KATHERINE B. FORREST, District Judge.
Plaintiff Irmastene Francine Clarke seeks review, pursuant to 42 U.S.C. § 405(g), of the decision by defendant Commissioner of Social Security ("Commissioner"), finding that she was not disabled and not entitled to Supplemental Security Income benefits under Title XVI of the Social Security Act. The parties have filed cross-motions for judgment on the pleadings. Plaintiff argues that the Commissioner made several errors in her decision and requests that the decision be reversed and plaintiff's claim be remanded for an award and calculation of benefits, or, in the alternative, for further proceedings. The Commissioner opposes, arguing that the decision was legally correct and supported by substantial evidence. For the reasons set forth below, the Court GRANTS plaintiff Clarke's motion for judgment on the pleadings and DENIES the Commissioner's cross-motion for judgment on the pleadings. As described below, this case is therefore remanded for calculation and disbursement of benefits.
Plaintiff Irmastene Francine Clarke filed an application for Supplemental Security Income ("SSI") benefits on March 28, 2012. (Tr. 143-151.) The Social Security Administration ("SSA") denied the application. (Tr. 68-69, 72-83.) Plaintiff then requested an administrative hearing, Tr. 85-86, which took place before an administrative law judge ("ALJ") on June 3, 2013, Tr. 44-67. The ALJ, before whom plaintiff and her attorney appeared, issued a decision finding that plaintiff was not disabled and not eligible for monthly SSI benefits. (Tr. 24-38.) The ALJ's decision became the final decision of the Commissioner of Social Security ("Commissioner") when the Appeals Council denied plaintiff's request for review on January 28, 2015. (Tr. 1-6.)
Plaintiff was born in August 1967. (Tr. 143.) She attended school through the tenth grade (in special education) and had past work experience primarily as a home aid. (Tr. 48, 54, 178-79, 192.) Plaintiff testified that she was disabled due to manic-depressive disorder, schizophrenia, diabetes, asthma, and high blood pressure. Plaintiff reported multiple instances of past sexual and physical abuse. (Tr. 238, 331, 350, 506.) Plaintiff also reported past substance abuse issues. (Tr. 53.)
Dr. Elva Naco is plaintiff's treating psychiatrist at the Center for Urban Community Services (also referred to as the Jericho Project). (Tr. 234-40, 521-25, 539-608.) Dr. Naco saw plaintiff on November 20, 2010, February 19, 2011, and March 19, 2011, and on an approximately monthly basis from May 2012 through March 2013. (
Using the multi-axial system of assessment,
On May 5, 2012, plaintiff reported to Dr. Naco that plaintiff had been clean and sober for six weeks, but that she continued to experience mood swings, poor focus, and periods of irritability. (Tr. 237.) Dr. Naco noted that plaintiff appeared well-groomed and wore casual and clean clothes. (Tr. 238.) Dr. Naco reported that plaintiff experienced ongoing symptoms of insomnia, flashbacks from past rapes, decreased focus, anger, and mood swings. (
On May 5, 2012, Dr. Naco also detailed her medical opinion on the severity of plaintiff's bipolar disorder in a Psychiatric/Psychological Impairment Questionnaire. Dr. Naco noted clinical evidence of poor memory, sleep and mood disturbances, substance dependence, intrusive recollections of traumatic experience, difficulty concentrating, and hostility/irritability. (Tr. 275.) Dr. Naco assessed that plaintiff had no limitations of her abilities to understand, remember and carry out one or two step instructions; ask simple questions, or request assistance; be aware of normal hazards; take appropriate precautions; and travel to unfamiliar places or take public transportation. (Tr. 277-79.) She assessed that plaintiff had mild limitations of her abilities to make simple work-related decisions. (Tr. 278.)
Dr. Naco further opined that plaintiff was markedly limited — defined as being effectively precluded from performing the activities in a meaningful manner — in her ability to perform activities within a schedule, maintain regular attendance, and be punctual with customary tolerance; work with or near others without being distracted; set realistic goals or make plans independently; and complete a workweek without interruption from psychologically based symptoms. (Tr. 276-279.) Dr. Naco assessed that plaintiff was moderately limited — defined as significantly limited but not totally precluded — in her ability to remember locations and work-like procedures; understand, remember, and carry out detailed instructions; maintain attention and concentration for extended periods; sustain ordinary routine without supervision; interact appropriately with the general public; accept instructions and respond appropriately to criticism from supervisors; get along with co-workers or peers without distracting them or exhibiting behavioral extremes; maintain socially appropriate behavior and adhere to basic standards of neatness and cleanliness; and respond appropriately to changes in the work setting. (Tr. 276-78.)
On May 5, 2012, Dr. Naco also completed a separate questionnaire for the Social Security Administration ("SSA") opining that plaintiff was unable to work. Dr. Naco further opined that plaintiff had limited understanding and memory due to poor focus and limited sustained concentration and persistence, social interaction, and adaptation due to mood swings, racing thoughts and irritability. (Tr. 514-19, duplicated at Tr. 609-12, 615.) In this report, Dr. Naco included mental status findings, indicating that plaintiff's thought process was goal-directed, but that plaintiff's mood was irritable and angry at times; she had occasional mood swings and her affect was reactive. (Tr. 616.) Plaintiff's ability to perform calculations was fair due to diminished focus. (
On May 19, 2012, Dr. Naco responded to the SSA's request for specific examples to support her conclusion that plaintiff was limited with respect to her abilities in understanding and memory, sustained concentration, social skills, and adaptation. (Tr. 497, duplicated at Tr. 603.) Dr. Naco responded that her report was based upon her own observations that plaintiff was "quite hyper" and needed redirection and was "easily irritable, nervous, and impatient" during severe mood swings, causing problems with focus and memory. (
On October 20, 2012, Dr. Naco completed a FEGS WeCare Medical report. (Tr. 234.) Plaintiff's diagnoses were bipolar disorder, PTSD, and cocaine abuse in partial remission. (
On March 2, 2013, Dr. Naco completed a second Psychiatric/Psychological Impairment Questionnaire that recorded findings generally unchanged from the first questionnaire completed on May 5, 2012. (Tr. 618-625.) Dr. Naco reported that plaintiff's use of drugs and/or alcohol was a symptom of her condition or form of self-medication, and that plaintiff's disability was independent of any substance use. (Tr. 626.)
From October 2012 through April 2013, plaintiff also saw Eloisa Negron Rodriguez, a licensed social worker, in the medical office of Dr. Indrani Persaud, plaintiff's primary care physician. (Tr. 638-39, 642-43, 647-56, 663, 686, 695, 715-18, 721.) Ms. Rodriquez saw plaintiff approximately monthly, providing therapeutic counseling for complaints of depression.
In addition, plaintiff was seen by Dr. Persaud for medical care. Dr. Persaud saw plaintiff anywhere from once a month to once in six months. (Tr. 242.) On July 18, 2012, Dr. Persaud completed a "Multiple Impairment Questionnaire" diagnosing plaintiff with uncontrolled diabetes, asthma, bipolar disorder, schizophrenia, and bilateral leg pain. (
Dr. Persaud opined that in an eight-hour workday, plaintiff could sit for one hour and stand/walk one hour. (
Dr. Persaud stated that plaintiff's condition would interfere with her ability to keep her neck in a constant position and that her symptoms would interfere with her attention and concentration. (Tr. 246-47.) Stress impacted plaintiff's symptoms, and according to Dr. Persaud, she was therefore unable to tolerate even low stress work. (Tr. 247.) Dr. Persaud indicated that plaintiff would regularly need to take unscheduled breaks of one hour, Tr. 247, and miss work more than three times a month, Tr. 248. In addition, from a check off list, Dr. Persaud indicated that plaintiff had psychological limitations; had to avoid noise, fumes, gases, temperature extremes, humidity, dust, and heights; had limited vision; and was unable to pull, kneel, bend or stoop. (Tr. 248.)
On October 23, 2012, Dr. Persaud completed a medical report for the FEGS WeCare program. (Tr. 232-33.) She diagnosed plaintiff with diabetes, asthma and bipolar disorder. (Tr. 232.) She noted that plaintiff was alert and oriented times three (she had orientation of time, place, and person). (Tr. 232.) Plaintiff had a normal physical examination with the exception of bilateral expiratory wheezing. (Tr. 232.) Despite medication, her diabetes was uncontrolled. (Tr. 232.) Plaintiff's asthma was mild and persistent. (Tr. 233.) Her bipolar disorder was in "remitting course." (Tr. 233.) Dr. Persaud indicated that plaintiff had no functional limitations, but that she was unable to work for at least twelve months due to depression and mood swings. (Tr. 233.)
On May 14, 2012, Howard Tedoff, Ph.D. conducted a consultative psychiatric assessment of plaintiff at the request of SSA. (Tr. 505-08.) Plaintiff reported sobriety for the past year. (Tr. 506.) She complained of hearing voices and seeing faces. (
Plaintiff was cooperative during a mental status examination. (
Plaintiff was tearful about her history; her affect was congruent with her speech and thought content. (
Dr. Tedoff opined that plaintiff was able to follow and understand simple directions and instructions and perform simple tasks independently, and that she had adequate attention and memory to perform the demands of simple tasks. (
On May 14, 2012, Dr. Sharon Revan conducted a consultative internal medicine examination of plaintiff at the request of SSA. (Tr. 509-11.) Dr. Revan assessed diabetes, asthma, bipolar disease, and depression. (Tr. 511-12.) Dr. Revan noted that plaintiff had numbness and spasm in her hands and feet. (Tr. 509.) Plaintiff reported blurred vision and elevated liver function test results. (
Finally, on June 8, 2012, Dr. V. Reddy reviewed plaintiff's file as a nonexamining consulting physician for the SSA. Dr. Reddy reviewed the record and concluded that plaintiff could follow and understand simple directions and instructions and perform simple tasks independently; that she had adequate skills to perform simple tasks; and that she could relate adequately to others. (Tr. 494.) Dr. Reddy noted that plaintiff had bipolar disorder and a long history of alcohol, cocaine, and heroin use. (
At the administrative hearing held on June 3, 2013, plaintiff testified that she last worked in 2010, when she was terminated after passing out from uncontrolled blood sugar levels. (Tr. 48.) Plaintiff described numbness in her hands and sharp pains in her feet, which she attributed to uncontrolled diabetes. (Tr. 49, 56.) Plaintiff estimated that she can only stand for 45 minutes and walk for two blocks, after which she is tired and must "take a breather." (Tr. 51-52, 54.) Plaintiff testified that she no longer cuts herself, hears voices, or contemplates suicide, but that she still has nightmares and hallucinates, seeing faces as often as four days a week. (Tr. 59.) Plaintiff further testified that she had mood swings, problems with forgetfulness, difficulty being around other people she does not know, and difficulty concentrating most of the time. (Tr. 51, 61.) Plaintiff explained that she forgets simple things such as her own phone number. (Tr. 61.) She also testified that she had problems completing paperwork and cannot fill out forms by herself. (Tr. 62.) In addition, plaintiff reported that she falls asleep at inappropriate times during the day. (Tr. 57.)
"After the pleadings are closed—but early enough not to delay trial—a party may move for judgment on the pleadings." Fed. R. Civ. P. 12(c). "The same standard applicable to Fed. R. Civ. P. 12(b)(6) motions to dismiss applies to Fed. R. Civ. P. 12(c) motions for judgment on the pleadings."
The Commissioner will find a claimant disabled under the Act if he or she demonstrates an "inability 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 12 months." 42 U.S.C. § 423(d)(1)(A). The claimant's impairment 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." Id. § 423(d)(2)(A). The disability must be "demonstrable by medically acceptable clinical and laboratory diagnostic techniques."
The Commissioner uses a five-step process when making disability determinations.
The Commissioner and ALJ's decisions are subject to limited judicial review. The Court may only consider whether the ALJ applied the correct legal standard and whether his or her findings of fact are supported by substantial evidence. When these two conditions are met, the Commissioner's decision is final.
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."
While the Court must consider the record as a whole in making this determination, it is not for this Court to decide
Finally, it is the function of the Commissioner, not the Court, "to resolve evidentiary conflicts and to appraise the credibility of witnesses, including the claimant."
"[T]he treating physician rule generally requires deference to the medical opinion of a claimant's treating physician," although an ALJ need not afford controlling weight to a treating physician's opinion that is "not consistent with other substantial evidence in the record, such as the opinions of other medical experts."
Although the ALJ will consider a treating source's opinion as to whether a claimant is disabled or able to work, the final responsibility for deciding those issues is reserved to the Commissioner, and the treating source's opinion on them is not given "any special significance." 20 C.F.R. § 416.927(d)(3);
Although "[t]he claimant has the general burden of proving that he or she has a disability within the meaning of the Act," "the ALJ generally has an affirmative obligation to develop the administrative record."
Plaintiff advances three arguments in support of her position that the ALJ erred in finding that she was not disabled: (1) the ALJ failed to properly weight the medical evidence; (2) the ALJ failed to properly evaluate plaintiff's credibility; and (3) the ALJ erred by relying on the medical-vocational guidelines. (
The ALJ evaluated plaintiff's claim pursuant to the five-step sequential evaluation process and concluded that plaintiff has not been under a disability within the meaning of the Act since March 28, 2012, the date of plaintiff's application. At step one, the ALJ found that plaintiff had not engaged in substantial gainful activity since March 28, 2012 (the application date). (Tr. 29.) At step two, he determined that plaintiff had the following severe impairments: obesity, mood disorder, and anxiety disorder.
At step four, the ALJ determined that plaintiff had the residual functional capacity to perform "light work" as defined in the regulations, except that she is limited to simple and unskilled jobs, particularly those with a Specific Vocational Preparation ("SVP") level of 1 or 2.
At step five, considering plaintiff's "age, education, work experience, and residual functional capacity," the ALJ found "that there are jobs that exist in significant numbers in the national economy that [plaintiff] can perform." (Tr. 37.) The ALJ relied on the Medical-Vocational Guidelines (the "Grids") as a framework for his decision and did not utilize a vocational expert. (Tr. 37-38.)
Plaintiff first claims that the ALJ failed to properly weigh the medical evidence. (Mem. in Supp. at 7.) Specifically, plaintiff claims that the ALJ failed to apply the treating physician rule in giving "limited weight" to Dr. Naco. For the reasons discussed below, the Court agrees.
In primary support of his decision to give Dr. Naco's opinions limited weight, the ALJ noted that he found Dr. Naco's opinions inconsistent with "corresponding treatment notes." (Tr. 34.) The ALJ did not sufficiently support such inconsistencies. The only "inconsistency" described by the ALJ was that in a March 2, 2013 report Dr. Naco stated that plaintiff had a GAF score of 48 while treatment notes from the same day indicate that plaintiff had a GAF score of 58.
The ALJ also noted that Dr. Naco saw plaintiff relatively infrequently and prescribed only "conservative care." (Tr. 35.) The Second Circuit has noted that "the opinion of the treating physician [is not] to be discounted merely because he has recommended a conservative treatment regimen," and the "ALJ and the judge may not `impose[ ] their [respective] notion[s] that the severity of a physical impairment directly correlates with the intrusiveness of the medical treatment ordered.'"
In determining that plaintiff was able to perform simple and unskilled jobs from a mental standpoint, the ALJ gave "weight" to State agency evaluator Dr. Reddy. (Tr. 35.) As previously noted, Dr. Reddy did not examine plaintiff but reviewed her record and concluded that plaintiff could follow and understand simple directions and instructions and perform simple tasks independently; that she had adequate skills to perform simple tasks; and that she could relate adequately to others. (Tr. 494.) Dr. Reddy noted Dr. Naco's assessment precluding plaintiff from even entry level work, but found it to be inconsistent with the doctor's treatment notes reflecting that plaintiff was cooperative, maintained good eye contact, had normal psychomotor activity, and normal concentration. (
The ALJ's reliance in this case on the opinions of Dr. Reddy, a consultative non-examining psychiatrist, was error. The record and findings by treating physician Dr. Naco contradict those of Dr. Reddy. As discussed above, Dr. Naco opined that plaintiff was markedly limited — defined as being effectively precluded from performing the activities in a meaningful manner — in her ability to perform activities within a schedule, maintain regular attendance, and be punctual with customary tolerance; work with or near others without being distracted; set realistic foals or make plans independently; and complete a workweek without interruption from psychologically based symptoms. (Tr. 276-279.) Dr. Naco found that plaintiff had limited understanding and memory due to poor focus and limited sustained concentration and persistence, social interaction and adaptation due to mood swings, racing thoughts and irritability. (Tr. 518-19, duplicated at Tr. 609-12, 615.) Dr. Naco explained that her opinions were based upon her own observations that plaintiff was "quite hyper" and needed redirection and had "trouble focusing" and was "easily irritable, nervous, and impatient" during severe mood swings, causing problems with focus and memory. (Tr. 497.) She also stated that plaintiff could be quite sensitive to minor criticisms "and has had issues with staff members." (
Defendant correctly notes that the opinions of non-examining sources can be given great weight where they are supported by medical evidence in the record. Here, however, Dr. Reddy's opinion, adopted by the ALJ, is not supported by medical evidence in the record.
Even Dr. Tedoff, who conducted a consultative psychiatric assessment of plaintiff at the request of the SSA, opined that plaintiff had a poor prognosis for maintaining employment. (Tr. 508.) The ALJ gave this opinion "little overall weight" because he claimed that Dr. Tedoff "was not privy to the other evidence of record in conducting his examination." However, the only piece of evidence discussed by the ALJ is a notation by Dr. Naco that plaintiff had been sober for the past six weeks; which the ALJ described as inconsistent with plaintiff's statement to Dr. Tedoff that she had had not used drugs for a year. (Tr. 35;
In short, the ALJ's failure to apply the correct legal standard in considering Dr. Naco's medical opinion is grounds for reversal.
Plaintiff also contends that the ALJ failed to properly evaluate her testimony. (Mem. in Supp. at 12-15.) The Court agrees.
It is the function of the Commissioner, not the Court, "to resolve evidentiary conflicts and to appraise the credibility of witnesses, including the claimant."
The ALJ first described plaintiff's testimony regarding the intensity, persistence, and limiting effects of her alleged symptoms. (Tr. 32-33.) The ALJ noted that plaintiff testified to numerous ailments including manic-depressive disorder, bipolar disorder, schizophrenia, diabetes, asthma, and high blood pressure. (Tr. 32.) The ALJ further noted that plaintiff testified that she stopped working in 2010 after she was laid off; has learning problems; sees her psychologist twice a month and sees a counselor weekly; continues to smoke cigarettes; and last used cocaine about a year before the hearing. (Tr. 33.) The ALJ ultimately concluded that plaintiff's "statements concerning the intensity, persistence and limiting effects of these symptoms are not entirely credible." (
The ALJ found that while plaintiff "alleges severe mental health issues, the record indicates that her primary psychiatric problem is due to polysubstance abuse." (
The ALJ's boilerplate assertion that plaintiff's testimony was "not entirely credible" is insufficient. The ALJ provided no support for his assertion that "the record indicates that [plaintiff's] primary psychiatric problem is due to polysubstance abuse." To the contrary, Dr. Naco reported that plaintiff's use of drugs and/or alcohol was a symptom of her condition or form of self-medication, and that plaintiff's disability was independent of any substance use. (Tr. 626.) The ALJ cannot substitute his own views for actual medical evidence in the record.
Furthermore, the ALJ failed to give a single reason for finding plaintiff's statements related to her physical limitations not credible.
Lastly, plaintiff argues that the ALJ erred at step five of the sequential analysis by relying on the medical-vocational guidelines. (Mem. in Supp. at 15.) Once the ALJ determined that plaintiff could not complete her past relevant work, he was required, under step five, to determine whether there was work in the national economy that plaintiff can do.
"If a claimant has nonexertional limitations that `significantly limit the range of work permitted by his exertional limitations,' the ALJ is required to consult with a vocational expert."
Here, the ALJ acknowledged that plaintiff had "moderate limitations of her ability to maintain concentration, persistent and pace" and that plaintiff's mental impairments were "severe" yet found that "there is no evidence that [plaintiff's] impairments so drastically limit these abilities as to preclude gainful employment at the light exertional level." (Tr. 37.) For the reasons described above, this finding is not supported by substantial evidence. The record clearly demonstrates — including treatment notes and the opinions of Dr. Naco and Dr. Tedoff — that plaintiff's impairments significant limit her capacity to work. If the ALJ did not wish to call a vocational expert, he was required to "submit other evidence of jobs that an individual with [plaintiff's] limitations could perform, or to explain fully why plaintiff's limitations are not significant enough to warrant the opinion of such expert."
The Social Security Act directs that "[t]he court shall have power to enter, upon the pleadings and transcript of the record, a judgment affirming, modifying, or reversing the decision of the Commissioner of Social Security, with or without remanding the cause for a rehearing." 42 U.S.C. § 405. The Second Circuit has explained that "where the administrative record contains gaps, remand to the Commissioner for further development of the evidence is appropriate."
The Court finds that this is one of the rare cases where a remand solely for the calculation of benefits is appropriate. This is so because the Commissioner failed to sustain his burden at step five and there is no substantial evidence to support the ALJ's conclusion; there has been no showing that further development of the record and additional proceedings would result in the evidence required to substantiate a conclusion that plaintiff is not disabled; and there is substantial evidence in the record that plaintiff is disabled.
For the aforementioned reasons, plaintiff's motion is GRANTED, and defendant's motion is DENIED. This case is remanded for calculation and disbursement of benefits. The Clerk of Court is directed to terminate the motions at ECF Nos. 16, 22, and to terminate this action.
SO ORDERED.