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Daniels v. Berryhill

United States District Court, D. South Carolina

July 1, 2019

James Phillip Daniels, Plaintiff,
v.
Nancy Berryhill, Acting Commissioner of Social Security, Defendant.

          ORDER

          Richard Mark Gergel, United States District Judge

         Plaintiff has brought this action pursuant to 42 U.S.C. § 405(g) seeking judicial review of the final decision of the Commissioner of Social Security denying his application for child insurance benefits based upon disability. In accordance with 28 U.S.C. § 636(b) and Local Civil Rule 73.02 DSC, this matter was referred to a United States Magistrate Judge for pre-trial handling. The Magistrate Judge issued a Report and Recommendation ("R & R") on May 31, 2019 recommending that the Court affirm the decision of the Commissioner. (Dkt. No. 15). Plaintiff filed objections to the R & R, arguing that the opinions of Plaintiff s treating physicians were not given appropriate weight. (Dkt. No. 17). As set forth more fully below, the Court reverses the decision of the Commissioner and remands this matter to the agency for further action consistent with this Order.

         Legal Standard

         The Magistrate Judge makes only a recommendation to this Court. The recommendation has no presumptive weight, and the responsibility to make a final determination remains with the Court. Mathews v. Weber, 423 U.S. 261 (1976). The Court is charged with making a de novo determination of those portions of the Report and Recommendation to which specific objection is made. The Court may accept, reject, or modify, in whole or in part, the recommendation of the Magistrate Judge. 28 U.S.C. § 636(b)(1).

         The role of the federal judiciary in the administrative scheme established by the Social Security Act is a limited one. The Act provides that the "findings of the Commissioner of Social Security as to any fact, if supported by substantial evidence, shall be conclusive." 42 U.S.C. § 405(g). "Substantial evidence has been defined innumerable times as more than a scintilla, but less than preponderance." Thomas v. Celebrezze, 331 F.2d 541, 543 (4th Cir. 1964). This standard precludes de novo review of the factual circumstances that substitutes the Court's findings of fact for those of the Commissioner. Vitek v. Finch, 438 F.2d 1157 (4th Cir. 1971).

         Although the federal court's review role is a limited one, "it does not follow, however, that the findings of the administrative agency are to be mechanically accepted. The statutorily granted right of review contemplates more than an uncritical rubber stamping of the administrative action." Flack v. Cohen, 413 F.2d 278, 279 (4th Cir. 1969). Further, the Commissioner's findings of fact are not binding if they were based upon the application of an improper legal standard. Coffman v. Bowen, 829 F.2d 514, 519 (4th Cir. 1987).

         Under the regulations of the Social Security Administration, the Commissioner is obligated to consider all medical evidence and the opinions of medical sources, including treating physicians. 20 C.F.R § 404.1545. The regulation, known as the "Treating Physician Rule," imposes a duty on the Commissioner to "evaluate every medical opinion we receive." Id. § 404.1527(c). The Commissioner "[g]enerally . . . give[s] more weight to opinions from . . . treating sources" based on the view that "these sources are likely to be the medical professionals most able to provide a detailed, longitudinal picture of [the claimant's] medical impairment(s) and may bring a unique perspective to the medical evidence that cannot be obtained from objective medical findings alone or from reports of individual examinations, such as consultative examinations or brief hospitalizations." Id. § 404.1527(c)(2). Further, the Commissioner "[g]enerally .. . give[s] more weight to the opinion of a source who has examined [the claimant] than to the opinion of a source who has not examined [the claimant]." Id. § 404.1527(c)(1).

         Under some circumstances, the opinions of the treating physicians are to be accorded controlling weight. Even where the opinions of the treating physicians of the claimant are not accorded controlling weight, the Commissioner is obligated to weigh those opinions in light of a broad range of specifically identified factors, including the examining relationship, the nature and extent of the treatment relationship, supportability of the opinions in the medical record, consistency, and whether the treating physician is a specialist. Id. §§ 4O4.l527(c)(1)-(5). The Commissioner is obligated to weigh the findings and opinions of treating physicians and to give "good reasons" in the written decision for the weight given to a treating source's opinions. SSR 96-2P, 61 Fed. Reg. 34490, 34492 (July 2, 1996).

         The opinions of non-examining sources and state agency medical consultants must be weighed under the same standards of the Treating Physician Rule, including the source's "medical specialty and expertise ..., the supporting evidence in the case record, supporting explanations ... and other factors relevant to the weighing of opinions." Id. §§ 404.1527(e)(2)(ii). The Commissioner further pledges that the opinions of non-examining sources will be evaluated on "the degree to which these opinions consider all the pertinent evidence .. ., including the opinions of treating and other examining sources." Id. §§ 404.1527(c)(3).[1]

         Factual Background

         Plaintiff, born on October 27, 1992, applied for child insurance benefits based upon a disability arising from his diagnosis of schizophrenia and claimed an onset date of October 27, 2010. Plaintiff has been treated by Dr. McLeod Gwynette, a board certified Child and Adolescent Psychiatrist and director of the residency training program at the Medical University of South Carolina, who began his treatment of the claimant in December 2009. He continuously provided psychiatric care for Plaintiff over the ensuing seven years, and personally had at least two dozen office visits with the claimant, with the last office note in the record from May 19, 2016. (Tr. 257, 261, 276, 277, 279, 281, 284, 285, 287, 291, 303, 304, 305, 306, 307, 308, 311, 313, 314, 326, 327-28, 341-43, 390, 393, 398).

         Dr. Gwynette also completed a number of questionnaires and letters summarizing his treatment, diagnoses and opinions regarding Plaintiff and consistently offered to provide the Social Security Administration additional information if needed. (Tr. 259, 334-338, 339, 378-82, 383). Dr. Gwynette described in these documents and his office notes Plaintiffs illogical thinking, difficulty concentrating, paranoia, irrational fears, delusions, and audio hallucinations, all secondary to his schizophrenia. He opined that Plaintiffs mental illness was exacerbated by stress, which rendered him at "high risk for decompensation in work and work-like settings due to his difficulty in coping with stressors and changes in environment." (Tr. 335, 336, 383, 378, 379, 380). Dr. Gwynette noted that while Plaintiffs mental health symptoms worsened when he was non-compliant in taking his prescribed anti-psychotic medications, he continued to have "breakthrough" incidents of hearing voices one to two times per week even when he took his medications, which caused Plaintiff "significant impairment." (Dkt. No. 339, 341, 383, 389, 392, 394, 398). Dr. Gwynette opined that Plaintiffs chronic mental illness "profoundly impacted the patient's ability to function" and rendered him incapable of working in a competitive environment. (Tr. 336, 339, 380, 383). Plaintiffs family physician, Dr. James Dantzler, shared that same view about Plaintiffs inability to function in the workplace. (Tr. 252).

         The record documents the struggles of Plaintiff s family in attempting to manage his chronic mental illness, sometimes resulting in violent confrontations with family members and requiring the intervention of law enforcement or medical personnel. (Tr. 41, 44, 46, 371, 394). These conflicts often arose when his mother sought to supervise and confirm that Plaintiff had taken his anti-psychotic medicine, which he at times resisted because of the unfounded belief that the drugs were somehow tainted or that his mother was attempting to harm him. (Tr. 50, 329). Due to Plaintiffs periodic episodes of decompensation, rapid mood swings, and extreme agitation, Plaintiffs mother told the Social Security staff she does not leave Plaintiff alone with his little brother, fearing he might try to harm him, and has refused to help Plaintiff obtain a driver's license, fearing he might hurt someone in the car. (Tr. 329).

         The only contrary views offered in the administrative record involved in-house physicians working with the Social Security Administration who did not examine or treat Plaintiff and reviewed only a limited number of medical records (all before September 15, 2014). They concluded that Plaintiff was not disabled, each providing abbreviated entries in the administrative record. (Tr. 65, 67, 79, 90-91). Due to their time limited review of the record, these chart reviewing physicians did not have access to and did not review Dr. Gwynette's letters and questionnaire responses that were produced on September 30, 2014, May 19, 2016, or August 30, 2016, or his office notes of January 12, 2015, August 4, 2015, November 3, 2015, and February 9, 2016.[2] These notes and documents, all produced subsequent to the last review by the in-house chart reviewers, provided some of the most detailed and ...


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