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Clay v. Berryhill

United States District Court, W.D. Kentucky, Paducah Division

February 22, 2018

NANCY A. BERRYHILL, Acting Commissioner of Social Security DEFENDANT



         This matter is before the Court on Plaintiff's Complaint seeking judicial review, pursuant to 42 U.S.C. § 405(g), of the final decision of the Commissioner denying his claim for Social Security disability benefits. Plaintiff filed a Motion for Judgment on the Pleadings (Docket #23), to which Defendant responded in opposition (Docket # 30), and the case is ripe for determination. The parties have consented to the jurisdiction of the undersigned Magistrate Judge to determine this case, with any appeal lying before the Sixth Circuit Court of Appeals. (Docket # 18).

         Plaintiff, a former combat veteran, applied for disability benefits through the Veterans Administration (VA). The VA adjudicated him to be 70-percent disabled due to service-connected post- traumatic stress disorder (PTSD) and, effective December 3, 2014, increased his disability rating to 100 percent based on the December 3, 2014 findings and opinions of VA clinical psychologist Anne Goodnow, Psy.D. Adjudication at Administrative Record (AR), p. 297; findings at AR, pp. 1541-48.

         20 C.F.R. § 404.1527(c) requires that “[r]egardless of its source [e.g., the VA], we [i.e., the Social Security Administration] will evaluate every medical opinion we receive.” The Administrative Law Judge's (ALJ's) mental residual functional capacity (RFC) finding did not accord with applicable legal standards because the ALJ's decision did not “evaluate” (or even mention) Dr. Goodnow's assessment.

         Accordingly, the Court will GRANT Plaintiff's Motion for Judgment on the Pleadings (Docket # 23) and REMAND this matter to the Commissioner for a new decision evaluating Dr. Goodnow's findings and opinions.

         In performing the requested review of the ALJ's mental RFC determination, the Court considered Dr. Goodnow's assessment.

         Plaintiff argues that the ALJ's mental “RFC determination is not supported by substantial evidence” (Docket # 23-1, p. 10), and he gives six supporting reasons (Id., pp. 11-16). The fourth reason is the VA's December 3, 2014 increase of disability rating to 100 percent. According to Plaintiff: “[t]his change was based on total occupational and social impairment; difficulty in adapting to work, stressful circumstances, and worklike setting; disturbances of motivation and mood; difficulty in establishing effective work and social relationships; impairment of short- and long-term memory; mild memory loss; depressed mood; chronic sleep impairment; anxiety; and suspiciousness” (Docket # 23-1, p. 15 referring to VA Reasons For Decision at AR, p. 297).

         These reasons for changing its disability rating cited by the VA correspond precisely to the clinical symptoms identified by Dr. Goodnow in her completion of the PTSD Disability Benefits Questionnaire (AR, pp. 1547-48). While Plaintiff's Memorandum in Support of Motion for Judgment on the Pleadings (Docket # 23-1) does not specifically mention Dr. Goodnow by name, the Court will exercise its discretion to consider Dr. Goodnow's findings and opinions contained in her completion of the PTSD Questionnaire (AR, pp. 1541-48) in reviewing the ALJ's mental RFC determination.

         The ALJ erred in not evaluating the weight given to Dr. Goodnow's assessment.

         Plaintiff is a veteran of the Gulf War Era, having served in the Army from September 22, 1998 through November 26, 2013. AR, p. 296. He was deployed to Iraq on three occasions. During his first deployment from February 2003 through February 2004, he was engaged in heavy firefights, which resulted in his witnessing many deaths. (AR, pp. 733-734). One particularly traumatic event occurred when he was forced to kill a young boy who was about the same age as his 10 year old son. (Id.) The Iraqi boy had an AK-47, and Plaintiff felt his life was in danger. (Id.) During Plaintiff's second deployment from April 2005 through April 2006, his unit provided route security, his convoy took direct and indirect fire daily and experienced a No. of improvised explosive device (IED) attacks. (Id.)

         During his third deployment from April 2008 through April 2009, Plaintiff provided personal security detail, engaged in firefights, mortar fire, and rocket attacks. (Id.) Plaintiff never felt safe. (Id.)

         Dr. Goodnow's PTSD Questionnaire tracks Criteria A through H of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). According to Dr. Goodnow, Plaintiff's A through H Criteria ratings are as follows (AR, pp. 1545-47):

         Criterion A

         Exposure to actual or threatened a) death, b) serious injury, c) sexual violation, in one or more of the following ways:

• Directly experiencing the traumatic event(s)
• Witnessing, in person, the traumatic event(s) as they occurred to others.

         Criterion B

         Presence of (one or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred:

• Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s)
• Recurrent distressing dreams in which the content and/or affect of the dream are related to the ...

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