HENRY PITMAN, Magistrate Judge.
Plaintiff Nancy Altagracia Maisonave brings this action pursuant to section 205(g) of the Social Security Act (the "Act"), 42 U.S.C. § 405(g), seeking judicial review of a final decision of the Commissioner of Social Security ("Commissioner"), denying her application for disability insurance benefits ("DIB") for the period beginning December 13, 2011 and continuing to the present (Complaint, dated Apr. 4, 2018 (Docket Item ("D.I.") 1) ("Compl.")). Plaintiff has moved for judgment on the pleadings pursuant to Rule 12(c) of the Federal Rules of Civil Procedure (D.I. 14). All parties have consented to my exercising plenary jurisdiction pursuant to 28 U.S.C. § 636(c). For the reasons set forth below, plaintiff's motion is denied.
On October 4, 2014, plaintiff filed an application for DIB, alleging that she became disabled on December 13, 2011 (Tr. 236). After her application for benefits was initially denied on December 6, 2013 (Tr. 158-63), she requested, and was granted, a hearing before an administrative law judge ("ALJ") (Tr. 165-66, 185-210).
Plaintiff and her attorney appeared before ALJ Seth Grossman for a hearing on July 23, 2015 and May 9, 2016, at which plaintiff, vocational expert ("VE") Dr. Tites,
Plaintiff was born on June 9, 1965 and was 49 years old when she applied for DIB (Tr. 236). Plaintiff was married with two adult daughters (Tr. 43), and she lived with her husband in the Bronx (Tr. 236). Plaintiff's "Work History Report" stated that she was employed from 1998 to 2011 as a factory worker who washed linens (Tr. 285-86). She worked eight hours per day, five days per week, and her work included lifting laundry baskets that weighed up to 20 pounds (Tr. 286). Plaintiff's "Disability Report" stated that she could speak and understand English, but that she was unable to read or write in English (Tr. 292); she testified at the hearing through an interpreter (Tr. 33-34, 77-78).
Plaintiff's primary care physician referred plaintiff to Dr. Virginia Contreras, a psychiatrist, for depression and irritability (Tr. 363, 412). In plaintiff's first appointment with Dr. Contreras on December 13, 2011, plaintiff reported feeling angry at times during the previous six months, with the urge "to hurt someone" (Tr. 363, 412). Plaintiff also reported an inability to sleep and decreased libido, but she denied any suicidal thoughts (Tr. 363, 412). In her examination of plaintiff's mental status, Dr. Contreras noted that plaintiff was alert and oriented, with coherent speech and a depressed, tearful mood (Tr. 363, 412).
On February 1, 2012, plaintiff reported that she continued to feel irritable (Tr. 364, 413), but at her March 3, 2012 appointment, she told Dr. Contreras that she was sleeping better (Tr. 365, 415). In May of 2012, plaintiff reported feeling very angry at her daughter after her daughter was caught stealing and got into a fight with another girl (Tr. 365, 415). At plaintiff's September 13, 2012 appointment, Dr. Contreras noted that plaintiff was depressed as a result of the deaths of her brother and sister and that plaintiff was no longer working because the laundry business where she had been employed had burned down (Tr. 366, 414).
On November 15, 2012, Dr. Contreras noted that plaintiff was stable and that she denied any suicidal or homicidal thoughts (Tr. 416). In February of 2013, plaintiff reported that she had gone to the psychiatric emergency room twice "due to angry episodes"; she was discharged after a few hours (Tr. 367, 424). Plaintiff again denied any suicidal or homicidal thoughts (Tr. 367, 424).
In August of 2013, Dr. Contreras diagnosed plaintiff with depression (Tr. 368, 423). Plaintiff's PHQ-9
On August 8, 2013, Dr. Contreras wrote that plaintiff sufferered from "frequent decompensations and psychiatric hospitalizations which require highly dosed treatment with psychotropic medications" (Tr. 328). Dr. Contreras opined that as a result of her psychiatric condition and the sedative effects of her medication, plaintiff was unable to work (Tr. 328).
At plaintiff's November 8, 2013 appointment, Dr. Contreras noted that plaintiff was stable and denied any suicidal or homicidal thoughts (Tr. 369, 422). However, plaintiff's PHQ-9 score remained at 27 (Tr. 438), and she reported that her husband had lost his job and that they were four months behind on their rent payments (Tr. 369, 422).
In a medical source statement dated January 29, 2014 (Tr. 397-99), Dr. Contreras opined that plaintiff's abilities to understand, remember and carry out simple and complex instructions and to make judgments on simple and complex work-related decisions were markedly limited (Tr. 397). Dr. Contreras also found that plaintiff's abilities to interact appropriately with the public, supervisors and co-workers and to respond appropriately to usual work situations and changes in a routine work setting were markedly limited (Tr. 398). Dr. Contreras wrote that she based her findings on clinical assessments, laboratory testing and plaintiff's PHQ-9 scores (Tr. 398). Finally, she opined that plaintiff's limitations first presented on December 13, 2011 (Tr. 398).
Throughout the rest of 2014 and into 2015, plaintiff remained stable according to Dr. Contreras (Tr. 417-21). Although plaintiff's mood was depressed in March of 2014, it improved to "pleasant" by August (Tr. 420-21), but her August 6, 2014 PHQ-9 score was 26 (Tr. 435). However, on October 27, 2014, plaintiff's PHQ-9 score had improved to 17 (Tr. 434). In December of 2014 and April of 2015, plaintiff reported that her sleep and appetite were adequate (Tr. 417-18). On April 17, 2015, Dr. Contreras wrote a letter identical to her August 8, 2013 letter on plaintiff's behalf (Tr. 410). Dr. Contreras reiterated her opinion that plaintiff was unable to work (Tr. 410). On June 29, 2015, plaintiff's PHQ-9 score had gone up to 22 (Tr. 432).
In a mental impairment questionnaire dated June 29, 2015, Dr. Contreras wrote that plaintiff "presents with severe depression that has been recurring and remitting for the past several years. [Plaintiff] also presents with uncontrollable anger." (Tr. 426). Dr. Contreras listed plaintiff's signs and symptoms as anhedonia,
Dr. Marilee Mescon, a consulting internist, examined plaintiff on November 14, 2013 (Tr. 384-87). Plaintiff complained of an accidental puncture wound to her right hand, which she sustained when she fell on a key (Tr. 384). Plaintiff reported undergoing two hand surgeries after her fall (Tr. 384). Plaintiff denied any history of high blood pressure, diabetes, heart problems, asthma, emphysema or seizures (Tr. 384).
Plaintiff reported to Dr. Mescon that she started smoking cigarettes in 2010 and that she smoked one pack per day (Tr. 384). She denied drinking alcohol or using illegal drugs (Tr. 384). Plaintiff reported that she cooked, cleaned, did laundry and shopped (Tr. 384). She showered, bathed and dressed herself and spent her time watching television (Tr. 384).
Upon examination, plaintiff appeared to be in no acute distress (Tr. 385). She was able to sit, stand and walk normally and without assistance, and she did not require help changing her clothes or getting on and off the exam table (Tr. 385). Plaintiff was wearing a splint on her right wrist (Tr. 385). She reported a loss of sensation in her right thumb and right index finger and a tingling sensation in the third finger of her right hand (Tr. 386). Dr. Mescon assessed plaintiff's motor strength in her right hand at a 2 out of 5 and in her left hand at a 5 out of 5 (Tr. 386).
Dr. Mescon diagnosed plaintiff with penetrating trauma to her right hand (Tr. 386). Dr. Mescon wrote in her medical source statement that plaintiff had no limitations on her ability to sit, stand, climb, push, pull or carry heavy objects, but that her ability to pinch or "to pick up a coin from a flat surface would be severely limited because of loss of feeling in the right thumb and right index finger" (Tr. 386).
Dr. W. Amory Carr, a consulting psychologist, evaluated plaintiff on November 14, 2013 (Tr. 389-93). Plaintiff reported to Dr. Carr that she had been taken to the psychiatric emergency room at North Central Bronx Hospital twice in 2013 because she did not "feel like herself" (Tr. 389). At the time of the evaluation, she was seeing Dr. Contreras and a therapist once per month and taking Zoloft, Seroquel, vitamin D, Viibryd, co-trimoxazole, gabapentin and Ambien
Plaintiff reported that she had difficulty falling asleep and that she had an increased appetite which resulted in weight gain (Tr. 390). Plaintiff also reported experiencing symptoms of depression and anxiety, including crying spells, irritability, difficulty concentrating, social withdrawal, excessive worry, nightmares, restlessness and muscle tension (Tr. 390). She denied any symptoms of mania or thought disorder, but she reported poor short-term memory and "receptive language deficits" (Tr. 390).
In an evaluation of plaintiff's mental status, Dr. Carr noted that plaintiff was cooperative but that her manner of relating was somewhat childish (Tr. 390). She was casually dressed and well groomed, with normal posture and appropriate eye contact but somewhat restless motor behavior (Tr. 390). Plaintiff's speech was fluent and clear, but Dr. Carr was unable to assess her expressive and receptive language due to a language barrier (Tr. 390). Plaintiff's thought processes were coherent and goal-directed, with no evidence of hallucinations, delusions or paranoia (Tr. 391). Plaintiff had a full range of affect with one occasion of inappropriate laughter (Tr. 391). Her attention and concentration were impaired; she was unable to count to 20 or to perform simple calculations or serial subtractions (Tr. 391). Her recent and remote memory skills were also impaired; she could recall only two out of three objects after a five-minute period and could not recite four digits forward or three digits backward (Tr. 391). Finally, Dr. Carr found that plaintiff's intellectual functioning was below average, her fund of information was appropriate and her insight and judgment were fair (Tr. 391).
Dr. Carr noted that plaintiff was able to dress, bathe and groom herself, but she had sometimes gone two or three days without showering and feared drowning in the bath (Tr. 391). She did not cook because she forgot to turn the stove off, and she did not clean because she forgot to do so or put it off (Tr. 391). She did not shop because she did not like to go outside, and she did not manage money because she was "too forgetful" (Tr. 391). She did do some laundry (Tr. 391). Her social life was limited to her immediate family (Tr. 391-92).
In a medical source statement, Dr. Carr wrote that plaintiff's ability to understand and follow simple directions and instructions was mildly limited (Tr. 392). Her abilities to maintain attention and concentration, learn new tasks, make appropriate decisions, relate adequately with others and appropriately deal with stress were moderately limited (Tr. 392). Her abilities to perform simple tasks independently and to maintain a regular schedule were moderately-to-markedly limited (Tr. 392). Plaintiff's ability to perform complex tasks independently was markedly limited (Tr. 392). Dr. Carr attributed plaintiff's limitations to her anxiety and depression and wrote that, "[t]he results of the evaluation are consistent with psychiatric problems and may significantly interfere with the claimant's ability to function on a daily basis" (Tr. 392). Dr. Carr diagnosed plaintiff with unspecified depressive disorder and unspecified anxiety disorder (Tr. 392). Dr. Carr also ruled out a diagnosis of borderline intellectual functioning (Tr. 392). Dr. Carr recommended that plaintiff continue with mental health treatment (Tr. 392).
Dr. Ruby Phillips, a consulting psychologist, evaluated plaintiff on June 4, 2016 (Tr. 453-56). Plaintiff reported to Dr. Phillips that she had been hospitalized for depression in October 2015 and for high blood pressure in 2016 (Tr. 453). At the time of the evaluation, plaintiff reported that she had been seeing a psychiatrist once per month since 2011 and a psychologist once per week since 2011 and taking omeprazole, ibuprofen, Zoloft, Seroquel, metformin, Ambien, ferrous sulfate, penicillin and verapamil
Plaintiff reported that she had difficulty falling asleep but that her appetite was normal (Tr. 453). Plaintiff also reported experiencing symptoms of depression and anxiety, including crying spells, difficulty concentrating, excessive worry and restlessness (Tr. 453). She denied any symptoms of mania, but she reported poor short-term memory and auditory hallucinations, including hearing voices and knocks at the door (Tr. 453-54).
In an evaluation of plaintiff's mental status, Dr. Phillips noted that plaintiff was cooperative but that her manner of relating was somewhat immature (Tr. 454). She was appropriately dressed and adequately groomed, with normal posture and motor behavior and appropriate eye contact (Tr. 454). Plaintiff's speech was fluent and clear, and her expressive and receptive language skills were adequate (Tr. 454). Plaintiff's thought processes were coherent and goal-directed, with no evidence of hallucinations, delusions or paranoia (Tr. 454). Plaintiff had a full range of affect (Tr. 454). Her attention and concentration were intact; she was able to count and to perform simple calculations and serial subtractions (Tr. 455). Her recent and remote memory skills were impaired; she could recall only one out of three objects immediately and zero out of three objects after a five-minute period and could not recite digits forward or backward (Tr. 455). Finally, Dr. Phillips found that plaintiff's intellectual functioning was average, her fund of information was appropriate, her insight was poor and her judgment was fair (Tr. 455).
Dr. Phillips noted that plaintiff was able to dress, bathe and groom herself, but she did not cook because of poor concentration (Tr. 455). She sometimes cleaned but did not do laundry or shop (Tr. 455). She managed her own money but did not take public transportation (Tr. 455). Plaintiff reported good familial relationships (Tr. 455). She spent her time playing dominoes, drinking coffee and sitting in front of her building (Tr. 455).
In her medical source statement, Dr. Phillips wrote that plaintiff's abilities to learn new tasks, perform complex tasks independently, make appropriate decisions and deal appropriately with stress were markedly limited (Tr. 455). Her ability to relate adequately with others was moderately limited (Tr. 455). Plaintiff demonstrated no limitation in her abilities to understand and follow simple directions and instructions, perform simple tasks independently, maintain attention and concentration and maintain a regular schedule (Tr. 455). Dr. Phillips attributed plaintiff's limitations to her anxiety and "psychotic symptoms" and wrote that, "[t]he results of the present evaluation are consistent with psychiatric and cognitive problems, and these may significantly interfere with the claimant's ability to function on a daily basis" (Tr. 456). Dr. Phillips diagnosed plaintiff with an unspecified psychotic disorder and persistent depressive disorder (Tr. 456). She also ruled out a diagnosis of neurocognitive disorder (Tr. 456). Dr. Phillips recommended that plaintiff continue with mental health treatment and undergo a neuropsychological examination (Tr. 456).
In a separate medical source statement also dated June 4, 2016, Dr. Phillips indicated that plaintiff's abilities to understand, remember and carry out simple instructions and to interact appropriately with supervisors, co-workers and the public were moderately limited (Tr. 457-58).
Dr. Sharon Revan, a consulting internist, examined plaintiff on June 4, 2016 (Tr. 462-65). Plaintiff complained of a history of shoulder pain, right knee pain, hypertension and diabetes (Tr. 462). Plaintiff reported suffering from high blood pressure for ten years and from diabetes for eight years (Tr. 462).
Plaintiff reported that she started smoking cigarettes at age 21 and that she smoked two packs per day (Tr. 463). She denied drinking alcohol or using illegal drugs (Tr. 463). Plaintiff reported that she showered and dressed herself, but that her husband and daughter cooked, cleaned, did laundry and shopped (Tr. 463).
Upon examination, plaintiff appeared to be in no acute distress (Tr. 463). She was able to sit, stand and walk normally and without assistance, and she did not require help changing her clothes or getting on and off the exam table (Tr. 463). Plaintiff had a full range of motion in both knees, with crepitus
Dr. Revan diagnosed plaintiff with right shoulder pain, right knee pain, hypertension and diabetes (Tr. 465). Dr. Revan wrote in her medical source statement that plaintiff had no limitations in her speech, vision, hearing, and fine and gross motor activity of her upper extremities (Tr. 465). Plaintiff's abilities to walk, stand and climb stairs were mildly limited due to her right knee pain, and her abilities to sit and lie down were limited due to knee numbness (Tr. 465). Finally, Dr. Revan found that plaintiff's activities of daily living were mildly-to-moderately limited as a result of her depression (Tr. 465).
In a separate medical source statement also dated June 4, 2016, Dr. Revan opined that plaintiff could lift and carry items weighing up to 20 pounds one-third of the time, but that she would be unable to lift and carry an item weighing more than 20 pounds (Tr. 466). Dr. Revan found that plaintiff could sit or stand for 30 minutes without interruption and could walk for 10 minutes without interruption (Tr. 467). Out of an eight-hour work day, Dr. Revan opined that plaintiff could sit for two hours, stand for two hours and walk for one hour (Tr. 467).
Plaintiff testified that she was fifty years old, that she was born in Santo Domingo, Dominican Republic, and that she had lived in the United States for more than 18 years (Tr. 35, 78-79). She completed only a year or two of school in the Dominican Republic (Tr. 35-36). Plaintiff worked for 13 or 14 years at a laundry, operating a machine that sorted towels (Tr. 36, 50, 79, 82-83). She also testified that she was unable to work due to the damage to a tendon in her hand that resulted from her falling on her keys (Tr. 60-61, 79-80). Plaintiff testified that her right hand and elbow felt numb and that she experienced cramping from her fingers up to her elbow (Tr. 85-86, 101-02). The cramping and loss of sensation was worst in her thumb and index finger (Tr. 104). She had had several previous surgeries on her hand and was scheduled for another surgery on her hand and elbow a few months after the July 23, 2015 hearing (Tr. 61-62, 80). However, plaintiff testified that she had no difficulty standing or walking (Tr. 64).
With respect to her mental impairments, plaintiff testified that she was also unable to work because of her inability to concentrate, that her "mind just starts [wandering] off" (Tr. 43, 79). She received treatment from Dr. Contreras frequently (Tr. 86-87). She was uncomfortable around other people and did not like having people "in back of" her (Tr. 84). Plaintiff testified that she did not cook, clean or do laundry, that she did not "have the desire" to bathe and that her 27-year-old daughter did "everything" for her (Tr. 98-100).
VE Dr. Tites ("VE Tites") testified at the July 23, 2015 hearing (Tr. 67-74). VE Tites characterized plaintiff's past work as a laundry worker, which is defined in the United States Department of Labor's Dictionary of Occupational Titles ("DOT") as either medium- or light-exertion, depending on the industry in which the laundry worker worked (Tr. 70). The ALJ asked VE Tites whether a hypothetical person of plaintiff's education and experience, with "no limitations in climbing, pushing, pulling or carrying heavy objects" but who could not "pick up a coin from a flat surface" could perform plaintiff's past work (Tr. 70-71). VE Tites testified that such an individual could perform plaintiff's past work (Tr. 71). The ALJ then asked VE Tites whether a hypothetical person of plaintiff's education and experience who could lift and carry up to 20 pounds with "no limitations on sitting or standing," but who was limited to carrying out simple instructions and who could not pick up a coin from a flat surface or "perform a similar type operation" could perform plaintiff's past work (Tr. 71). VE Tites testified that such an individual could also perform plaintiff's past work (Tr. 71). VE Tites also confirmed that plaintiff's past work required only occasional contact with supervisors and co-workers and no contact with the public, and that an individual doing such work could be off-task up to ten percent of the time and absent once per month (Tr. 71-72).
When asked by plaintiff's counsel if the hypothetical individual described by the ALJ could perform plaintiff's past work if she was off-task 20 percent of the time, VE Tites testified that she could not (Tr. 72-73).
VE David Festa ("VE Festa") testified at the May 9, 2016 hearing (Tr. 118-26, 131-40). VE Festa characterized plaintiff's past work as a laundry laborer, which is defined in the DOT as medium-exertion, unskilled work (Tr. 123). VE Festa characterized plaintiff's performance of her past work as light-exertion because she was required to lift and carry a maximum of 20 pounds (Tr. 123). The ALJ asked VE Festa if a hypothetical individual who could perform the full range of light-exertion work with the limitation that she "avoid forceful torque," such as using a screwdriver, could perform plaintiff's past work (Tr. 124). VE Festa testified that such an individual could perform plaintiff's past work as she actually performed it (Tr. 124). When asked by the ALJ if the same hypothetical individual could perform plaintiff's past work if she could lift up to 20 pounds with either her left hand or both hands, VE Festa testified that such an individual could also perform plaintiff's past work (Tr. 125). When asked by the ALJ if a hypothetical individual of plaintiff's education and experience who could perform a full range of light-exertion work except for tasks involving "forceful torque" and who was limited to simple tasks with only occasional contact with supervisors, co-workers and the public could perform plaintiff's past work, VE Festa testified that such an individual could perform plaintiff's past work (Tr. 126).
In response to testimony by plaintiff that her past work involved pushing wheeled carts of towels weight approximately 100 pounds, VE Festa testified that the work of a laundry laborer who had to push such carts would be considered medium-exertion or heavy-exertion (Tr. 132).
Finally, when asked by the ALJ if there were any jobs that a hypothetical individual of plaintiff's education and experience who could do medium-exertion work of lifting and carrying up to 30 pounds, except for tasks involving "forceful torque," and who was limited to simple tasks with only occasional contact with supervisors, co-workers and the public could perform, VE Festa testified that such an individual could work as a hand packager, DOT code number 920.587-018, with 53,252 jobs nationally (Tr. 133-35).
Dr. Allan Levine, a medical expert in orthopedic surgery, testified at the May 9, 2016 hearing (Tr. 93-117). He testified that an x-ray of plaintiff's right hand on May 24, 2013 revealed mild radial displacement or partial dislocation of the first metacarpal (Tr. 106). Plaintiff was diagnosed with right carpal tunnel syndrome and trigger finger
Dr. Levine opined that plaintiff's physical impairments did not meet or equal one of the listed impairments in 20 C.F.R., Part 404, Subpart P, Appendix 1 because he "found no evidence of extreme loss of fine and gross manipulation of both upper extremities"; he explained that plaintiff's impairment only affected her right hand (Tr. 109). He also noted plaintiff's statements in the record that she was able to cook, clean, do laundry, shop, dress, bathe, shower, watch television and smoke cigarettes (Tr. 109).
With respect to plaintiff's RFC, Dr. Levine opined that plaintiff was capable of lifting and carrying 30-pound objects occasionally and 10-pound objects frequently (Tr. 111). She was able to sit, stand and walk for six hours out of an eight-hour work day, with no limitations on her abilities to kneel, crouch, stoop or climb stairs (Tr. 111, 113). Dr. Levine found that plaintiff should avoid ladders, scaffolds and repetitive forceful gripping or twisting activities with her hand (Tr. 113-15).
The Court may set aside the final decision of the Commissioner only if it is not supported by substantial evidence or if it is based upon an erroneous legal standard. 42 U.S.C. § 405(g);
The Court first reviews the Commissioner's decision for compliance with the correct legal standards; only then does it determine whether the Commissioner's conclusions were supported by substantial evidence.
"Substantial evidence is evidence that `a reasonable mind might accept as adequate to support a conclusion.'"
Under Title II of the Act, a claimant is entitled to DIB if she can establish an "inability to engage in any substantial gainful activity [("SGA")] by reason of any medically determinable physical or mental impairment which can be expected to ... last for a continuous period of not less than 12 months." 42 U.S.C. § 423(d)(1)(A);
42 U.S.C. § 423(d)(2)(A). In addition, to obtain DIB, the claimant must have become disabled between the alleged onset date and the date on which she was last insured.
In determining whether an individual is disabled, the Commissioner must follow the five-step process required by the regulations. 20 C.F.R. § 404.1520(a)(4)(i)-(v);
If the claimant does not meet any of the listings in Appendix 1, step four requires an assessment of the claimant's residual functional capacity ("RFC") and whether the claimant can still perform her past relevant work given her RFC. 20 C.F.R. § 404.1520(a)(4)(iv);
RFC is defined in the applicable regulations as "the most [the claimant] can still do despite [her] limitations." 20 C.F.R. § 404.1545(a)(1). To determine RFC, the ALJ "`identif[ies] the individual's functional limitations or restrictions and assess[es] [her] ... work-related abilities on a function-by-function basis, including the functions in paragraphs (b),(c), and (d) of 20 [C.F.R. §] 404.1545....'"
The claimant bears the initial burden of proving disability with respect to the first four steps. Once the claimant has satisfied this burden, the burden shifts to the Commissioner to prove the final step — that the claimant's RFC allows the claimant to perform some work other than her past work.
When the ALJ finds that the nonexertional limitations significantly diminish a claimant's ability to work, then the Commissioner must introduce the testimony of a vocational expert or other similar evidence in order to prove "that jobs exist in the economy which the claimant can obtain and perform."
The ALJ applied the five-step analysis described above and determined that plaintiff was not disabled (Tr. 15-24).
As an initial matter, the ALJ found that plaintiff met the insured status requirements of the Act through December 31, 2017 (Tr. 17).
At step one, the ALJ found that plaintiff had not engaged in SGA since December 13, 2011 (Tr. 17,
At step two, the ALJ found that plaintiff suffered from the following severe impairments: "carpal tunnel syndrome and trigger finger in the right hand, anxiety and depression" (Tr. 17,
At step three, the ALJ found that plaintiff's impairments, considered individually or in combination, did not meet or medically equal the criteria of one of the listed impairments in 20 C.F.R., Part 404, Subpart P, Appendix 1 (Tr. 17,
The ALJ also found that plaintiff's mental impairments did not meet or medically equal listings 12.04 or 12.06, 20 C.F.R., Part 404, Subpart P, Appendix 1. In reaching his conclusion, the ALJ stated that he considered whether the paragraph B criteria were satisfied and concluded that, because plaintiff's mental impairments did not cause at least one extreme or two marked limitations, the paragraph B criteria were not satisfied (Tr. 18). The ALJ found that plaintiff experienced moderate restriction in activities of daily living, moderate difficulties in social functioning and marked difficulties in maintaining concentration, persistence or pace, with no episodes of decompensation lasting longer than a day (Tr. 18). The ALJ also stated that he considered whether the paragraph C criteria were satisfied, but he found no evidence that plaintiff required a highly supportive living arrangement or that a minimal increase in mental demands or a change in her environment would cause her to decompensate (Tr. 18). Accordingly, the ALJ concluded that plaintiff did not meet the paragraph C criteria (Tr. 18).
The ALJ then determined that plaintiff retained the RFC to perform medium work as defined in 20 C.F.R. § 404.1567(c) with the limitations that she only occasionally be required to lift or carry more than 30 pounds and that she not be required to perform tasks with her right hand that require "forceful torque, such as tightening screws" (Tr. 19). He also limited plaintiff to "simple, unskilled work that does not require significant work with others" (Tr. 19). To reach his RFC determination, the ALJ examined the opinions of the treating and consulting physicians and determined the weight to be given to each opinion based on the objective medical record, including the treatment notes of plaintiff's treating physicians (Tr. 19-22).
The ALJ afforded little weight to the opinions of Dr. Contreras, plaintiff's treating psychiatrist (Tr. 20-21). The ALJ concluded that Dr. Contreras's own treatment notes and the evaluation by Dr. Phillips, the second consultative psychologist, did not support Dr. Contreras's opinions dated January 29, 2014 and June 29, 2015 (Tr. 20-21). Specifically, the ALJ found that the examinations of plaintiff's mental status from March 27, 2014 through April 17, 2015 were "virtually completely normal," in contrast to Dr. Contreras's opinions that plaintiff's psychological functioning was "markedly limited in every category" and that plaintiff met the requirements of listings 12.04 and 12.06, 20 C.F.R., Part 404, Subpart P, Appendix 1 (Tr. 20-21). With respect to Dr. Contreras's April 17, 2015 opinion, the ALJ found that plaintiff's statement that her medication did not result in any side effects contradicted Dr. Contreras's assertion that the sedative effects of plaintiff's medication caused her to become completely disabled and that the ultimate issue of disability is reserved to the Social Security Administration (Tr. 19-20).
The ALJ afforded limited weight to the opinion of Dr. Carr because "the weight of the evidence ... indicates the claimant can do a simple task/instruction job" (Tr. 21). The ALJ did not assign a specific weight to the opinion of Dr. Phillips.
The ALJ afforded "good weight" to the opinion of Dr. Levine, the orthopedic medical expert who reviewed the medical evidence in the record and testified at the hearing (Tr. 21). The ALJ concluded that Dr. Levine's opinion that plaintiff could perform medium-exertion work with the limitations that she not be required to grasp or twist objects with her right hand or to lift or carry more than 30 pounds occasionally or 10 pounds frequently was "supported by the weight of the record evidence" (Tr. 21). The ALJ also afforded "good weight" to Dr. Mescon's opinion that plaintiff had no limitations in her abilities to push or pull objects with her hands (Tr. 21).
Finally, the ALJ afforded "limited weight" to Dr. Revan's opinion that plaintiff's knee pain limited her abilities to stand, walk, sit and lift and carry objects because he did not find sufficient evidence that plaintiff's knee pain had lasted or could be expected to last for more than one year (Tr. 22).
At step four, the ALJ found that plaintiff was capable of performing her past relevant work as a factory worker who washed linens (Tr. 22).
At step five,
Plaintiff attacks the ALJ's disability determination on two grounds. First, plaintiff claims that in reaching his RFC determination, the ALJ violated the treating physician rule by assigning less-than-controlling weight to the opinions of Dr. Contreras, plaintiff's treating psychiatrist. Second, plaintiff claims the ALJ failed to evaluate her testimony properly (Memorandum of Law in Support of Plaintiff's Motion for Judgment on the Pleadings, dated Oct. 1, 2018 (D.I. 15) ("Pl. Mem.") at 8-17). The Commissioner contends that the ALJ's decision was supported by substantial evidence and should be affirmed (Memorandum of Law in Response to Plaintiff's Motion for Judgment on the Pleadings and in Support of the Commissioner's Motion for Judgment on the Pleadings, dated Nov. 28, 2018 (D.I. 16) ("Def. Mem.") at 15-25).
In considering the evidence in the record, the ALJ must afford deference to the opinions of a claimant's treating physicians. A treating physician's opinion will be given controlling weight if it is "well-supported by medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with the other substantial evidence in ... [the] record." 20 C.F.R. § 404.1527(c)(2);
"[G]ood reasons" must be given for declining to afford a treating physician's opinion controlling weight. 20 C.F.R. § 404.1527(c)(2);
The ALJ did provide good reasons for declining to give controlling weight to the opinions of Dr. Contreras, plaintiff's treating psychiatrist, and his reasoning is supported by substantial evidence. As the ALJ correctly noted, Dr. Contreras's assessments of plaintiff's mental condition, as set forth in her own treatment notes, do not support her opinions that plaintiff is incapable of working.
Furthermore, Dr. Contreras's opinions are contradicted by the results of the consultative evaluations of Dr. Carr and Dr. Phillips. In her January 29, 2014 medical source statement, Dr. Contreras found plaintiff to be markedly limited with respect to all work-related mental activities (Tr. 397-98). However, in November of 2013, less than three months earlier, Dr. Carr opined that plaintiff was markedly limited only in her ability to perform complex tasks independently and her abilities to perform simple tasks independently and to maintain a regular schedule were moderately-to-markedly limited (Tr. 392); in all other respects, Dr. Carr found that plaintiff's limitations ranged between mild and moderate (Tr. 392). Similarly, as explained above, Dr. Contreras found that plaintiff was "[u]nable to meet competitive standards" in most respects in June of 2015 (Tr. 428). However, in June of 2016 Dr. Phillips opined that plaintiff's abilities to learn new tasks, perform complex tasks independently, make appropriate decisions and deal appropriately with stress were markedly limited, but that plaintiff demonstrated no limitation in her abilities to understand and follow simple directions and instructions, perform simple tasks independently, maintain attention and concentration and maintain a regular schedule (Tr. 455).
Finally, although plaintiff claims — and the ALJ accepted — that she did not engage in SGA after December 13, 2011, it appears from the record that plaintiff continued to perform her past work for some part of 2012. Plaintiff's earnings records indicate earnings of $9,405.30 for 2012, as compared to $11,355.70 in 2011 and $15,082.60 in 2010 (Tr. 245-46, 259-60). Dr. Contreras's treatment note from September 13, 2012 indicates that plaintiff "is not working
The Second Circuit set out the framework an ALJ must follow in assessing the credibility of a plaintiff's subjective complaints when making an RFC finding:
Plaintiff argues that despite the fact that she "gave detailed statements regarding her psychiatric symptoms and resulting limitations, her limited activities of daily living, and her lack of any significant response to treatment," the ALJ "merely made a conclusory finding suggesting that he discounted [p]laintiff's statements ... solely based on his characterization of [her] treatment records ..." (Pl. Memo. at 16). First, the single paragraph of plaintiff's brief that summarizes her testimony belies the characterization of her statements as "detailed." Plaintiff testified only that she could not concentrate, that she felt uncomfortable around other people and that, with respect to activities of daily living, her daughter did "everything" for her.
Second, as explained above, the ALJ considered plaintiff's subjective complaints and the assessments of her treating psychiatrist and the consultative psychologists in determining plaintiff's mental RFC. The ALJ compared Dr. Contreras's opinions to her notes from plaintiff's treatment, which included plaintiff's statements about her mental health over a period of more than three years. The ALJ then contrasted Dr. Contreras's assessment of plaintiff's abilities with the opinions of the consultative psychologists, which, again, included plaintiff's statements with respect to her activities of daily living and her mental limitations. Thus, contrary to plaintiff's argument, the ALJ's consideration of plaintiff's statements exceeded "a conclusory finding." Furthermore, as the Commissioner correctly argues (Def. Memo. at 25), the ALJ was not required to discuss all of the relevant factors.
Accordingly, for all the foregoing reasons, plaintiff's motion is denied. The Clerk of the Court is respectfully requested to mark this matter closed.
SO ORDERED.
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Ferrous sulfate is an iron supplement "used to treat or prevent anemia...."
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