Kay v. Berryhill, 3:16-cv-00951

Background

Plaintiff Donna Trull Kay (born 1951) applied for Disability Insurance Benefits, alleging onset January 20, 2011; ALJ denied benefits and Appeals Council denied review, leading to this district-court appeal.
Record shows treatment for hip/lumbar strain, right foot/shoulder complaints, diabetes; consultative exams found mild degenerative changes but generally normal strength, gait, coordination, and intact memory; mental-status consult found moderate impairments in concentration and coping with stress.
Two state agency psychologists (Drs. Carr and Posey) opined moderate limitations but ability to carry out detailed (not complex) instructions; consultative psychologist (Dr. Adibian) opined capability for 1–2 step instructions but could do detailed tasks according to ALJ summary.
Treating PCP Dr. Morrill submitted multiple questionnaires (2013 and 2015) asserting marked physical and mental limitations and that plaintiff "cannot work;" his treatment notes were largely cursory.
At hearing, plaintiff testified to significant pain, limited standing/sitting, daily naps, and anxiety; vocational expert testified that, under the ALJ’s hypothetical RFC, plaintiff could perform past housekeeper work and other medium unskilled jobs.
ALJ found severe impairments (hip degenerative disease, diabetes, hypertension, anxiety, depression), assessed RFC allowing detailed (not complex) tasks, limited social interaction, occasional postural activity, and concluded plaintiff could perform past relevant work and other jobs; magistrate judge recommended affirming the Commissioner.

Issues

Issue	Plaintiff's Argument	Defendant's Argument	Held
Whether ALJ erred by not adopting consultative psychologist’s 1–2 step instruction limitation in RFC	Kay: ALJ gave significant weight to Dr. Adibian but omitted his 1–2 step restriction without explanation, harming Step 4/5 findings	Commissioner: ALJ explicitly discussed Dr. Adibian, adopted limitations as "detailed tasks"/limited interactions, and reasonably rejected the 1–2 step restriction in light of other evidence	ALJ did not err; substantial evidence supports integrating Dr. Adibian’s findings as limiting to detailed (not complex) tasks and limiting social contact
Whether ALJ improperly rejected treating physician Dr. Morrill’s physical and mental opinions without detailed §404.1527 analysis	Kay: ALJ gave little/partial weight to Morrill but failed to give "good reasons" and did not apply factor-by-factor analysis; treating opinions went uncontradicted	Commissioner: ALJ permissibly discounted Morrill because his extreme restrictions were inconsistent with his own records and other examining opinions; where competing first-hand evidence exists, detailed factor-by-factor recitation is not required	ALJ did not err; substantial evidence supports rejecting Morrill’s extreme limitations because they conflicted with examining consultative opinions and Morrill’s sparse treatment notes
Whether ALJ had duty to re-contact Dr. Morrill under Newton when treating opinion was allegedly uncontradicted	Kay: ALJ should have sought clarification from Morrill before rejecting his opinion	Commissioner: ALJ relied on other examining opinions and found competing evidence, so re-contact was unnecessary	No error; re-contact not required because ALJ relied on contrary first-hand examining evidence

Key Cases Cited

Greenspan v. Shalala, 38 F.3d 232 (5th Cir.) (substantial-evidence standard for SSA determinations)
Leggett v. Chater, 67 F.3d 558 (5th Cir.) (claimant bears burden at steps 1–4; defer to ALJ when supported by substantial evidence)
Newton v. Apfel, 209 F.3d 448 (5th Cir.) (treating-physician rule and when ALJ must seek clarification)
Johnson v. Bowen, 864 F.2d 340 (5th Cir.) (standard for finding lack of substantial evidence)
Walker v. Barnhart, [citation="158 F. App'x 534"] (5th Cir.) (competing first-hand medical evidence can obviate detailed treating-physician factor analysis)
Perez v. Heckler, 777 F.2d 298 (5th Cir.) (ALJ responsible for RFC assessment based on record)