CLAIRE C. CECCHI, District Judge.
Raid El Fadly ("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 under Title II ("DIB") and supplemental security income under Title XVI ("SSI," collectively "Benefits") from the Social Security Administration ("SSA") on February 4, 2010. (R. 165-75.) Plaintiff alleged disability beginning on December 7, 2008. (R. 165, 172.) Plaintiff's claim was denied initially on August 26, 2010. (R. 92-96.), and Plaintiff requested an administrative hearing on October 5, 2010. (R. 97.) The ALJ held a hearing in this matter on August 19, 2011 (R. 33-64), and a supplemental hearing on February 1, 2012 (R. 65-80.) In a written opinion dated March 5, 2012, the ALJ determined Plaintiff was not disabled. (R. 22-28.) The Appeals Council denied review on March 19, 2012, rendering the ALJ's decision the final judgment of Defendant. (R. 5-9.) Plaintiff timely filed this action.
Plaintiff was 44 years old at the onset of his alleged disability. (R. 165-66.) Plaintiff was employed as a taxi driver and dispatcher in North Bergen, NJ from 1999 to 2009. (R.39-40; 231.)
The Vocational Expert at Plaintiff's hearing before the ALJ characterized Plaintiff's past taxi driving as medium work, and his past taxi dispatching as sedentary. (R. 55.)
Plaintiff claims he suffers from depression, brittle diabetes impairment, hypertensive cardiovascular disease, anxiety, and coronary artery disease. (Pl. Compl. 1.) Plaintiff testified that he feels pain in his chest upon minimal exertion, such as walking up stairs or beyond a few blocks. (R. 41.) He experiences shortness of breath and occasional sweating. (
Plaintiff originally alleged that he became disabled and unable to work on or about December 7, 2008. (Pl. Compl. 1.) Plaintiff was treated for chest pain in the emergency room at Jersey City Medical Center on December 3, 2008. (R. 392.) He returned to the hospital with similar symptoms on December 7, 2008. (R. 323.) Doctors determined that Plaintiff was experiencing systolic heart failure and gave Plaintiff a left heart catheterization. (
Plaintiff was treated for chest pain at White Memorial Medical Center on April 24, 2009. (R. 476.) Plaintiff received his second catheterization and was diagnosed with coronary artery disease and cardiomyopathy, with an ejectment fraction of 20%. (R. 482.) Plaintiff was scheduled to receive an implantable cardioverter-defibrillator (ICD), but refused the procedure against doctors' advice. (R. 478.)
On June 28, 2009 Plaintiff was admitted to Scripps Mercy Hospital upon feeling chest pressure. (R. 501.) An ICD was implanted in the Plaintiff's chest and he was discharged with an ejection fraction of 30-35%. (
Plaintiff's ICD was reprogrammed at Scripps in December of 2009, in response to chest pain and occasional diaphragmatic stimulation. (R. 487-88.) This reprogramming turned off the leads to Plaintiff's left ventricle and minimized pacing in the right. (R. 490.) Doctors programed Plaintiff's ICD to only function as a defibrillator (
On July 6, 2010 Dr. Rocely Ella Tamayo examined the Plaintiff and his medical records at the request of the Defendant. (R. 592-98.) Dr. Tamayo diagnosed Plaintiff with diabetes mellitus, hypertension, tenderness from his defibrillator, nicotine abuse and a history of coronary artery disease. (R. 597.) In her functional analysis, Dr. Tamayo determined that Plaintiff could lift and carry twenty pounds occasionally and ten pounds frequently, albeit with limitations to his left arm. (
Dr. Ashraf Elamashat performed a psychiatric evaluation of Plaintiff on August 13, 2010. (R. 600-05.) Dr. Elamashat diagnosed Plaintiff with an unspecified depressive disorder and alcohol dependence in remission. (R. 604.) He assigned Plaintiff a Global Assessment of Functioning (GAF) score of 60. (
Medical/psychological consultant Dr. Tashjian evaluated Plaintiff's mental impairment on a form mirroring the standards set forth in 20 C.F.R. §§ 404.1520a and 416.920a. (R. 614). Dr. Tashjian reported that Plaintiff had a medically determinable, but non-severe, mental impairment. (R. 606.)
Cardiologist Dr. Anthony Inguaggiato began treating Plaintiff in June or July of 2010. (Compare R. 702 (July 22, 2010 listed as "1st Exam"), with R. 705 (June 29, 2010 listed as date of first treatment)). In an examination on July 29, 2010, Dr. Inguaggiato diagnosed Plaintiff with congestive heart failure, diabetes mellitus and degenerative joint disease. (R. 702.) He reported that Plaintiff could not work because of his heart condition and that this disability would continue for twelve months or more. (R. 703.)
On June 24, 2011 Dr. Inguaggiato completed a cardiac impairment questionnaire. (R. 705-10.) He diagnosed Plaintiff with Class "II/III" congestive heart failure with an ejection fraction of 25%. (R. 705.) The doctor reported that Plaintiff showed signs of depression and anxiety related to his chest pain. Dr. Inguaggiato estimated that Plaintiff could sit for 5 or 6 hours a day, but could not stand or walk for over an hour, nor lift or carry any weight. (R. 707-08.) He opined that Plaintiff's pain was a constant interference with his ability to concentrate and that Plaintiff was incapable of low stress work. (R. 708.)
Dr. Inguaggiato reiterated this prognosis in his Examining Physician's Report, dated August 2, 2011, in which he opined that the Plaintiff was currently unable to work part-time and would never be able to return to full-time employment. (R. 720.) On this exam, Dr. Inguaggiato indicated Plaintiff had Class II heart failure. (R. 717.) Dr. Inguaggiato measured Plaintiff's ejection fraction at "~30%" on August 8, 2011. (R. 721.) On January 23, 2012, Dr. Inguaggiato signed a letter stating that Plaintiff was totally disabled and that drug and/or alcohol abuse was not a material cause of the disability. (R. 731.)
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.
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 she is disabled by demonstrating that she 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 be expected to last for a continuous period of not less than twelve months." 42 U.S.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 her 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, 416.920. First, the ALJ must determine whether the claimant is currently engaged in gainful activity.
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), 416.920(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.
In step two of the SSA's disability analysis the ALJ must determine whether the claimant has a medically determinable impairment or combination of impairments that are "severe."
The ALJ ruled that Plaintiff's only "severe" impairment under the Regulations was coronary artery disease. (R. 24.) The ALJ determined that Plaintiff's other claimed impairments: hypertension, diabetes, sleep apnea, history of resolved alcoholic cardiomyopathy, and depressive disorder, were non-severe. (R. 25.)
Plaintiff contends that the ALJ erred in finding his mental impairments non-severe. (Pl. Br. 14-16.) The Court disagrees. The ALJ's mental impairment determination is supported by substantial evidence. In reaching his conclusion, the ALJ relied upon the report of Dr. Elamashat, and Dr. Tashjian's psychiatric review. (R. 25.) Although Dr. Elamashat diagnosed Plaintiff with depressive disorder, he found no functional limitations. (R. 604-05.) Similarly, Dr. Tashjian's review of Plaintiff's file indicated that Plaintiff's limitations were not severe.
In an attempt to overcome these findings, Plaintiff contends that the ALJ should have credited Dr. Inguaggiato's Cardiac Impairment Questionnaire of June 24, 2011 and Dr. Gerber's oral testimony as evidence that Plaintiff's mental impairment was severe. (Pl. Br. 15-16.) The ALJ's decision to the contrary is supported by the Record.
First, the ALJ correctly noted that Dr. Inguaggiato's functional assessment that Plaintiff was unable to work did not indicate "longitudinal mental health treatment." (R. 25-27.) Accordingly, he specifically credited Dr. Elamashat's testimony instead. (R. 25-27.) Second, Dr. Gerber's testimony does not relate to Plaintiff's impairment and so does not provide evidence as to whether the impairment was "severe." Dr. Gerber stated generally that psychological factors can impact cardiac conditions. (R. 77.) Dr. Gerber also specifically stated that his opinion was not addressing non-physical impairments. (R. 69.) Accordingly, the ALJ's decision with respect to Plaintiff's mental impairments is supported by substantial evidence.
When determining Plaintiff's RFC the ALJ found that Plaintiff could "lift and carry 20 pounds occasionally and 10 pounds frequently; stand and walk 6 hours out of an 8-hour day; sit for 6 hours out of an 8-hour day; and is precluded from above the shoulder reaching with the right upper extremity."
Plaintiff contends that the ALJ erred in its determination of Plaintiff's RFC by (1) not following the treating physician rule and (2) not properly crediting Plaintiff's testimony at the first oral hearing. (Pl. Br. 11-14, 17-21.) The Court addresses each in turn.
Plaintiff sets forth two arguments for why the ALJ failed to follow the treating physician rule, which governs how a treating physician's opinion must be evaluated. First, he argues that the ALJ erred by not identifying substantial non-opinion evidence contradicting Dr. Inguaggiato's opinion, and so Dr. Inguaggiato's opinion should control. (Pl. Br. 13.) Second, he argues that the ALJ erred by not evaluating Dr. Inguaggiato's opinion according to the factors set forth in 20 CFR §§ 404.1527 and 416.927. (Pl. Br. 13-14.) Neither argument is convincing.
A treating physician's opinion is given controlling weight when it is (1) "well supported by medically acceptable clinical and laboratory diagnostic techniques" and (2) "is not inconsistent with the other substantial evidence in [the claimant's] case record."
In weighing this contradictory evidence, the ALJ also determined that Dr. Inguaggiato's handwritten calculations were unreliable, based on medical expert testimony. (R. 26-27.)
Accordingly, due at least to the found inconsistency between Dr. Inguaggiato and the Record, the ALJ properly found that Dr. Inguaggiato's opinions were not controlling pursuant to 20 C.F.R. §§ 404.1527, 416.927.
If not given controlling weight, the ALJ must determine the weight given to the treating physician's opinion based on the following factors: length of treatment relationship and frequency of exam; nature and extent of treatment relationship; supportability; consistency; specialization; and other relevant factors brought to the ALJ's attention. 20 C.F.R. §§ 404.1527, 416.927;
An essential element of an ALJ determination on evidence is to provide reasons for its decision. When there is a conflict between medical sources, "the ALJ may choose whom to credit but `cannot reject evidence for no reason or for the wrong reason.'"
In regards to weighing a non-treating source over a treating source, an ALJ "may reject a treating physician's opinion outright only on the basis of contradictory medical evidence, but may afford a treating physician's opinion more or less weight depending upon the extent to which supporting explanations are provided."
The ALJ's decision to not accord Dr. Inguaggiato's opinions "significant weight" was supported. Unlike
Plaintiff's final contention is that the ALJ failed to properly credit Plaintiff's testimony. (Pl. Br. 17-21.) Plaintiff objects to the ALJ's finding that his alleged symptoms are "not credible to the extent they are inconsistent with the above residual functional capacity assessment." (R. 26.) In particular, Plaintiff alleges that the ALJ did not consider the factors enumerated in SSR 96-7p when evaluating Plaintiff's testimony regarding his chest pain, shortness of breath, fatigue, stress, and memory loss. (Pl. Br. 21, 9-10.)
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, 416.929. When impairment is found, the ALJ must evaluate a claimant's subjective statements in relation to the objective evidence and other evidence. 20 C.F.R. §§ 404.1529(c)(4), 416.929(c)(4);
The ALJ specifically discussed Plaintiff's testimony with respect to his daily activities and symptoms, and considered factors such as exertion that aggravate the symptoms. (R. 26.) The ALJ then noted the treatment that Plaintiff had received for these symptoms. (
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.