MADELINE COX ARLEO, District Judge.
Before this Court is Ibolya Nagy's ("Plaintiff") request for review, pursuant to 42 U.S.C. §§ 1383(c)(3), 405(g), of the Commissioner of Social Security Administration's ("Commissioner") decision with respect to Plaintiff's application for Disability Insurance Benefits and Supplemental Security Income Benefits (collectively, "Disability Benefits"). Plaintiff argues in the alternative that: (1) the Commissioner's decision should be reversed with an award of benefits because there is substantial evidence in the record to support a finding of disability; and (2) the numerous deficiencies in the Commissioner's decision require the case to be remanded for reconsideration. For the reasons set forth in this Opinion, the Court finds that this matter must be
This Court has jurisdiction to review the Commissioner's decision under 42 U.S.C. § 405(g). This Court must affirm the Commissioner's decision if there exists substantial evidence to support the decision. 42 U.S.C. § 405(g);
"[T]he substantial evidence standard is a deferential standard of review."
In determining whether there is substantial evidence to support the Commissioner's decision, the Court must consider: "(1) the objective medical facts; (2) the diagnoses of expert opinions of treating and examining physicians on subsidiary questions of fact; (3) subjective evidence of pain testified to by the claimant and corroborated by family and neighbors; and (4) the claimant's educational background, work history, and present age."
In order to determine whether a claimant is disabled, the Commissioner must apply a five-step test. 20 C.F.R. § 404.1520(a)(4). First, it must be determined whether the claimant is currently engaging in "substantial gainful activity." 20 C.F.R. § 404.1520(a)(4)(i). "Substantial gainful activity" is defined as work activity, both physical and mental, that is typically performed for either profit or pay. 20 C.F.R. § 404.1572. If it is found that the claimant is engaged in substantial gainful activity, then he or she is not disabled and the inquiry ends.
At the third step, the Commissioner must determine whether there is sufficient evidence showing that the claimant suffers from a listed impairment or its equivalent. 20 C.F.R. § 404.1520(a)(4)(iii). If so, a disability is conclusively established and the claimant is entitled to benefits.
Under 42 U.S.C. § 405(g) and Third Circuit precedent, this Court is permitted to "affirm, modify, or reverse the [Commissioner's] decision with or without a remand to the [Commissioner] for a rehearing."
This case arises out of Plaintiff's application for disability insurance benefits and supplemental security income filed on June 15, 2011. Tr. 16, 22, 133-43. In both applications, the claimant alleged a disability beginning on February 3, 2009. Tr. 22. Both claims were denied initially on October 18, 2011, whereupon claimant filed a written request for an administrative hearing. Tr. 22. The claimant appeared and testified at the hearing on August 6, 2012, in front of The Honorable John J. Barry ("The ALJ"). Tr. 22. On January 28, 2013, the ALJ decided that the claimant was not disabled during the relevant time period, because although she could no longer perform her past work, jobs existed in significant numbers in the national economy that Plaintiff could perform. Tr. 22-35. Plaintiff then sought review before the Appeals Council, which was denied on May 30, 2014. Tr. 1. Having exhausted her administrative remedies, Plaintiff subsequently timely filed the instant action on July 16, 2014.
Plaintiff is a 54-year-old woman who alleged in her application for Disability Benefits that she became disabled on February 3, 2009. Tr. 16, 31. Plaintiff previously worked as a certified nurse's assistant ("CNA"), a job that is medium and semi-skilled, according to Andrew Pasternak, the vocational expert ("VE") assigned to Plaintiff's case. Tr. 62. Plaintiff was fired from her last CNA position due to an altercation with her boss regarding overtime payments. Tr. 44. According to Plaintiff's testimony, she has lost five jobs for yelling at her bosses. Tr. 57-58. Since she did not have any positive references, and due to the previous terminations and her temper, Plaintiff was unsuccessful in obtaining work. Tr. 46. After she was fired in 2009, Plaintiff testified that her back problems further prevented her from working. Tr. 47. Plaintiff testified she first injured her back in 2000, and reinjured it in 2007 and 2009. Tr. 47.
The medical records indicate that Plaintiff does have some limitations in terms of her back and left hand. A March 3, 2009, x-ray of Plaintiff's lumbar spine showed degenerative changes at L4-L5 with disc space narrowing and osteophyte formation, but no fracture. Tr. 403. More than a year later on July 10, 2010, Plaintiff was seen at New York Hospital — Queens ("NYHQ") for intermittent left thumb pain, which radiated to her wrist and forearm, including numbness and tingling. Tr. 227. Upon examination, she was diagnosed with carpal tunnel and trigger finger, with normal range in the wrist and fingers.
In October 2010, Plaintiff made several visits to her family practitioner, Dr. Yosef Morad, for lower back pain and weakness (October 8), and pain that radiated down her legs (October 10). Tr. 404. After laser treatments, plaintiff told Dr. Morad she no longer was in pain (October 14), and had continued improvement in her condition (October 17).
On July 10, 2011, Dr. Morad opined to the State Agency that Plaintiff could perform less than sedentary work. Tr. 301-02. Dr. Morad wrote in his report that Plaintiff could only lift 0-5 pounds occasionally, stand or walk up to two hours a day, and had limitations in pushing and pulling, with no limitations in respect to her sight, posture, and communication skills.
During the same time period, Plaintiff also underwent psychiatric exams for depressive symptoms linked to her bipolar disorder. She had previously attempted suicide roughly 25 years prior to her hearing. Tr. 392. Plaintiff underwent a psychiatric examination at NYHQ on August 20, 2010, and again on September 1, 2010. Tr. 230, 237, 289. On June 6, 2011, Plaintiff complained to Dr. Morad that she was depressed and Dr. Morad noted that Plaintiff had a history of bipolar disorder. Tr. 426. On July 6, 2011, Plaintiff underwent a psychosocial assessment at Long Island Consultation Center ("LICC"), complaining of depression and anger, but claimed no prior mental health treatment despite antidepressants prescribed by Dr. Morad. Tr. 325-36. Plaintiff told LICC doctors that she isolated herself, but despite passive thoughts of suicide, she did not want to die. Tr. 327, 330. According to the record, Plaintiff's mood and affect seemed depressed, but appropriate. Tr. 333. The LICC assigned Plaintiff a global assessment of function ("GAF") score of 50,
On September 2, 2011, Plaintiff saw Dr. Carl Rosenmann, who found that Plaintiff had no limitation in understanding and remembering. Tr. 345. Separately, Dr. Arlene Broska, during a consultative psychiatric evaluation, posited that Plaintiff could get easily distracted. Dr. Broska, however, concluded that although the Plaintiff's exam results were consistent with psychiatric problems, they did not appear to be significant enough to interfere with Plaintiff's ability to function on a daily basis. Tr. 351. Dr. T. Bruni, a New York State Office of Temporary and Disability Assistance psychologist, saw Plaintiff a month later, finding that she had mild restrictions of activities of daily living, and mild restrictions on concentration, persistence, or pace, with moderate difficulties in terms of social functioning. Tr. 28, 370. Dr. Bruni also found Plaintiff markedly limited in interacting with the general public. Tr. 375.
On August 30, 2012, Plaintiff underwent a psychosocial examination at Medex Diagnostic & Treatment Center ("Medex"), where she appeared to be clean, friendly, and cooperative, demonstrating a normal thought process. Tr. 487. Her GAF was raised to 60, indicating she suffered from moderate symptoms or moderate difficulty in functioning. Tr. 488;
In his January 28, 2013, decision, the ALJ first noted that Plaintiff had not engaged in substantial gainful activity since the alleged onset date, February 3, 2009. Tr. 24. The ALJ also noted that Plaintiff suffered from the following severe impairments: (1) degenerative disc disease of the cervical and lumbar spine with herniated disc at L4-L5; and (2) mild carpal tunnel syndrome in the left hand and trigger finger. Tr. 25. The ALJ found no severe mental impairments.
At step three, the ALJ found that Plaintiff's impairments or a combination thereof did not meet or medically equal the severity of one of the listed impairments. Tr. 26. In reaching that decision, the ALJ specifically reviewed the applicable listing 1.00 (musculoskeletal system), finding that the medical record did not indicate any impairment severe enough to meet the criteria of any listed impairment, and those impairments, singly or in combination, did not medically equal the criteria of any listed impairment.
Next, the ALJ determined Plaintiff's RFC. The ALJ found Plaintiff capable of performing light work, as defined at 20 C.F.R. §§ 404.1567(b) (2015), 416.967(b), with some limitations, finding Plaintiff able to:
In determining Plaintiff's RFC, the ALJ weighed Plaintiff's subjective statements against objective medical evidence to find that although the impairments could be reasonably expected to cause the alleged symptoms, Plaintiff's statements concerning the intensity, persistence, and limiting effects of the symptoms were not entirely credible. Tr. 27.
At step four, the ALJ found that Plaintiff was not able to perform past relevant work as a certified nursing assistant because the job exceeded Plaintiff's capacity for less than a full range of light work. Tr. 29;
The analysis then moved to step five. The ALJ found that considering Plaintiff's education, work experience, and RFC, jobs exist in significant numbers in the national economy that Plaintiff can perform. Tr. 30. Given Plaintiff's RFC to perform light work with some limitations, the VE opined Plaintiff could work as a ticket taker, officer helper, and mailroom clerk.
Based upon the abovementioned RFC determination and the VE's testimony, the ALJ entered a finding of "not disabled." Tr. 31.
Plaintiff argues that the ALJ erred at step two by finding no severe mental impairments. The Court disagrees. So long as the ALJ rules in Plaintiff's favor by finding that any single impairment meets the severity threshold required at step two, any error the ALJ makes at step two is harmless error.
As noted above, the ALJ determined that Plaintiff was capable of performing light work with some limitations. Tr. 26. Plaintiff argues that the ALJ's RFC assessment was not supported by substantial evidence because the ALJ failed to consider or explain the basis for rejecting contrary evidence in the record.
An ALJ must consider all pertinent evidence.
Plaintiff argues that the ALJ did not provide a detailed enough credibility analysis of her subjective complaints of pain. In determining whether the claimant is disabled, the ALJ must give consideration to subjective complaints of pain, but the subjective testimony alone will not establish that a claimant is disabled. 20 C.F.R. §§ 404.1529, 416.929;
In the present matter, the ALJ found that Plaintiff's medically determinable impairments could reasonably be expected to cause her alleged symptoms, but determined that she overstated the intensity, persistence, and limiting effects of those symptoms "for the reasons explained in th[e] decision." Tr. 27. With regards to Plaintiff's back pain, Plaintiff's testimony of her daily activities and range of motion, along with medical evidence, contradicted the severity of the pain.
Additionally, there were discrepancies in Plaintiff's mental health testimony and her doctors' opinions. Dr. Rosenmann found that Plaintiff had no limitation in understanding and remembering. Tr. 345. Dr. Broska found that Plaintiff's problems were not significant enough to interfere with Plaintiff's ability to function. Tr. 351. Dr. Bruni found that Plaintiff's largest amount of mental difficulty were in terms of social functioning, due to her affinity to isolate herself. Tr. 310. As for her testimony, Plaintiff stated she tended to stay by herself, but two months later told her mental healthcare provider she would be going to Florida with a friend whom she got along with well. Tr. 59, 479, 516. She also did not account for the fact that she stopped looking for work in 2009 due to her back, but told a healthcare worker that she worked up until at least 2011 as an elderly woman's caretaker.
The ALJ appropriately evaluated Plaintiff's subjective complaints of pain. Tr. 29.
As part of his analysis, the ALJ must consider Plaintiff's treating physicians' opinions.
Plaintiff asserts that the ALJ erred in assigning some weight to the opinions of Dr. Morad, her family doctor, and Dr. Tranese, the consultative orthopedic examiner, arguing that the ALJ's conclusions were not consistent with the doctors' opinions. The Court finds these arguments to be without merit.
First, Plaintiff rests her argument on the premise that the RFC assessment must be based on a medical opinion, however, the RFC is an administrative finding reserved to the ALJ. 20 C.F.R. § 404.1456(c) (2015) ("Although we consider opinions from medical sources on issues such as [RFC] the final responsibility for deciding these issues is reserved to the Commissioner");
The ALJ cited specific reasons to support his determination, including the Plaintiff's subjective testimony that her daily activities entail showering without assistance, walking, shopping, and cooking. Tr. 56. Plaintiff is able to feed herself and bathe herself, with some difficulty putting her socks on.
Dr. Morad's opinions were only given some weight because the record evidence showed a finding that Plaintiff could perform a reduced range of light work, not the "less than sedentary" work opined by Dr. Morad. Tr. 26, 29, 301-02, 318-22. As previously discussed, Plaintiff's own testimony negated Dr. Morad's opinion, as an individual who could not perform even sedentary work would not be able to perform her daily activities. Tr. 56;
For the above reasons, the ALJ properly evaluated Plaintiff's physical limitations.
As for her mental RFC, Plaintiff argues that none of the medical opinions purportedly given weight by the ALJ in fact demonstrate she has work-related mental limitations. The Court agrees in part.
First, Plaintiff argues that even though Dr. Arlene Broska was given significant weight by the ALJ, the ALJ failed to account for any of the limitations described by her. This argument is without merit. Dr. Broska diagnosed Plaintiff with bipolar disorder, and suggested that Plaintiff has potential difficulties handling stress, making decisions in the workplace, and being easily distracted. Tr. 28;
Second, Plaintiff argues that the ALJ failed to account for the opinions from treating psychiatrist Dr. Carl Rosenmann altogether. However, Dr. Rosenmann's opinions were given some weight.
Lastly, Plaintiff argues that while the ALJ gave Dr. T. Bruni's opinion "great weight," the ALJ overlooked Plaintiff's particular limitations described by this doctor. The Court agrees. The ALJ did properly consider Dr. Bruni's observation, that Plaintiff had mild limitations of activities of daily living, mild restrictions in terms of concentration, perseverance, or pace, moderate restrictions of social functioning, and noted episodes of decompensation. Tr. 370.
Nonetheless, the ALJ failed to adopt, or contradict, Dr. Bruni's findings that Plaintiff has a marked limitation in interacting with the general public, a limitation that could have impacted her RFC.
Because the Court is unable to conduct meaningful judicial review, the Commissioner's disability determination is