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If an administrative law judge fails to give the treating physician’s opinion controlling weight in a disability hearing, they must explain why the analysis was rejected, the U.S. District Court for the District of Delaware has ruled. The federal court’s decision remanded a military veteran’s denied disability claim back to the administrative law judge, or ALJ, to explain how much deference the treating physician’s opinion should have received.

“Where an ALJ finds that a treating physician’s opinion does not merit controlling weight, the ALJ must perform a specific analysis to determine how much weight to afford the opinion,” said U.S. District Judge Sue L. Robinson of the District of Delaware. “To that end, the ALJ must consider the treatment relationship, the length of the treatment relationship, the frequency of examinations, the nature and extent of the treatment relationship, supportability of the opinion offered by the medical evidence, consistency of the opinion with the record as a whole, and the specialization of the treating physician.”

Adonis I. Goins filed an April 2007 claim for disability insurance benefits, asserting back problems, migraines, depression and post-traumatic stress disorder. An army veteran, Goins served from 1989 to 1993, including being “partially in combat” during the 1990-91 Gulf War, according to court documents. Goins held several jobs after he left the U.S. Army, according to the court’s opinion. He was a custodian, park services worker, airline baggage handler, construction worker and dialysis technician.

A Social Security Administration ALJ denied Goins’ claim in an August 2009 decision. The ALJ concluded that Goins was not disabled and could work.

Goins appealed the decision to the Social Security Administration’s Appeals Council. The review body concluded the ALJ failed to adequately consider evidence offered by Goins’ treating psychiatrist, Dr. Cyndia Choi. Upon remand, the ALJ again concluded in an August 2011 opinion the plaintiff was not disabled.

The Appeals Council refused to hear a second review and Goins filed a May 2012 lawsuit in the district court seeking to overturn the ALJ’s ruling.

Medical evidence reflected that Goins received treatment as recently as 1998 after sustaining an injury while lifting a heavy box, according to court documents. Since then, he has seen doctors for back pain, migraines, post-traumatic stress disorder, depression and sleep problems. In 2006, Goins began seeing Choi for PTSD. During later sessions, Choi declared Goins “totally disabled and unemployable due to his PTSD.” She also concluded the PTSD “interferes with his ability to maintain employment and work with others.”

Choi also performed laboratory and diagnostic tests and diagnosed Goins as “markedly limited” in understanding and memory, sustained concentration, social interaction and adaptation. However, Choi determined the plaintiff did not have suicidal or homicidal thoughts.

During Goins’ second hearing with an ALJ, vocational expert Mitchell A. Schmidt testified that Goins could not perform some of the jobs he held in the past, but could hold a “level one or two unskilled occupation.” Schmidt listed garment sorter and folder and surveillance systems manager as among the jobs Goins could hold.

Based partially on Schmidt’s testimony, the ALJ ruled in the second hearing that Goins “had the residual capacity to perform light work,” and was “limited to simple, unskilled jobs.”

On appeal to the district court, Robinson remanded the case to the ALJ because controlling weight had not been given to the opinion of Goins’ treating psychiatrist. Robinson said if an ALJ believes a primary doctor’s opinion should not be given the bulk of consideration, they must perform an analysis to determine how much weight it should receive.

“An ALJ may only outrightly reject a treating physician’s assessment based on contradictory medical evidence, not due to his or her own credibility judgments, speculation or lay opinion,” she said.

Robinson noted that Choi was likely more familiar with Goins than anyone else who participated in the hearing. Goins had at least 19 appointments with Choi between 2006 and 2010, according to court documents. Choi included information on the plaintiff’s progress, health history, prognosis and examination results, according to court documents.

“Although the ALJ implicitly suggests that the absence of hospitalization or emergency care impugns Dr. Choi’s opinions, there is no medical opinion or evidence to support this supposition,” Robinson said. “Instead, the ALJ has impermissibly substituted his own lay opinion to support his rejection of Dr. Choi’s opinion.”

Gary W. Lipkin of Duane Morris represented Goins.

The Social Security Administration was represented by a team of its lawyers including Eric P. Kressman and Katie M. Gaughan.

Jeff Mordock can be contacted at 215-557-2485 or jmordock@alm.com. Follow him on Twitter @JeffMordockTLI.