ANN M. DONNELLY, District Judge.
The plaintiff, Theresa Johnson, brings this action appealing the Commissioner of Social Security's decision that she is not disabled for purposes of receiving Supplemental Security Income ("SSI") payments under Title XVI of the Social Security Act. For the reasons that follow, I grant the plaintiffs motion for judgment on the pleadings, deny the Commissioner's cross-motion, and remand the case for further proceedings.
On August 11, 2014, the plaintiff applied for SSI with an onset date of November 30, 2013 (Tr. 239-44), alleging disability because of depression, anxiety, bipolar disorder, anemia, and high blood pressure. (Tr. 152, 260.) On November 1, 2016, Administrative Law Judge ("AU") David Tobias held a hearing, at which the plaintiff and a vocational expert testified. (Tr. 117.) In a January 13, 2017 decision, the All found that the plaintiff had severe impairments of dysthymic disorder, depressive disorder, and bipolar disorder, but that she was not disabled because her impairments—individually, or in combination—were not severe enough to meet or medically equal the criteria listed in the Social Security regulations. (Tr. 166-70, 176.) The All determined that the plaintiff had the residual functional capacity ("RFC") to perform a full range of work at all exertional levels, except that her work had to be "low stress," could not "involve more than occasional, superficial interaction[s] with coworkers or the public," or require her "to carry out complex tasks or instructions." (Tr. 170-71.) AU Tobias concluded that the plaintiff could not return to her prior jobs as a child monitor and grounds keeper, but that she could perform other jobs that existed in the national economy. (Tr. 175-76.)
On December 11, 2017, the Appeals Council denied the plaintiff's request for review (Tr. 1-6), and the plaintiff appealed on February 12, 2018. (ECF No. 1.) Both parties moved for judgment on the pleadings. (ECF Nos. 12-1, 15.)
A district court reviewing a final decision of the Commissioner "must determine whether the correct legal standards were applied and whether substantial evidence supports the decision." Butts v. Barnhart, 388 F.3d 377, 384 (2d Cir. 2004), as amended on reh'g in part, 416 F.3d 101 (2d Cir. 2005). If there is substantial evidence in the record to support the Commissioner's factual findings, they are conclusive and must be upheld. 42 U.S.C. §405(g). "Substantial evidence" means "more than a mere scintilla. It means such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Richardson v. Perales, 402 U.S. 389, 401 (1971) (quoting Consolidated Edison Co. v. NLRB, 305 U.S. 197, 229 (1938)) (internal quotation marks omitted). A district court should remand the case when "the Commissioner has failed to provide a full and fair hearing, to make explicit findings, or to have correctly applied the. . . regulations." Manago v. Barnhart, 321 F.Supp.2d 559, 568 (E.D.N.Y. 2004).
All Tobias held a hearing on the plaintiff's application for benefits and reviewed the plaintiff's medical records, including the records of the psychiatric treatment by Dr. Sonea Mahboob, who concluded that the plaintiff had a marked loss in her ability to deal with stress of work and complete a normal workweek without interruption, and would be absent from work "more than 3 times a month." (Tr. 407-08.) The ALJ decided that the doctor's opinion was entitled to little weight because it was "not supported by treatment records and [was] largely conclusory in nature." (Tr. 173.) The plaintiff challenges that decision, and maintains that the ALJ should have given controlling weight to Dr. Mahboob's opinion. (ECF No. 12-1 at 10). For the reasons that follow, I remand the case for the ALJ to reconsider Dr. Mahboob's opinion and explain his decision.
"The `treating physician' rule requires that the opinion of a claimant's treating physician be accorded `controlling weight' if it is well supported and not inconsistent with other substantial evidence in the record." Corporan v. Comm'r of Soc. Sec., No. 12—CV-6704, 2015 WL 321832, at *4 (S.D.N.Y. Jan. 23, 2015) (citing Shaw v. Chafer, 221 F.3d 126, 134 (2d Cir. 2000)); 20 C.F.R. §
An All who decides that the treating physician's opinion should not be given controlling weight must "comprehensively set forth his [or her] reasons for the weight assigned to a treating physician's opinion." Burgess v. Astrue, 537 F.3d 117, 129 (2d Cir. 2008) (quoting Halloran v. Barnhart, 362 F.3d 28, 33 (2d Cir. 2004) (internal quotation marks omitted); 20 C.F.R. § 404.1527(c)(2). In determining whether a treating source's opinion warrants controlling weight, the All must consider: "(1) the frequency, length, nature, and extent of treatment; (2) the amount of medical evidence supporting the opinion; (3) the consistency of the opinion with the remaining medical evidence; and (4) whether the physician is a specialist." Selian v. Astrue, 708 F.3d 409, 418 (2d Cir. 2013); see Burgess, 537 F.3d at 129. "Failure to provide `good reasons' for not crediting" a treating physician's opinion constitutes grounds for remand. Snell v. Apfel, 177 F.3d 128, 133 (2d Cir. 1999) (quoting Schaal v. Apfel, 134 F.3d 496, 505) (internal quotation marks omitted); see Halloran, 362 F.3d at 33 ("We do not hesitate to remand when the Commissioner has not provided `good reasons' for the weight given to a treating physicians opinion.").
Dr. Mahboob, a psychiatrist at the Interfaith Medical Center, saw the plaintiff for the first time in December of 2013, when the WeCare Program
On July 15, 2016, Dr. Mahboob submitted a medical source statement in which she noted that the plaintiff suffered from "mood disturbance," "emotional lability," "paranoia or inappropriate suspiciousness," and "social withdrawal or isolation." (Tr. 406.) In Dr. Mahboob's opinion, the plaintiff would be absent from work "more than 3 times a month" because of these impairments. (Tr. 407.) The plaintiff had a marked loss in her ability to "maintain attention and concentration for extended periods," "maintain regular attendance and be punctual," "sustain an ordinary routine without special supervision," "deal with stress of semi—skilled and skilled work," "complete a normal workday or workweek without interruptions from psychologically based symptoms," and "perform at a consistent pace without an unreasonable number and length of rest periods." (Tr. 408.) The plaintiff would have moderate difficulties "maintaining social functioning," and frequent "deficiencies of concentration, persistence or pace resulting in failure to complete tasks in a timely manner," as well as repeated "episodes of deterioration or decompensation in work." (Tr. 409-10.)
The All assigned little weight to Dr. Mahboob's medical source statement, concluding that it was "not supported by treatment records and [was] largely conclusory in nature." (Tr. 173.) All Tobias also found that Dr. Mahboob's opinion was inconsistent with "recent mental status examinations [that] showed that the claimant was well related and cooperative" (id.); he did not identify the examinations to which he was referring. Nor did he explain why the plaintiff's seeming cooperation at her examination was inconsistent with the inability to maintain a regular work schedule. (Tr. 408.) The ALI cited Dr. Mahboob's observation that "the claimant's memory was normal and her thought content was logical" as inconsistent with her ultimate diagnosis, but did not explain why. (Tr. 173.)
Moreover, substantial evidence in the record—including the conclusions of other professionals—supports Dr. Mahboob's opinion. See 20 C.F.R. § 404.1527(c)(2); Tanner v. Colvin, No. 10-CV-1308, 2014 WL 2215762, at *5 (N.D.N.Y. May 28, 2014). In August of 2014, psychiatrist Dr. Richard Storch saw the plaintiff, and noted that she was "tearful throughout the visit" and seemed to be "conflicted and tense with a sad mood and affect;" she was "unkempt" and was not eating or sleeping much. (Tr. 372.) According to notes taken during another examination, the plaintiff's depression and anxiety affected her physical condition, and "emotional factors contribute[d] to the severity of [her] symptoms and functional limitation." (Tr. 343-44.) The plaintiff was "incapable of performing even `low stress' work," and could sit, stand, or walk for less than two hours in an eight hour workday (Tr. 344, 346); the plaintiff would be "off-task" 25% or more of a typical workday, when her symptoms were "likely [to] be severe enough to interfere with attention and concentration needed to perform even simple work tasks" (Tr. 346).
Ms. Lawford Smith, the plaintiff's treating social worker, saw her weekly beginning in December of 2013; her observations—made two years before Dr. Mahboob's medical source statement—are similar to Dr. Mahboob's. In Ms. Smith's view, the plaintiff was "overwhelmed," and her symptoms included "frequent crying," a "depressed mood, irritable feelings, [and] poor concentration;" the plaintiff also had "difficulty thinking or concentrating," "persistent disturbances of mood or affect," and "emotional withdrawal or isolation." (Tr. 337-38.) The plaintiff was "seriously limited"
The plaintiff also objects to the ALJ's evaluation of Dr. John Miller, a consulting psychiatrist who examined the plaintiff only once, and concluded that she had no limitations to maintain a regular work schedule and deal with stress; the All gave greater weight to Dr. Miller's opinion than Dr. Mahboob's opinion. According to Dr. Miller, the plaintiff complained of "recurring depressive episodes . . ., crying spells, feelings of hopelessness, irritability, and social withdrawal." (Tr. 400.) Dr. Miller observed that the plaintiff had "excessive apprehension and worry," "no friends," and "difficulty relating with others and coping with stress." (Tr. 401-02.) Nevertheless, Dr. Miller found that the plaintiff had "no limitation in her ability to . . . relate adequately with others and deal appropriately with stress," "to follow and understand simple directions and instructions, perform simple tasks independently, maintain attention and concentration, maintain a regular schedule, learn new tasks, perform complex tasks independently, [and] make appropriate decisions." (Tr. 402.) All Tobias accorded some weight to Dr. Miller's opinion, but did not explain why, other than to say that Dr. Miller's opinion was "based on a complete mental examination." (Tr. 173). That explanation is not enough to justify the decision to afford greater weight to a consultative examiner's opinion. See Floyd v. Colvin, No. 13—CV-4963, 2015 WL 2091871, at *8 (E.D.N.Y. May 5, 2015) (The All did not adequately explain why he accorded significant weight to the opinion of a non-treating physician, who examined the plaintiff once.). A complete explanation is particularly important in these circumstances, since Dr. Miller's ultimate conclusion is not entirely consistent with his descriptions of the plaintiffs condition.
On remand, the ALT should reconsider his assessment of Dr. Mahboob's and Dr. Miller's opinions. If he finds that Dr. Mahboob's opinion is not entitled to controlling weight, he should set forth the reasoning behind that decision. After weighing the medical source opinions, the All should reconsider the plaintiff's RFC in light of all of the relevant medical and other evidence in the record.
Accordingly, the plaintiff's motion for judgment on the pleadings is granted, the Commissioner's cross-motion is denied, and the case is remanded for further proceedings consistent with this opinion.