LESLIE G. FOSCHIO, Magistrate Judge.
On June 19, 2018, the parties to this action, consented pursuant to 28 U.S.C. § 636(c) to proceed before the undersigned. (Dkt. 8). The matter is presently before the court on motions for judgment on the pleadings filed by Plaintiff on September 21, 2018 (Dkt. 15), and by Defendant on November 14, 2018 (Dkt. 17).
Plaintiff Desteny Jay Badgley ("Plaintiff"), brings this action under the Social Security Act ("the Act"), 42 U.S.C. § 405(g), seeking judicial review of the Commissioner of Social Security's final decision denying Plaintiff's application filed with the Social Security Administration ("SSA"), on February 10, 2014, for Supplemental Security Income under Title XVI of the Act ("SSI"), and on March 26, 2014, for Disability Insurance Benefits under Title II of the Act ("SSDI") (together, "disability benefits"). Plaintiff alleges she became disabled on February 6, 2013, AR
On July 27, 2016, the ALJ issued a decision denying Plaintiff's claim. AR at 17-38 ("the ALJ's decision"). On August 28, 2017, the Appeals Council issued a decision denying Plaintiff's request for review, rendering the ALJ's decision the Commissioner's final decision. AR at 1-6. On October 26, 2017, Plaintiff commenced the instant action seeking judicial review of the ALJ's decision.
On September 21, 2018, Plaintiff filed a motion for judgment on the pleadings (Dkt. 15) ("Plaintiff's Motion"), attaching the Memorandum of Law in Support of Plaintiff's Motion for Judgment on the Pleadings (Dkt. 15-1) ("Plaintiff's Memorandum"). On November 14, 2018, Defendant filed a motion for judgment on the pleadings (Dkt. 17) ("Defendant's Motion"), attaching The Commissioner's Brief in Support of Defendant's Motion for Judgment on the Pleadings Pursuant to Local Standing Order on Social Security Cases (Dkt. 17-1) ("Defendant's Memorandum"). In further support of Plaintiff's Motion, Plaintiff filed on December 5, 2018, Plaintiff's Response to the Commissioner's Brief in Support and in Further Support for Plaintiff's Motion for Judgment on the Pleadings (Dkt. 18) ("Plaintiff's Reply"). Oral argument was deemed unnecessary.
Based on the following, Plaintiff's Motion is DENIED; Defendant's Motion is GRANTED.
Plaintiff Desteny Jay Badgley ("Plaintiff" or "Badgley"), born July 19, 1990, was 22 years old as of February 6, 2013, her alleged disability onset date ("DOD"). AR at 273. It is undisputed that Plaintiff is of low-average to average cognitive ability, with weaknesses in verbal comprehension and working memory, attended high school until 10th grade, and was in special education classes because of her learning disability. AR at 271-72, 402, 572-95. Plaintiff's work history includes brief stints as a cashier, fast food service worker, secretary, babysitter, and restaurant hostess, AR at 66-68, 188-202, 211-230, but Plaintiff has not worked since January 26, 2014, because of her mental health condition. AR at 217. Plaintiff is married and lives with her husband and three young children, AR at 68, and the family lived for a year and a half with Plaintiff's terminally ill father for whom Plaintiff provided care until he passed away. AR at 84-85.
A claimant is "disabled" within the meaning of the Act and entitled to disability benefits when she is unable "to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which . . . has lasted or can be expected to last for a continuous period of not less than 12 months." 42 U.S.C. §§ 416(i)(1); 1382c(a)(3)(A). A district court may set aside the Commissioner's determination that a claimant is not disabled if the factual findings are not supported by substantial evidence, or if the decision is based on legal error. 42 U.S.C. §§ 405(g), 1383(c)(3); Green-Younger v. Barnhart, 335 F.3d 99, 105-06 (2d Cir. 2003). In reviewing a final decision of the SSA, a district court "is limited to determining whether the SSA's conclusions were supported by substantial evidence in the record and were based on a correct legal standard." Talavera v. Astrue, 697 F.3d 145, 151 (2d Cir. 2012) (internal quotation marks and citation omitted). "Substantial evidence is more than a mere scintilla. It means such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Id. It is not, however, the district court's function to make a de novo determination as to whether the claimant is disabled; rather, "the reviewing court is required to examine the entire record, including contradictory evidence and evidence from which conflicting inferences can be drawn" to determine whether the SSA's findings are supported by substantial evidence. Id. "Congress has instructed . . . that the factual findings of the Secretary,
The applicable regulations set forth a five-step analysis the Commissioner must follow in determining eligibility for disability benefits. 20 C.F.R. §§ 404.1520 and 416.920. See Bapp v. Bowen, 802 F.2d 601, 604 (2d Cir. 1986); Berry v. Schweiker, 675 F.2d 464 (2d Cir. 1982). If the claimant meets the criteria at any of the five steps, the inquiry ceases and the claimant is not eligible for disability benefits. 20 C.F.R. §§ 404.1520 and 416.920. The first step is to determine whether the applicant is engaged in substantial gainful activity ("SGA") during the period for which the benefits are claimed. 20 C.F.R. §§ 404.1520(b) and 416.920(b). The second step is whether the applicant has a severe impairment which significantly limits the physical or mental ability to do basic work activities, as defined in the relevant regulations. 20 C.F.R. §§ 404.1520(c) and 416.920(c). Third, if there is an impairment and the impairment, or its equivalent, is listed in 20 C.F.R. Part 404, Subpart P, Appendix 1 of the regulations ("Appendix 1" or "the Listings"), and meets the duration requirement,
In the instant case, the ALJ found Plaintiff meets the Act's insured status requirement for SSDI through June 30, 2013, AR at 22, Plaintiff has not engaged in SGA since her alleged disability onset date of February 6, 2013, id., that Plaintiff suffers from the severe impairments of obesity, migraines, bipolar disorder, depression, anxiety, and a learning disability, AR at 22-23, but that Plaintiff's other medically determinable impairment of a heart murmur does not have more than a minimal impact on Plaintiff's ability to do work activities, id., at 23, that Plaintiff does not have an impairment or combination of impairments meeting or medically equal to the severity of any listed impairment in 20 C.F.R. Part 404, Subpt. P, App. 1, id. at 23-25, and that Plaintiff retains the RFC to perform light work limited to occasionally climbing ladders, ropes, or scaffolds, occasional exposure to moving mechanical parts, occasionally operating a motor vehicle, occasional exposure to unprotected heights, performing simple, routine, repetitive tasks, working in a low stress job defined as requiring only occasional decision making with only occasional changes in the work setting, no interaction with the public, and occasional interaction with coworkers and supervisors. Id. at 25-33. The ALJ further found Plaintiff unable to perform any past relevant work, id. at 33, yet given Plaintiff's age, limited education, ability to communicate in English, lack of transferable skills from her past work experience and RFC, jobs exist in significant number in the national economy that Plaintiff can perform including small parts assembler, electronics assembly worker, and laundry folder, all jobs which the ALJ considered unskilled, such that Plaintiff is not disabled as defined under the Act. Id. at 33-34.
Plaintiff does not contest the ALJ's findings with regard to the first three steps of the five-step analysis, but argues the ALJ erred at step 4 in evaluating medical opinions and in failing to further develop the record such that the ALJ's assessment of Plaintiff's RFC is unsupported by substantial evidence. Plaintiff's Memorandum at 17-30. Defendant maintains Plaintiff essentially challenges the ALJ's failure to weigh the medical evidence in favor of finding Plaintiff disabled, Defendant's Response at 3, but that substantial evidence supports the ALJ's determination that Plaintiff, despite several severe impairments, retained the RFC to perform simple, low-stress work requiring limited social contact, id. at 16-18, and reasonably assessed the medical opinions in the record. Id. at 19-23. In reply, Plaintiff reiterates that the ALJ's failure to account for gaps in the record and failure to consider certain of Plaintiff's limitations resulted in an RFC that is unsupported by the substantial evidence in the record. Plaintiff's Reply at 1-10.
The so-called residual functional capacity or "`RFC' is an assessment of an individual's ability to do sustained work-related physical and mental activities in a work setting on a regular and continuing basis. A `regular and continuing basis' means 8 hours a day, for 5 days a week, or an equivalent work schedule." SSR
In short, "[w]here the record primarily discusses a plaintiff's impairments, symptoms, and treatment, but does not shed light on the plaintiff's limitations, the ALJ may not rely on the record in determining the plaintiff's RFC." Johnson v. Comm'r of Soc. Sec., 351 F.Supp.3d 286, 293 (W.D.N.Y. Dec. 27, 2018) (citing cases). In contrast, an ALJ is permitted to reject medical assessments by physicians and to rely, instead, on the underlying treatment notes where such notes provide contemporaneous medical assessments relevant to the claimant's ability to perform SGA. Monroe, 676 Fed.Appx. at 6-9 (holding the ALJ, despite rejecting the treating physician's post hoc medical opinion ostensibly based on observations reported in the treatment notes that were inconsistent with the opinion, properly determined the claimant's RFC that was based on the treating physician's contemporaneous treatment notes which constituted more than a scintilla of evidence supporting the ALJ's RFC assessment). Here, a thorough review of Plaintiff's medical records establishes they contain sufficient contemporaneous medical assessments relevant to Plaintiff's ability to engage in SGA such that the ALJ was not required to obtain any further medical source statement on the impact of any impairment on Plaintiff's ability to perform SGA, and did not impermissibly substitute her own lay opinion for that of a medical assessment.
In particular, with regard to Plaintiff's heart murmur, Plaintiff argues the ALJ substituted her own lay opinion for the "vague opinion" of Aharon Wolf, M.D. ("Dr. Wolf"), who performed an internal medical examination of Plaintiff on June 20, 2014, in connection with a heart murmur with which Plaintiff was diagnosed at six weeks of age. AR at 397-400. Dr. Wolf found Plaintiff felt palpitations of a few minutes' duration, four or five times a week, but no chest pain or shortness of breath, id. at 397, her heart had regular rhythm, with no gallop or rub audible, id. at 398, and Dr. Wolf diagnosed a grade 2 systolic murmur, id., resulting in "a moderate limitation for activities requiring exertion due to heart." Id. at 399. Plaintiff specifically argues the ALJ improperly equated Dr. Wolf's "moderate limitation" with an RFC for light work,
The ALJ also did not err in finding, without obtaining any further medical source statement, that Plaintiff's headaches posed no limitations beyond limiting Plaintiff to light work, and avoiding working in certain environmental conditions, including only occasionally climbing ladders, ropes, or scaffolds, operating a motor vehicle, working at unprotected heights, or occasional exposure to excessive noise, or moving mechanical parts. Rather, the medical evidence in the record establishes that commencing on October 21, 2014, Plaintiff sought treatment from neurologist Nicolas P. Saikali, M.D. ("Dr. Saikali"), at Dent Neurologic Institute ("Dent"), in Buffalo, New York, for migraine headaches, AR at 437-39, returning for re-evaluation on December 9, 2014, AR at 440-42, but not again until May 5, 2016. AR at 597-99. At the October 21, 2014 examination, Plaintiff reported her headaches began more than a year before she ceased working, but recently were more severe, with two migraines a week associated with intolerance to light (photophobia) and sound (phonophobia). Id. at 437. Plaintiff's examination was relatively unremarkable with Plaintiff's cranial nerves normal, and Plaintiff well-groomed, pleasant, and in no acute distress, and exhibiting appropriate affect and eye contact, alert and oriented in all spheres, with good attention and concentration, intact recent and remote memory. Id. at 438. Dr. Saikali assessed migraine headaches without aura, myofascial pain, or occipital neuralgia, and no need for prophylactic medications, but prescribed Topamax and Imitrex, and recommended stretching exercises. Id. Upon re-evaluation on December 9, 2014, Plaintiff reported intolerance of Topamax and Imitrex, but that she took Ibuprofen twice a week. Id. at 440. An MRI of Plaintiff's brain taken after her earlier examination was normal, neurological examination was completely normal, but Dr. Saikali found Plaintiff with tenderness in her trapezius muscles for which massages and stretching therapy were recommended, and amitriptyline and Maxalt were prescribed. Id. at 440-41. When Plaintiff next returned to Dent on May 5, 2016, she reported her migraines had worsened since February 2016, occurred three or four times per week, yet Plaintiff's examination was again unremarkable. Id. at 598. Botox therapy and Avert were prescribed, with Plaintiff's headaches attributed to her overuse of Ibuprofen and Excedrin. Id. at 598-99. Significantly, following none of Plaintiff's evaluations at Dent were any work limitations assessed based on Plaintiff's headaches, nor would any be expected in light of the scant medical evidence of physical impairment caused by Plaintiff's asserted headaches, such that the ALJ was permitted to use common sense in making a functional capacity assessment of the limitations to Plaintiff's ability to engage in SGA posed by her migraines, Walker, 2010 WL 2629832, at * 6, and did so in including additional restrictions to Plaintiff's RFC of avoiding working in certain environmental conditions, including only occasionally operating a motor vehicle, working at unprotected heights, or occasional exposure to excessive noise, or moving mechanical parts, and further limiting Plaintiff to low stress jobs with no interaction with the public and only limited interaction with supervisors and co-workers, which restrictions are consistent with Dr. Saikali's identifying Plaintiff's migraines triggers as intolerance to light and sound. AR at 437.
In contrast to Plaintiff's argument, Plaintiff's Reply at 7, the ALJ did not improperly "cherry-pick" the evidence pertaining to Plaintiff's mental health in finding Plaintiff remained capable of light work, with the additional limitations of occasionally climbing ladders, ropes, or scaffolds, occasional exposure to moving mechanical parts, occasionally operating a motor vehicle, occasional exposure to unprotected heights, performance of simple, routine, repetitive tasks, work in a low stress job defined as requiring only occasional decision making with only occasional changes in the work setting, no interaction with the public, and occasional interaction with coworkers and supervisors. Id. at 25. Significantly, Plaintiff's argument on this point suggests the ALJ erred in granting more weight to assessments made by the various mental health treating sources rather than to Plaintiff's complaints regarding her stress and depression, most of which are subjective in nature. For example, Plaintiff argues that "Plaintiff reported that stress and changes in schedule affected her because it made her very depressed and she did not want to be around anyone aka social isolation; and this is supported by the record. (Tr. 62-91, 251). Yet, the RFC findings do not account for individualized stress findings." Plaintiff's Memorandum at 25. The portion of the Administrative Record Plaintiff references, however, include the entire administrative hearing transcript, AR at 62-91, and Plaintiff's written statements on the Function Report — Adult, Anxiety & Work History completed by Plaintiff in connection with her disability benefits application. AR at 251. The ALJ is not required to accept such self-serving statements in considering a disability claim. See Genier v. Astrue, 606 F.3d 46, 49 (2d Cir. 2010) ("When determining a claimant's RFC, the ALJ is required to take the claimant's reports of pain and other limitations into account, . . . but is not required to accept the claimant's subjective complaints without question; he may exercise discretion in weighing the credibility of the claimant's testimony in light of the other evidence in the record." (citations omitted)). Further, the record shows that in arriving at Plaintiff's RFC, the ALJ considered all limitations identified by Plaintiff's mental health treating sources.
In particular, the ALJ considered evidence of Plaintiff's learning disability records from Jamestown Central School District where Plaintiff was enrolled throughout her school years, showing Plaintiff with low average cognitive functioning. AR at 27 (citing AR at 205). Plaintiff's learning disability, for which the only evidence is Plaintiff's school records, was not given as a reason for Plaintiff leaving any of her previous jobs. Moreover, Plaintiff's care of her ill father included making sure he took the proper dosage of his medications at the right time, a task which common sense informs could not be entrusted to someone with significantly reduced intelligence. Accordingly, given the limited medical evidence of Plaintiff's low cognitive function, the ALJ was permitted to use common sense in making a functional capacity assessment of the limitations to Plaintiff's ability to engage in SGA posed by her low average intelligence, including that Plaintiff's RFC of light work was further limited to performing simple, routine, repetitive tasks, and working in a low stress job defined as requiring only occasional decision making with only occasional changes in the work setting. Walker, 2010 WL 2629832, at * 6.
It is undisputed that Plaintiff has an extensive history of depression, anxiety, and panic attacks, for which Plaintiff has been treated by psychiatrist Ralph Walton, M.D. ("Dr. Walton"), at Family Health Medical Services ("Family Health"), in Jamestown, New York, from May 15, 2012 through April 10, 2014. AR at 334-94. Despite repeatedly assessing Plaintiff with depression, and anxiety, which conditions were attributed to Plaintiff's stress of coping with three children born to her before age 22, the unexpected death of her mother, caring for her terminally ill father until his recent death, and marital strife, Dr. Walton generally found Plaintiff with spontaneous and appropriate speech, normal thought process without dementia or overt, illogical thinking, no compulsion, intact associative thinking, no delusions, hallucinations, obsessions, preoccupations, or somatic (relating to the body) thoughts, alert and oriented in all three spheres, intact memory, grossly intact attention span, concentration, judgment, and insight, knowledge and vocabulary within normal limits, and Plaintiff was without suicidal or homicidal ideation, and was not considered dangerous. See, e.g., AR at 340 (April 9, 2013), 369 (March 12, 2013), 348 (October 1, 2013), 356 (January 21, 2014). Dr. Walton prescribed Plaintiff antidepressant medications, including Xanax, which Plaintiff reported "helps a great deal." Id. at 361. From February 27, 2014 through February 3, 2016, Plaintiff received mental health services from Chautauqua County Department of Mental Hygiene ("CCMH"), where she was followed by psychiatrist Robert Gibbon, M.D. ("Dr. Gibbon"), AR at 442-551, who consistently assessed Plaintiff with scores on the Global Assessment of Functioning ("GAF") Scale
The treatment notes from Family Health and CCMH are also consistent with the findings of two consultative mental health examinations including by Kristina Luna, Psy. D. ("Dr. Luna"), on June 20, 2014, AR at 402-06, and a mental residual functional capacity ("MRFC") completed by State Agency Psychological Consultant J. Straussner, Ph.D. ("Dr. Straussner"), on June 26, 2014. AR at 98-106. Specifically, Dr. Luna's mental status evaluation of Plaintiff found her cooperative though immature, manner of relating and overall social skills were poor, poor eye contact, and lethargic appearance. AR at 403. Speech intelligibility was fluent with clear voice and age appropriate expressive and receptive language, thought processes were coherent and goal directed without evidence of hallucinations, delusions, or paranoia, affect was depressed and apathetic, mood was dysthymic (persistently mildly depressed), clear sensorium, and Plaintiff was oriented in all three spheres. AR at 403-04. Mild impairment of Plaintiff's attention and concentration, and recent and remote memory skills was attributed to emotional distress, cognitive functioning was not assessed but appeared to be in average range with somewhat limited general fund of information, insight was fair and judgment good. Id. at 404. Plaintiff reported cleaning her home three times a week, doing laundry, showering three times a week, getting dressed three or four times a week, but concentration difficulties and fear of burning food prevented her from cooking,
As such, the ALJ's assessment of Plaintiff's RFC is supported by substantial evidence in the record.
Based on the foregoing, Plaintiff's Motion (Dkt. 15) is DENIED; Defendant's Motion (Dkt. 17) is GRANTED. The Clerk of Court is directed to close the file.
SO ORDERED.
20 C.F.R. § 404.1567(b).