United States District Court, D. Maryland
Lazette Seney o/b/o J.L.
Commissioner, Social Security Administration;
September 16, 2016, Plaintiff Lazette Seney petitioned this
Court to review the Social Security Administration's
denial of her claim for Children's Supplemental Security
Income (“SSI”) on behalf of her minor son, J.L.
(ECF No. 1). I have considered the parties' cross-motions
for summary judgment. (ECF Nos. 14, 17). I find that no hearing
is necessary. See Loc. R. 105.6 (D. Md. 2016). This
Court must uphold the decision of the Agency if it is
supported by substantial evidence and if the Agency employed
proper legal standards. See 42 U.S.C. §§
405(g), 1383(c)(3); Craig v. Chater, 76 F.3d 585,
589 (4th Cir. 1996). Under that standard, I will deny
Plaintiff's motion, grant the Commissioner's motion,
and affirm the Commissioner's judgment pursuant to
sentence four of 42 U.S.C. § 405. This letter explains
Seney applied for Children's SSI on behalf of J.L. on
June 29, 2012, alleging a disability onset date of April 1,
2011. (Tr. 139-47). Her claim was denied initially and on
reconsideration. (Tr. 87-90, 96-97). A hearing was held on
April 21, 2015, before an Administrative Law Judge
(“ALJ”). (Tr. 43-59). Following the hearing, the
ALJ issued an opinion denying benefits. (Tr. 24-42). The
Appeals Council (“AC”) denied Ms. Seney's
request for review, (Tr. 1-7), meaning that the ALJ's
decision is the final, reviewable decision of the Agency.
evaluated Ms. Seney's claim using the three-step
sequential process for claims involving childhood SSI, as set
forth in 20 C.F.R. § 416.924. The ALJ's findings at
steps one and two favored Ms. Seney's claim. At step one,
the ALJ found that J.L. had not engaged in any substantial
gainful activity since the application date. (Tr. 30). At
step two, the ALJ found that J.L. suffered from the severe
impairment of “seizure disorder.” Id. At
step three, however, the ALJ found that J.L. did not have an
impairment or combination of impairments that met any
listing. (Tr. 30-39). Additionally, the ALJ determined that
J.L. did not have an impairment or combination of impairments
that would be functionally equivalent to any listing.
Id. Therefore, the ALJ determined that J.L. was not
disabled for purposes of Children's SSI benefits. (Tr.
Seney raises two primary arguments in support of her appeal:
(1) that the ALJ failed to meet his heightened duty of care
towards a pro se claimant; and (2) that the ALJ
assigned inadequate weight to the opinion of the treating
physician, Dr. Williams. Pl. Mem. 1-8. Each argument lacks
merit and is addressed below.
Ms. Seney contends that the ALJ failed to meet his heightened
duty of care towards a pro se claimant in developing
the record. Pl. Mem. 6-7. Specifically, Ms. Seney
argues that the ALJ failed to order a “consultative
examination to consider whether [J.L.'s] seizures [met]
the [relevant] listing.” Id. at p. 7.
“[I]n pro se cases, ALJs have ‘a duty to assume a
more active role in helping claimants develop the
record.'” Craig v. Chater, 76 F.3d 585,
591 (4th Cir. 1996) (quoting Sims v. Harris, 631
F.2d 26, 28 (4th Cir. 1980)). However, “the ALJ is not
required to function as the claimant's substitute
counsel, but only to develop a reasonably complete
record.” Crussiah v. Colvin, No. CIV. TMD
12-2307, 2014 WL 3778615, at *12 (D. Md. July 29, 2014),
aff'd, 589 Fed.Appx. 76 (4th Cir. 2014) (internal
citation and quotation marks omitted). In this case, the
ALJ's opinion does not reflect an absence of sufficient
medical information to permit a decision to be made. Indeed,
several medical providers, including J.L.'s treating
neurologist, reported that there was no objective evidence to
support J.L.'s alleged seizure disorder and cited normal
findings on examination. (Tr. 31-33). Moreover, even
J.L.'s own treating physician noted that J.L.'s
“seizures [were] controlled with [medication], ”
that “[a] review of [J.L.'s] symptoms was normal,
” and that he was “doing very well
otherwise.” (Tr. 32). Accordingly, there was no
requirement that the ALJ order a consultative examination to
develop the record. Remand on this basis is therefore
Ms. Seney contends that the ALJ assigned inadequate weight to
the opinion of the treating physician, Dr. Williams. Pl. Mem.
7-8. A treating physician's opinion is given controlling
weight when two conditions are met: 1) it is well-supported
by medically acceptable clinical laboratory diagnostic
techniques; and 2) it is consistent with other substantial
evidence in the record. See Craig, 76 F.3d 585 (4th
Cir. 1996); see also 20 C.F.R. § 416.927(d)(2).
However, where a treating source's opinion is not
supported by clinical evidence or is inconsistent with other
substantial evidence, it should be accorded significantly
less weight. Craig, 76 F.3d at 590. If the ALJ does
not give a treating source's opinion controlling weight,
the ALJ will assign weight after applying several factors,
such as, the length and nature of the treatment relationship,
the degree to which the opinion is supported by the record as
a whole, and any other factors that support or contradict the
opinion. 20 C.F.R. § 416.927(c)(1)-(6). The Commissioner
must also consider, and is entitled to rely on, opinions from
SSR 96-6p, at *3 (“In appropriate circumstances,
opinions from State agency medical and psychological
consultants and other program physicians and psychologists
may be entitled to greater weight than the opinions of
treating or examining sources.”).
to Ms. Seney's assertion, the ALJ properly evaluated Dr.
Williams's opinion. Dr. Williams diagnosed J.L. with
seizures and determined that he met the Listing 111.02, which
pertains to epilepsy. (Tr. 31, 33). However, the ALJ
discredited Dr. Williams's opinion because it was
inconsistent with the medical evidence. Id.
Specifically, the ALJ found that, “[a]lthough Dr.
Williams, [J.L.'s] pediatrician, finds [that] [he] meets
the listing at 111.02, the undersigned does not find
sufficient evidence to support finding a listing.” (Tr.
31). Most significantly, the ALJ noted Dr. Williams's own
findings that J.L.'s “seizures [were] controlled
with [medication], ” that “[a] review of
[J.L.'s] symptoms was normal, ” that “[a] CT
of his head was normal, ” and that J.L. was
“doing very well otherwise.” (Tr. 32). The ALJ
also noted that “there was no evidence of
seizure” while J.L. was monitored at the University of
Maryland Medical Center, and cited normal objective findings
on examination. (Tr. 31). Moreover, the ALJ cited Dr.
Birmingham's determination that J.L. was “negative
for continuous video EEG” and noted her finding that
“a medical provider ha[d] not witnessed
seizures.” Id. Furthermore, the ALJ noted Dr.
Derouen's finding that J.L. “experienced seizures
approximately once a week because Mrs. Seney forgot to
administer [J.L.'s medication] as prescribed.”
Id. These inconsistencies, in addition to others
cited by the ALJ, provide sufficient justification for the
ALJ's decision to discredit Dr. Williams's opinion.
Seney also argues that the ALJ failed to consider the factors
outlined in 20 C.F.R. § 416.927(1)-(6), when assigning
weight to Dr. Williams's opinion. The regulations require
an ALJ to assess several factors when determining what weight
to assign to the medical opinions presented. 20 CFR §
416.927(d). These factors include: the examining relationship
between the physician and the claimant; the treatment
relationship between the physician and the claimant; the
specialization of the physician; the consistency of a medical
opinion with the record as a whole; and the extent to which a
medical opinion is supported by evidence. 20 CFR §
416.927(d)(1)-(5). Upon review of the record, I find that the
ALJ cited each factor required under the regulations.
Specifically, the ALJ noted that Dr. Williams was J.L.'s
treating physician and examined him between 2012 and 2015.
(Tr. 31-33). The ALJ also adduced Dr. Williams's opinion,
and cited her medical records, which contain Dr.
Williams's treatment notes and denotes her specialization
as a pediatrician. Id. The ALJ then found that Dr.
Williams's opinion was unsupported by the medical
evidence. Id. Considering the entirety of the
ALJ's RFC analysis, I find that the ALJ properly applied
the regulations in discrediting Dr. Williams's opinion,
and that his findings are supported by substantial evidence.
reasons set forth herein, Ms. Seney's Motion for Summary
Judgment (ECF No. 14) is DENIED and Defendant's Motion
for Summary Judgment (ECF No. 17) is GRANTED. The clerk is
directed to CLOSE this case.
the informal nature of this letter, it should be flagged as
an opinion and docketed as an order.
Stephanie A. Gallagher United ...