Court: Social Security Disability Judge Can't Reject Treating Physician's Opinion Without Medical Evidence - Carter v. Astrue

April 14,2009
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As experienced Social Security disability lawyers, we know that a person seeking disability benefits can go a long way in proving his or her case by presenting the opinion of a treating doctor. In Carter v. Astrue, the District Court for the Western District of Arkansas explains that a Social Security judge reviewing a claim can’t simply disregard such evidence without good reason.
The Social Security Administration (SSA) denied Plaintiff Dayna Carter’s disability benefits claim, in which Carter asserted that she’s unable to work due to the effects of a brain aneurism as well as severe fatigue and depression. In September 2009, Plaintiff appeared at an administrative hearing before an SSA Administrative Law Judge (ALJ). The ALJ found that although Plaintiff suffered from severe impairment resulting from the brain aneurysm, she nevertheless retained the residual functional capacity (RFC) “for a wide range of light work where interpersonal contact is incidental to the work performed, tasks are learned and performed by rote with few variables and little judgment required, and the supervision is simple and direct.”
The ALJ further determined that Plaintiff could not return to her previous jobs, but could perform other work existing in significant numbers in the national economy such as jobs as a cashier and machine operator. This decision was based largely on testimony by a vocational expert (VE) – a rehabilitation professional contracted by the SSA to advise an ALJ regarding a disability claimant’s ability to perform work – who stated that a hypothetical individual with Plaintiff’s limitations could perform the cashier and machine operator jobs.
The District Court reversed the ALJ’s decision on appeal, however, finding that it wasn’t supported by substantial evidence “because the ALJ failed to properly analyze the opinion of Plaintiff’s treating physician.” In determining a claimant’s RFC, the court noted that “[t]he ALJ should consider all the evidence in the record…including the medical records, observations of treating physicians and others, and an individual’s own description of his limitations.” Furthermore, according to the court, it is the ALJ’s responsibility to ensure that the RFC determination is supported by some medical evidence regarding the claimant’s ability to function in a workplace environment.
Dr. Paul Tucker treated Plaintiff for the effects of the aneurism from 2005 to 2008. In a 2008 RFC questionnaire, Dr. Tucker indicated that: 1) Plaintiff’s fatigue would frequently interfere with her attention and concentration; 2) she would need to take unscheduled breaks every two hours during the work day; and 3) she would likely miss approximately four days a month as a result of her impairments.

In reversing the ALJ’s decision, the court found that the judge wrongfully disregarded Dr. Tucker’s opinion regarding Plaintiff’s RFC. The court stated that the record must contain other medical assessments supported by better or more thorough medical evidence in order to disregard a treating physician’s opinion. Since no such evidence was present in this case, the court concluded that the ALJ should have sought to clarify any discrepancies that the ALJ found between Dr. Tucker’s statements in the questionnaire and his notes from previous examinations of Plaintiff. As a result, the court remanded the case to the ALJ for “a proper and complete analysis.”
While vital to proving a disability benefits claim, treating physician opinion isn’t the only evidence that a claimant may need to present in order to obtain benefits. An experienced Social Security disability attorney can assist a client by compiling all of the necessary evidence and following up with the SSA to ensure that it has what it needs to reach a decision.