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Kim v. Commissioner of Social Security Administration

United States District Court, D. South Carolina

July 7, 2017

INSUN KIM, Plaintiff,
v.
COMMISSIONER OF SOCIAL SECURITY ADMINISTRATION, Defendant.

          ORDER

          BRISTOW MARCHANT, UNITED STATES MAGISTRATE JUDGE

         Plaintiff files this pro se[1] Complaint pursuant to 42 U.S.C. § 405(g), seeking judicial review of the final decision of the Commissioner wherein she was denied disability benefits. The record reflects that Plaintiff applied for Disability Insurance Benefits (DIB)[2] and Supplemental Security Income (SSI)[3] on December 12, 2014 (protective filing date), alleging disability as of August 16, 2001 due to anxiety disorder, depression, and a back problem. (R.pp. 13, 219, 227, 249). Plaintiff's claims were denied both initially and upon reconsideration. Plaintiff then requested a hearing before an Administrative Law Judge (ALJ), [4] which was held on November 4, 2015. (R.pp. 29-84). The ALJ thereafter denied Plaintiff's claims in a decision issued December 14, 2015. (R.pp. 13-23). The Appeals Council denied Plaintiff's request for a review of the ALJ's decision, thereby making the determination of the ALJ the final decision of the Commissioner. (R.pp. 1-5).

         The Plaintiff then filed this action in United States District Court. Plaintiff appears to assert that there is not substantial evidence to support the ALJ's decision, and that she should therefore be awarded both DIB and SSI benefits, as well as $365, 000, 000.[5] See Complaint, ECF No. 1 at 15; Plaintiff's Brief, ECF No. 32 at 6. The Commissioner contends that the decision to deny benefits is supported by substantial evidence, and that Plaintiff was properly found not to be disabled.

         Scope of review

         Under 42 U.S.C. § 405(g), the Court's scope of review is limited to (1) whether the Commissioner's decision is supported by substantial evidence, and (2) whether the ultimate conclusions reached by the Commissioner are legally correct under controlling law. Hays v. Sullivan, 907 F.2d 1453, 1456 (4th Cir. 1990); Richardson v. Califano, 574 F.2d 802, 803 (4th Cir. 1978); Myers v. Califano, 611 F.2d 980, 982-983 (4th Cir. 1980). If the record contains substantial evidence to support the Commissioner's decision, it is the court's duty to affirm the decision. Substantial evidence has been defined as:

evidence which a reasoning mind would accept as sufficient to support a particular conclusion. It consists of more than a mere scintilla of evidence but may be somewhat less than a preponderance. If there is evidence to justify refusal to direct a verdict were the case before a jury, then there is “substantial evidence.” [emphasis added].

Hays, 907 F.2d at 1456 (citing Laws v. Celebrezze, 368 F.2d 640');">368 F.2d 640 (4th Cir. 1966)); see also Hepp v. Astrue, 511 F.3d 798, 806 (8th Cir. 2008)[Noting that the substantial evidence standard is even “less demanding than the preponderance of the evidence standard”].

         The Court lacks the authority to substitute its own judgment for that of the Commissioner. Laws, 368 F.2d at 642. “[T]he language of [405(g)] precludes a de novo judicial proceeding and requires that the court uphold the [Commissioner's] decision even should the court disagree with such decision as long as it is supported by substantial evidence.” Blalock v. Richardson, 483 F.2d 773, 775 (4th Cir. 1972).

         Medical History

         Although Plaintiff alleges disability since 2001, the treatment records provided are only from 2014 forward. According to these records, Dr. Ruth S. DeHaven of St. Andrews Medical began treating Plaintiff in 2013. (See R.p. 340). On January 6, 2014, Plaintiff requested medication changes, at which time Dr. DeHaven noted that Plaintiff was generally healthy, had no change in strength or exercise tolerance, no headaches, no pain in her muscles or joints, no limitation of her range of motion, and no paresthesias or numbness. Dr. DeHaven assessed Plaintiff with depression and anxiety and prescribed trials of Effexor, Xanax, and Lasix. (R.p. 330).

         On October 6, 2014, Plaintiff reported to Dr. DeHaven that she had been in a car accident the previous month, [5] was afraid to drive fast or in congested areas, had no pain at the time of the accident, but at the time of the appointment felt “like everything hurts.” Examination revealed that Plaintiff was in no acute distress, her back had no tenderness, and her extremities had free range of motion with no deformities. Dr. DeHaven assessed weight gain, motor vehicle accident, and “panic.” (R.p. 329).

         On December 5, 2014, Plaintiff reported that she did “nothing but lie around at home.” She requested x-rays of her entire spine and to see a psychiatrist for her nerves. Dr. DeHaven assessed Plaintiff with anxiety, depression, and back pain by history, gave Plaintiff a slip to get x-rays taken, and planned to find a psychiatrist who would take Plaintiff's insurance. (R.p. 354). That same day, x-rays were taken of Plaintiff's cervical, thoracic, and lumbar spines. Cervical spine x-rays showed no fracture, subluxation, or significant disc space narrowing, and no prevertebral soft tissue swelling. (R.p. 336). X-rays of Plaintiff's thoracic spine showed mild curvature of her lower thoracic spine, but no fracture or abnormal alignment. (R.p. 334). Lumbosacral x-rays showed no fracture, subluxation, or significant disc space narrowing; no pars defects were present, and her SI joints appeared within normal limits. (R.p. 335).

         On January 14, 2015, Dr. DeHaven completed an RFC Functional Capacity Questionnaire in which she opined that Plaintiff could sit for sixty minutes at a time; stand/walk for forty-five minutes at a time; sit for a total of eight hours in an eight-hour workday; stand/walk for a total of eight hours in an eight-hour day; frequently lift up to twenty pounds; occasionally lift up to fifty pounds; and work an eight-hour day, five days a week, on a sustained basis. Dr. DeHaven also opined that Plaintiff's symptoms associated with her impairments would never be severe enough to interfere with the attention and concentration required to perform simple work-related tasks; that Plaintiff would not need to take unscheduled breaks during an eight-hour workday; and that Plaintiff could walk four city blocks without rest or significant pain. (R.pp. 338-340).

         On January 27, 2015, Dr. DeHaven noted that Plaintiff was generally healthy, with no change in strength or exercise tolerance. Dr. DeHaven assessed borderline thyroid function and borderline hypertension, and planned to check Plaintiff's blood work and write prescriptions after the lab work was returned. (R.p. 353). Plaintiff also underwent physical therapy at Private Therapy Services in January 2015. (R.pp. 359-367).

         Plaintiff sought treatment at Fetter Health Care Downtown on February 9, 2015, for complaints of body pain and fatigue. Although Plaintiff said she was there to have a disability form completed, there is no evidence in the record that such a form was completed. (R.p. 373). Thereafter, on March 6, 2015, psychologist Dr. Cashton B. Spivey performed a consultative evaluation. Plaintiff stated that she took Wellbutrin, BuSpar, Xanax, and Effexor; had a history of a head injury with loss of consciousness (for which she stated no CT scan or x-rays were performed); had headaches; did not have memory deficits; and had not been hospitalized in a psychiatric facility or participated in outpatient psychological services for her mental impairments. Plaintiff complained of dysphoria, low energy level, attention/concentration problems, crying spells, generalized anxiety, ruminations, nightmares, intrusive thoughts, symbolic recollections of a traumatic event, and exaggerated startle response. As to activities of daily living, Plaintiff lived with her thirteen-year old daughter and her daughter's father, bathed and dressed independently, used a microwave oven, operated an automobile on an infrequent basis, was able to read a newspaper, performed household duties and chores with the assistance of her daughter or her daughter's father, performed grocery shopping, and drove her daughter to school in the morning and home in the afternoon.

         Dr. Spivey noted that Plaintiff was appropriately dressed and groomed, and was cooperative and compliant during the evaluation. Plaintiff scored 27 out of 30 points on a mini- mental state examination, which fell within normal limits; she was oriented times three; and she was able to perform serial 7s. Dr. Spivey noted that Plaintiff was only able to recall 1 of 3 objects at 5 minutes, suggesting mild impairment of her short-term auditory memory functioning, and estimated that Plaintiff's general intelligence score would fall in the low average range. Plaintiff's energy appeared to be satisfactory, her attention ranged from fair to poor, and her concentration was fair. Dr. Spivey diagnosed unspecified depressive disorder, unspecified anxiety disorder, and PTSD, and opined that Plaintiff would be capable of managing funds independently and accurately, would be capable of performing simple and complex tasks in the workplace, and did not appear to have any significant factors that would preclude her ability to relate well to others in the workplace. (R.pp. 368-371).

         Plaintiff returned to Dr. DeHaven on May 26, 2015, at which time she requested Oxycontin for pain “everywhere”. She wanted to have her teeth pulled and to get implants from a local dentist, complained she had arthritis and could hardly get out of bed, and stated she did not like the physical therapy she was undergoing. Plaintiff reported she had stopped her thyroid medications because they caused her to gain weight, and although she had been taking Effexor and Wellbutrin, she was out of her medications. Plaintiff reported no headaches and no neurologic weakness, and Dr. DeHaven noted that Plaintiff was in no apparent distress, her teeth were in poor repair with cavities at the gingival level and below, she had no tenderness of her back, and she had full range of motion in her extremities. Dr. DeHaven assessed dental cares, depression, joint pains, and ...


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