were available. (Tr. 5 (addressing letter to Plaintiff's attorney and stating that “[i]n the request for review, you told us that evidence is available from Shan[d]s.”).) Nevertheless, Plaintiff, on her own, attempted to fax multiple records to the Appeals Council. (Tr. 12-17.) The records include a handwritten cover sheet submitted by Plaintiff, indicating that 19 pages were faxed to the Appeals Council. Plaintiff listed on the cover sheet undated records from Drs. Haddad and Latteny, which apparently were never received by the agency, as well as the Clinic Note, which was received by the Appeals Council. On May 11, 2015, the Appeals Council denied Plaintiff's request for review. (Tr. 1-4.) In the denial letter, the Appeals Council notified Plaintiff that it received the Clinic Note dated January 5, 2016, but found it not to be chronologically relevant.[2] (Tr. 2.)

         B. ...

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