CLAIRE C. CECCHI, District Judge.
Joshua Kornecki ("Plaintiff) appeals the final determination of the commissioner of the Social Security Administration ("Commissioner" or "Defendant") denying Plaintiff disability benefits under the Social Security Act. The Court has jurisdiction under 42 U.S.C. §§ 405(g) and 1383(c)(3). This motion has been decided on the written submissions of the parties pursuant to Federal Rule of Civil Procedure 78.
Plaintiff applied for disability insurance benefits ("DIB") under Title II from the Social Security Administration ("SSA") on My 27, 2009. (R. 131-139.) Plaintiff alleged disability beginning on April 1, 2009. (R. 133.) Plaintiff originally claimed that a heart attack, open heart surgery, post traumatic stress disorder ("PTSD"), anxiety, and depression limited his ability to work. (R. 151.) On appeal, Plaintiff added fatigue, dizziness, and back, neck, chest, and shoulder pain. (R. 179.) His claim was denied initially on October 21, 2009 (R. 73-77), and denied upon reconsideration on May 19, 2010. (R. 81-83.) The ALJ held a hearing in this matter on July 13, 2011. (R. 37.) In a written opinion dated September 20, 2011, the ALJ determined that Plaintiff was not disabled. (R. 17-36.) The Appeals Council denied review on April 5, 2013, rendering the ALJ's decision the final judgment of the commissioner. (R. 7-12.) Plaintiff timely filed this action.
Plaintiff was 33 years old at the onset of his alleged disability. (R. 133.) He received a Bachelor of Arts in Accounting at Brooklyn College in May of 1999 and a Juris Doctor at Hofstra School of Law in June of 2006. (R. 49, 191.) Plaintiff worked as an accountant with various firms. (R. 50-51, 191-192.) He alleged that he had his heart injury while he was working as a senior associate at PricewaterhouseCoopers LLP ("PWC"). (R. 51.) He then went on short-term disability at PWC, but was not able to receive long-term disability. (R. 52.)
The Vocational Expert at Plaintiffs hearing before the ALJ characterized Plaintiffs past fifteen years of work as an accountant as sedentary and highly skilled. (R. 64-65.)
Plaintiff alleges that his disability stems from his heart attack when he was 31. (R. 53, 62.) He claims that panic attacks, tightness in his chest, shortness of breath, fatigue, dizziness, and pain in his back, neck, chest, and shoulder limit his ability to work. (R. 151, 179.) He also claims that he is limited by PTSD, anxiety, and depression. (R. 151.) At the hearing before the ALJ, Plaintiff testified that if he has any type of pain or breathing issues, he thinks he is having a heart attack and it is difficult for him to focus. (R. 62.) He then testified that he lacks focus at times and could not be depended to be at work on time. (R. 53.) Plaintiff also claimed that he can drive, but he does not drive in busy areas because he does not trust himself to drive while on his pain medication. (R. 52.)
Plaintiff submitted two self-evaluated function reports. The first—dated in August 2009 indicates that he makes light meals, cleans, that he shops, meets friends, and plays with his children. (R. 161.) He tries to go out three times a week. (R. 163.) The second, dated three months later in December 2009, indicates almost none of these activities. (R. 342.)
Plaintiffs documentation of his medical issues begins when he was admitted to the Staten Island University Hospital ("SIUH") on December 11, 2007. (R. 214.) Plaintiff was diagnosed with a myocardial infarction. (R. 195, 214.) He was then sent to the emergency department for emergent cardiac catheterization.
On April 22, 2009, Dr. EKyahu Kopstick evaluated an MRI of Plaintiff's thoracic spine. (R. 303.) Dr, Kopstick noted postoperative changes related to the prior heart surgery.
Plaintiff visited the Overlook Hospital emergency room for chest pain and anxiety on April 30, 2010. (R. 610. 612.) He claimed that he felt down all day and became very angry and stressed and started to hyperventilate while on the treadmill. (R. 610.) He was examined by Dr. Robert D. Slama. (R. 611.) Dr. Slama found atypical chest pain, with negative ck and troponin, hypokalemia unclear etiology, and stress/anxiety disorder in Plaintiff.
On November 18, 2010, Plaintiff had a treadmill stress test administered by Dr. Rama K. Reddy. (R. 606.) During the test, Dr. Reddy reported that Plaintiff underwent 11.1 minutes of Bruce Protocol and achieved a METS of 12.9.
Cardiologist Dr. Duccio Baldari tilled out two assessments of Plaintiffs physical abilities. (R. 350-401.) On a report dated January 8, 2010, Dr. Baldari diagnosed Plaintiff with coronary artery disease and s/p coronary artery bypass grafting. (R. 350.) He then found that Plaintiff had no chest discomfort or cardiovascular symptoms. (R 352.) He also found Plaintiff capable of lifting only five pounds, standing or walking for less than two hours a day, sitting for less than six hours a day, and limited pushing/pulling as well as hearing, speaking, and traveling. (R. 353.) In his other report, Dr. Baldari filled out a cardiac impairment questionnaire dated January 8, 2010. (R. 395.) He found that Plaintiff had symptoms of chest pain, palpitations, and angina equivalent pain.
On April 26. 2010, Dr. Rambhai C. Patel completed an internal medical examination of Plaintiff. (R. 478-484.) From the physical examination, Dr. Patel reported that Plaintiff had a regular sinus rhythm without murmur or gallop. (R. 480.) Dr. Patel then found that Plaintiffs chest x-ray showed no infiltration or pleural effusion.
For Plaintiffs mental capacity, Dr. Stephen J. Wakschal provided several reports that the ALJ considered. In the record, Dr. Wakschal took progress notes from individual cognitive behavioral psychotherapy sessions with Plaintiff from December 29, 2008 until August 4, 2009. (R. 508-544.) These sessions were performed twice per month. (R. 402.) Dr. Wakschal has also filled out two psychiatric impairment questionnaires of Plaintiff with one dated December 29, 2008 until January 19, 2010 (R. 402) and the other dated May 25, 2011. (R. 621-628.) In addition. Dr. Wakschal has filled out two medical reports with one dated November 10, 2009 (R, 341) and the other dated August 31, 2010. (R. 507.)
Plaintiff was referred to Dr. Wakschal for psychotherapy sessions by Staten Island Heart physician Dr. Homayuni and has reported symptoms of PTSD. (R. 510.) From December 29, 2008 until August 4, 2009, Dr. Wakschal provided psychotherapy sessions twice per month to Plaintiff and wrote a report after each visit. (R. 402, 508-544.) The intake note written by Dr. Wakschal reported that Plaintiff was experiencing anxiety, depression, flashbacks, irritability, impaired concentration, pessimistic thinking, and recurrent dreams of trauma. (R. 511.) Dr. Wakschal then noted that Plaintiff was found well oriented, alert, his affect was blunted, his mood was empty, his eye contact was poor, and his speech was halting.
In a medical report dated November 10, 2009, Dr. Wakschal noted that Plaintiff has obsessive compulsive disorder ("CCD") and developed PTSD secondary to his having undergone open heart surgery. (R. 341.) Dr. Wakschal reported that Plaintiffs symptoms of hyper-viligilence, irritability, phobic avoidance, and cognitive defects will remain Intractable for the foreseeable future due to Plaintiffs enduring stressors.
On August, 31, 2010, Dr. Wakschal filed a report that stated Plaintiff was still participating in sessions and has been in his office six times since February 2010.
Dr. Wakschal filled out a psychiatric impairment questionnaire at some point after January 19, 2010. (R. 402.) In the questionnaire, Dr. Wakschal diagnosed Plaintiff with PTSD and OCD.
Dr. Wakschal completed the same questionnaire at some point after May 25, 2011. (R. 621-628.) Here, Plaintiff was diagnosed with PTSD. (R. 621.) There were some clinical findings that demonstrated this diagnosis, but less than the earlier questionnaire.
Dr. Joan F. Joynson. a non-examining state agency psychologist, completed a mental residual functional capacity assessment on October 14, 2009. (R. 337-340.) In this assessment, Plaintiff was found to have not significant or only minor limitations on cognition. (R. 337-338.) Dr. Joynson then explained that Dr. WaksehaPs progress notes and Plaintiffs own reports lead her to the conclusion that Plaintiff can follow complex directions, respond adequately to supervision, and adapt to workplace changes for simple work. (R. 339.)
Dr. Vasudev Makhija evaluated Plaintiff at the request of the Social Security Administration on April 13, 2010. (R. 473.) Dr. Makhija noted that Plaintiff claimed to have had lost interest in everything. (R. 473-474.) Dr. Makhija also reported that Plaintiff claims he is constantly afraid that he is going to have another heart attack, even though doctors told him that his corrective surgery made another attack unlikely. (R. 474.) Dr. Makhija observed that Plaintiff appeared to be withdrawn, his mood was anxious and depressed, but he had no thoughts of suicide. (R. 476.) Dr. Makhija then reported that Plaintiff was alert and oriented, but had difficulty with serial seven subtractions and could not spell the word "world" backwards after two attempts.
Dr. Jane Shapiro, a non-examining state agency psychologist, completed a mental residual functional capacity assessment on May 18, 2010. (R. 500-503.) In this assessment, Plaintiff was only listed as markedly limited in the ability to interact appropriately with the general public. (R. 501.) Dr. Shapiro considered Dr. Wakschal's notes from December of 2008 until August of 2009, Dr. Wakschal's assessment from January 2010, and Dr. Makhija's mental status examination in order to fill out the assessment. (R. 502.) Dr. Shapiro noted that Plaintiff is able to manage only simple instructions, concentrate sufficiently to complete only simple tasks, respond appropriately to supervision (but not to the general public), and would do best in a setting with minimal need to coordinate with others.
This court has jurisdiction to review the Commissioner's decision under 42 U.S.C. §§ 405(g) and 1383(c)(3). Courts are not "permitted to re-weigh the evidence or impose their own factual determinations." but must give deference to the administrative findings. Chandler
Pursuant to the Social Security Act, to receive DIB, a claimant must satisfy the insured status requirements of 42 U.S.C. § 423(c). In order to be eligible for Benefits, a claimant must show that he is disabled by demonstrating that he Is unable to "engage in any substantial gainful activity by reason of any medically determinable physical or mental Impairment which can be expected to result in death or which has lasted or can he expected to last for a continuous period of not less than twelve months." 42 U.8.C. §§ 423(d)(1)(A), 1382c(a)(3)(A). Taking into account the claimant's age, education, and work experience, disability will be evaluated by the claimant's ability to engage in his previous work or any other form of substantial gainful activity existing in the national economy. 42 U.S.C. §§ 423(d)(2)(A), 1382c(a)(3)(B). Thus, the claimant's physical or mental impairments must be "of such severity that he is not only unable to do his previous work but cannot, considering his age, education, and work experience, engage in any other kind of substantial gainful work which exists in the national economy . . . ."
The SSA follows a five-step sequential evaluation to determine whether a claimant is disabled within the meaning of the statute. 20 C.F.R. § 404.1520. First, the ALJ must determine whether the claimant is currently engaged in gainful activity. Sykes, 228 F.3d at 262. Second, if he is not, the ALJ determines whether the claimant has a severe impairment that limits his ability to work.
The evaluation will continue through each step unless it can be determined at any point that the claimant is or is not disabled. 20 C.F.R. § 404.1520(a)(4). The claimant bears the burden of proof at steps one. two. and four, upon which the burden shifts to the Commissioner at step five.
When determining Plaintiffs RFC the ALJ found that Plaintiff could "lift or carry 20 pounds occasionally and 10 pounds frequently; stand or walk for 6 hours in an eight hour work day; sit for 6 hours in an eight hour work day; and perform unlimited pushing or pulling within the weight restriction given." (R. 24.) Moreover, the ALJ found that Plaintiff is able to perform jobs that require no use of ladders, ropes, or scaffolds; that require frequent use of ramps or stairs: that require occasional balancing, stooping, kneeling, crouching, and/or crawling; and that require no exposure to unprotected heights, hazards or dangerous machinery. Id Furthermore, the ALJ found that "as to the mental demands of work . . . claimant is able to perform jobs: that are unskilled, and repetitive; that permit at least three breaks during the workday-each of at least 15 minutes duration; that are low stress . . .; that require no work in close proximity (closer than 3-5 feet) to others to avoid distraction; and that require occasional contact with supervisors, co-workers, and no contact with the general public." (R. 24-25.)
Plaintiff contends that the A LJ erred in its determination of Plaintiffs RFC by (1) not following the treating physician rule and (2) not properly evaluating Plaintiffs credibility. (Pl. Br. 17-22, 22-26.) The court addresses each in turn.
The so-called `treating physician rule* states that the ALJ should give a treating physician's opinion regarding the severity of an alleged impairment "controlling weight" if the opinion "is well-supported by medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with other substantial evidence." 20 C.F.R. § 404.1527(c)(2)(2012);
Plaintiff sets forth two arguments for why the ALJ failed to properly follow the treating physician rule. First, Plaintiff alleges that the ALJ erred by not giving treating psychologist Dr. Wakschal"s opinions controlling weight. (Pl. Br. 21.) Second, Plaintiff argues that the ALJ erred by not evaluating Dr. RWakschal's opinion according to the factors set forth in 20 CFR §§ 404.1527(c)(2)-(6) and SSR 96-2p. (Pl. Br. 21-22.) The Court finds neither argument persuasive.
Plaintiff argues that because the opinions from treating psychologist Dr. Wakschal are supported by appropriate findings and are uncontradicted by substantial evidence, then these opinions should have been controlling. (Pl. Br. 21.) Defendant disagrees, arguing that Dr. Wakschal's determination was contradicted by other substantial evidence in the administrative record. Defendant argues that the ALJ's reliance on this substantial evidence should not be disturbed by this Court. The Court agrees.
First, the ALJ found Dr. Wakschal's opinions are contradicted by the Plaintiffs reported activities of daily living. (R. 29.) It is proper for an ALJ to consider whether daily activities contradict a treating physician's opinion.
The ALJ's opinion also contrasts Dr. Wakschal's opinion with the opinion of state agency psychologist, Dr. Shapiro. (R. 29.) The opinion notes that while Dr. Shapiro's conclusions are well supported, Dr. Wakschal's "are not supported by the record." (
Here, the ALJ reported that Dr. Shapiro's conclusions are consistent with the residual functional capacity while Dr. Wakschal's opinions arc not. (R. 29.) Dr. Shapiro noted that Plaintiff is able to manage only simple instructions, concentrate sufficiently to complete only simple tasks, respond appropriately to supervision (but not to the general public), and would do best in a setting with minimal need to coordinate with others. (R. 502.)
Plaintiff notes that Dr. Shapiro's evaluation of the record excluded a medical report and second questionnaire submitted by Dr. Wakschal. (Pl. Br. 17). Plaintiff argues that this renders Dr. Shapiro's opinion unreliable. (
Accordingly, the record supports the ALJ's holding that Dr. Wakschal's opinions were not controlling pursuant to 20 C.F.R. § 404.1527.
If the treating physician's opinion is not given controlling weight, the ALJ applies the factors listed in 20 C.F.R. § 404.1527(c)(1)-(6) to determine the appropriate weight to give a medical opinion.
The ALJ must consider all of the evidence and may weigh the credibility of that evidence, but must give some indication of the evidence that was rejected and the reasoning for rejecting it.
The ALJ's decision to not accord Dr. Wakschal's opinions controlling weight was supported. As set forth in the preceding section, the ALJ's found that Dr. Wakschal's opinions were inconsistent with the record. The ALJ specifically noted that Dr. Wakschal's opinions were inconsistent with the Plaintiffs reported activities of daily living, visit to the emergency room in 2010, and Dr. Shapiro's opinion. (R. 29.) Thus, ALJ followed the standard set forth in
Plaintiffs final contention is that the ALJ failed to properly credit Plaintiffs testimony. (Pl. Br. 22-26.) Plaintiff alleges that the ALJ did not consider the factors enumerated in SSR 96-7p prior to making the RFC determination. (Pl. Br. 25-26.) Plaintiff claims that "[t]he regulations at 20 C.F.R. § 404.1529(c)(4) instruct the ALJ to evaluate the consistency of a claimant's statements not against the adjudicator's own RFC finding, as the ALJ did here, but rather instruct the ALJ to compare the claimant's testimony against the evidence of the record." (Pl. Br. 20.)
In evaluating a claimant's testimony regarding symptoms and pain, an ALJ must first determine whether there is a medically determinable impairment that could reasonably be expected to produce the alleged pain or symptoms. 20 C.F.R. § 404.1529. When impairment is found, a claimant's statements about their pain and symptoms do not alone establish disability. 20 C.F.R. § 404.1529(a);
Here, the ALJ first found that Plaintiffs medically determinable impairments could be expected to cause the alleged symptoms. (R. 26.) The ALJ then found that "the claimant's statements concerning the intensity, persistence, and limiting effects of these symptoms are not credible to the extent that they are inconsistent with the above residual capacity assessment."
In the ALJ's examination of the evidence, she found that Plaintiffs reported activity is inconsistent with his follow-up visits with Dr. Wakschal. (R. 29.) The ALJ did not find Plaintiffs inability to perform concentration exercises with Dr. Makhija indicative of Plaintiffs functioning. (R. 29.) The ALJ supported this finding by reporting that Plaintiff was listed to have intact memory and concentration by Dr. Wakschal's mental status examination
For the foregoing reasons, the ALJ's decision that Plaintiff is not disabled within the meaning of the Social Security Act is hereby affirmed. An appropriate order accompanies this Opinion.