GABRIEL W. GORENSTEIN, Magistrate Judge.
Plaintiff Alba Luz Carela Rosa ("Carela") brings this action pursuant to 42 U.S.C. § 405(g) for judicial review of the final decision of the Commissioner of Social Security (the "Commissioner") denying her claim for Supplemental Security Income and Disability Insurance Benefits under the Social Security Act (the "Act"). Both parties have moved for judgment on the pleadings pursuant to Federal Rule of Civil Procedure 12(c).
Carela applied for Disability Insurance Benefits ("DIB") on July 10, 2014.
The Social Security Administration ("SSA") denied the applications, R. 75-76, 93-97, and Carela sought review by an Administrative Law Judge ("ALJ"), R. 101-09. The hearing was held, via video teleconferencing, on June 13, 2016, before ALJ Sheila Walters, who was located in Stockton, California. R. 43, 45. Carela testified from the Bronx, New York, and was represented at the hearing by Edward Rao, an attorney. R. 44-45. An interpreter was also present with Carela. R. 45. In a written decision dated September 2, 2016, the ALJ found Carela not disabled within the meaning of the Act. R. 19-41. On February 13, 2018, the Appeals Council denied Carela's request for review of the ALJ's decision, making the ALJ's decision the final decision of the Commissioner. R. 3-10. This action followed.
Carela was represented by attorney Edward Rao at her hearing. R. 45. At the very beginning of the hearing, the ALJ asked Carela whether Carela could "understand most of what [the ALJ was] saying." R. 45. The ALJ stated that the hearing "could . . . proceed a little faster" if Carela could understand the ALJ without the assistance of an interpreter.
When asked by the ALJ whether the record was complete, Rao indicated that Carela had just given him a prescription list that he would submit after the hearing, and that he was uncertain that the record contained all records from Carela's treating primary care physician Dr. Comas-Espinal. R. 45-46. Rao stated that he "want[ed] to make sure that the opinion evidence is backed up by treatment records," and expressed concern that there were only "six pages of handwritten notes in addition to the impairment questionnaire" from Dr. Comas-Espinal in the record at the time of the hearing. R. 46-47. The ALJ agreed to hold the record open for two additional weeks. R. 47.
At the hearing, Carela testified that she was born on April 3, 1965, and was 51 years old. R. 49. She was five foot one inch tall, weighed 135 pounds, and was right-handed. R. 49. She was single with no dependent children under the age of 18, and lived in an apartment with her adult niece. R. 49-50. She walked to the hearing that day. R. 50. She completed twelfth grade, but stated that she "did not graduate." R. 50. She obtained a vocational certificate in manicure, pedicure, and hairstyling 27 years before the hearing. R. 50. When asked whether she could "read and write in English," Carela responded "[v]ery little." R. 50. Carela stated that she has been on Medicaid since approximately 1996 or 1997 and receives food stamps, but denied having filed for worker's compensation or unemployment insurance. R. 51. Carela testified that she spends the day lying down and then getting up, and stated that her only hobby is watching television. R. 52. Her niece and daughter-in-law do her laundry and housework and cook, and her niece does the grocery shopping. R. 52.
Carela denied working at the time of the hearing, but stated that she was self-employed performing manicures and pedicures in 2001 and 2003. R. 52-53. She did not recall whether she was working during the years of 2005, 2006, and 2007, which showed earnings. R. 53. She attributed earnings in 2009, 2010, and 2011, to self-employment performing manicures and pedicures. R. 53-54.
Carela testified that she stopped working because of her "leg and [her] back." R. 54. She has not looked for work since her alleged disability onset date and has not attended vocational rehabilitation programming. R. 54-55. The ALJ inquired about evidence concerning Carela's leg, and Rao indicated that he did not believe that there was any objective evidence of leg injury in the record at the time of the hearing. R. 55. Carela testified that she has herniated discs, and that her doctor has advised that she needs surgery. R. 55-56. With respect to her leg, Carela indicated that her doctor says she has "damaged nerves because the disc pinched it" and that she has "cramps." R. 56. Carela also testified that she has pain and cramps in her hands, "just like [her] foot." R. 56. The ALJ remarked that the was "nothing in the record" with respect to Carela's "hands or the feet," and Rao directed her to Dr. Alberto Comas-Espinal's progress notes diagnosing carpal tunnel syndrome, R. 56, and noted that "we are looking for his full treatment notes." R. 56-57.
Carela testified that she sees Dr. Comas-Espinal monthly, and that she takes Oxycodone, Naproxen, and Zolpidem "to sleep." R. 57. She also stated that she used a "cream," and did not recall whether she took other medications. R. 57. Carela stated she could walk for one block, or for twenty to twenty-five minutes. R. 57-58. She stated that in an eight-hour day with normal breaks, she would be able to walk for a total of half an hour. R. 58. She testified that she could stand at one time for fifteen to twenty minutes, and could sit for approximately twenty to thirty minutes at a time. R. 58. She could lift a gallon of milk, but not two gallons of milk. R. 58. Carela denied having breathing problems, smoking, drinking, or using substances, but noted that she had prescribed glasses. R. 59.
During an examination by her attorney, Carela testified that her medications make her "[d]izzy the next day," and affirmed that they make her "very dizzy." R. 59. She is unable to touch her toes. R. 59. While she has no trouble with her right hand, she has had problems with her left hand, and could not open a jar with her left hand. R. 60. She denied being able to type. R. 60. Carela denied having trouble dressing herself, but noted that she "[s]ometimes" has trouble getting in and out of the shower, R. 60, because of "strong pain in her back" and leg, R. 61. She denied being able to reach overhead with her arms. R. 61. Carela affirmed that she walked to the hearing, and noted that lives half a block away from the hearing office. R. 60. Carela explained that she could not return to her previous work "in the hair salon" because of "[t]he standing up" required. R. 61. She also noted that her pain affects her ability to concentrate, and that she "[s]ometimes" has issues with her memory. R. 61.
The ALJ then heard testimony from a vocational expert ("VE"), Daniel Wolstein. The VE first identified Carela's past relevant work experience as manicurist, with a Dictionary of Occupational Titles ("DOT") code of 331.674-010.
The ALJ then posed several hypothetical questions to the VE. The ALJ first asked the VE to "assume a hypothetical individual of the same age, education, and work experience as the claimant," who also has following limitations: the ability to lift and carry ten pounds frequently and twenty pounds occasionally; the ability to sit for six hours in an eight hour work day; the ability to stand and/or walk for six hours in an eight hour workday; the inability to ever climb ladders, ropes, or scaffolds; and the ability to only occasionally climb ramps and stairs, and to only occasionally stoop, kneel, crouch, and crawl. R. 65-66. The VE testified that such an individual would be able to perform Carela's past work as a manicurist or a hairstylist. R. 66. The ALJ then asked the VE whether either the manicurist or hairstylist job had transferrable skills, and, after discussing transferrable skills, the VE identified the position of "fingernail former," DOT code 331.674-014, with 83,840 jobs in the national economy, as the only position that used transferrable skills from either position. R. 67. In addition, the VE testified that the hypothetical individual could perform the jobs of toll collector (DOT code 211.462-038), cleaner/housekeeping (DOT code 323.687-014), and chaperone (DOT code 359.667-010). R. 68.
Rao then asked the VE whether the jobs available would be affected if the hypothetical individual was "limited to only occasional gross and fine manipulative movements with the nondominant hand." R. 69. The VE confirmed that the chaperone position could still be performed, but the others could not. R. 70. In response to a further question from Rao regarding the allowable amount of time off-task, the VE proffered that based on his professional observations, an individual could be off task "up to ten percent of the day," and could be absent from work one day per month. R. 70. Rao then asked the VE to assume that the hypothetical individual could only sit for a total of two hours and stand and/or walk for two hours, and the VE confirmed that none of the jobs the ALJ mentioned, including past relevant work, would be available on a full-time basis. R. 71.
Rao then asked Carela additional questions about her consultative examination with Dr. Marilee Mescon. R. 71. Carela testified that Dr. Mescon spent ten minutes with her during the examination, and confirmed that she saw the doctor only once. R. 71. As a closing, Rao asked that the consultative examination by Dr. Mescon be given "little to no weight for lack of treatment and only having seen the client for ten minutes," which he did "not believe to be enough to properly assess the client's residual functional capacity." R. 72. Rao next discussed the difficulty of applying the Medical-Vocational Guidelines, 20 C.F.R. Part 404, Subpart P, Appendix 2 (commonly known as the "grids"), in this case, because "there's no grid for somebody who is a younger individual, illiterate or unable to — well she is unable to communicate effectively in English and yet there's no grid rule for someone with those two characteristics, but also someone who has skilled or semi-skilled past relevant work." R. 72. Rao offered that the ALJ could use grid 201.17, but said he left "that open as a question for the Court." R. 72. The ALJ noted that grid rules 202.11 or 202.12 seemed to be appropriate.
Both Carela and Commissioner have provided summaries of the medical evidence contained in the administrative record.
The ALJ denied Carela's application for DIB and SSI on September 2, 2016. R. 25-37. Following the five-step test set forth in the SSA regulations, the ALJ first found that Carela met the insured status requirements and had not engaged in "substantial gainful activity since June 3, 2014, the alleged [disability] onset date." R. 27-28. At step two, the ALJ found that Carela had the following severe impairment: "degenerative disk disease status post 2001 and 2002 corrective surgery." R. 28. The ALJ also noted that Carela had the nonsevere impairments of carpal tunnel syndrome and high blood pressure. R. 28. With respect to Carela's carpal tunnel syndrome, the ALJ noted that it "was not diagnosed until May 2016," and that a note included in Carela's medical records consisted of "a generic description of carpal tunnel syndrome, not the claimant's own symptoms." R. 28. The ALJ concluded that because "[a] review of the record revealed no continuous 12 months of complaints regarding the use of her hand," and because "the claimant should respond to treatment for carpal tunnel syndrome," the impairment was non-severe. R. 28. With respect to Carela's high blood pressure, the ALJ noted that "treatment appears has relived [sic] the condition," and "no acceptable medical source has specifically attributed any functional limitations specifically to high blood pressure," making the impairment non-severe. R. 28.
At step three, the ALJ concluded that none of Carela's severe impairments singly or in combination met or medically equaled an impairment listed in 20 C.F.R. Part 404, Subpart P, Appendix 1 (the "Listings"). R. 28. The ALJ specifically considered Listings 1.02 and 1.04 in determining that Carela did not exhibit the necessary medical criteria. R. 28-29.
Before moving to step four, the ALJ assessed Carela's residual functional capacity ("RFC"). R. 29-34. The ALJ determined that Carela retained the RFC "to perform light work" with the following limitations:
R. 29. The ALJ considered Carela's allegations that "spinal pathologies and left-leg numbness prohibit [her] from working," and the additional functional limitations that she alleged. R. 30. However, the ALJ concluded that based on her review of the record, Carela's "alleged impairments, and the limitations they impose upon her capacities to perform regular and sustained work, cannot be wholly accepted." R. 30.
In reaching this conclusion, the ALJ noted that "[o]bjective signs and laboratory testing have confirmed" the conditions alleged by Carela. R. 30. She noted that "a nerve conduction study in May 2016 confirmed both spinal radiculopathy . . . and right-side carpal tunnel syndrome," R. 30 (citing R. 414, 419), and that "Dr. Comas-Espinal further observed the claimant with a limited spinal range of motion," R. 30 (citing R. 431). However, the ALJ concluded that "the objective medical evidence does not establish physical limitations of a
The ALJ also noted that the record was missing "medical records that one would expect from conditions as debilitating as the claimant alleges." R. 31. While the record did "contain the aforementioned irregular nerve condition study," R. 31 (citing R. 422-55); Dr. Comas-Espinal's observation of limited spinal range of motion, R. 32 (citing R. 431); "and notations of edema," R. 32, the ALJ explained that "besides these records, the evidence is largely devoid of objective documentation of either carpal tunnel syndrome, or degenerative disc disease." R. 32. The ALJ noted that it was "[e]specially noticeable, [that] the record does not contain radiographs actually visualizing any degenerative changes." R. 32.
The ALJ next considered other evidence that the ALJ concluded undercut the credibility of Carela's allegations of the severity of her symptoms. The ALJ cited Carela's "own reported functionality," her non-compliance with physical therapy treatment, observations recorded by Social Security field office representatives, and Carela's work history, which the ALJ believed "does not demonstrate a strong motivation to work." R. 32. The ALJ also noted that Carela's alleged RFC was inconsistent with the Dr. Mescon's opinion, which the ALJ deemed to be "the most credible medical opinion[] of record." R. 32. Finally, the ALJ considered the medical opinions of record. The ALJ assigned "great weight" to the opinion of Dr. Mescon, the physiological consultative examiner, and "little weight" to the opinion of treating source Dr. Comas-Espinal. R. 33.
At step four, the ALJ concluded that Carela could not perform her past relevant work of manicurist/hairstylist. R. 34. The ALJ then moved to step five. The ALJ noted that while Carela was a "younger individual" on the alleged disability onset date, she changed age category to "closely approaching advanced age," R. 34-35, and observed that Carela had acquired work skills from past relevant work, R. 35. The ALJ also concluded that Carela "has a high school education," and that she "is able to communicate in English." R. 35. On the latter point, the ALJ noted that "[a]lthough an interpreter communicated the hearing to the claimant in Spanish, she testified that she can read and write `a little' English," and that "[m]any of the claimant's treatment records further indicate that the claimant's preferred language is `English.'" R. 35 (citing R. 422, 423, 424, 426). The ALJ then concluded that based on the testimony of the VE, there were jobs in the national economy Carela could perform and thus that she was not disabled. R. 36.
A court reviewing a final decision by the Commissioner "is limited to determining whether the [Commissioner's] conclusions were supported by substantial evidence in the record and were based on a correct legal standard."
"Even where the administrative record may also adequately support contrary findings on particular issues, the ALJ's factual findings must be given conclusive effect so long as they are supported by substantial evidence."
The Social Security Act defines the term "disability" as the "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);
To evaluate a Social Security claim, the Commissioner is required to examine: "(1) the objective medical facts; (2) diagnoses or medical opinions based on such facts; (3) subjective evidence of pain or disability testified to by the claimant or others; and (4) the claimant's educational background, age, and work experience."
Regulations issued pursuant to the Act set forth a five-step process that the Commissioner must use in evaluating a disability claim.
Carela raises five grounds for reversing the ALJ's decision, arguing that: (1) the ALJ failed in her affirmative duty to develop the record, Pl. Mem. at 15-17; (2) the ALJ failed to follow the treating physician rule,
When an ALJ assesses a claimant's alleged disability, an ALJ must develop the claimant's medical history for at least a 12-month period. 42 U.S.C. § 423(d)(5)(B); 20 C.F.R. §§ 404.1512(d), 416.912(d) (2017);
At the same time, it is well established that "where there are no obvious gaps in the administrative record, and where the ALJ already possesses a `complete medical history,' the ALJ is under no obligation to seek additional information in advance of rejecting a benefits claim."
Carela argues,
The Commissioner is correct that Carela did not list Dr. Mercado as a treating source in her initial application for benefits.
This case is distinguishable from the cases that the Commissioner cites in support of the proposition that Carela "has not actually demonstrated that any records are missing from Wadsworth Medical Group." Def. Mem. at 17. In
Carela also argues that the ALJ did not discharge her duty to develop the record because the ALJ failed to obtain two potential MRI reports, from 2012 and March 2015. Pl. Mem. at 16. The September 2014 notes of consultative examiner Dr. Mescon indicate that Carela orally informed the doctor that she "had an MRI done of her back two years ago." R. 315. On November 30, 2015, Carela orally informed her physical therapist that she underwent an MRI in March 2015, "which revealed lumbar disc herniation." R. 335. Additionally, in the "Spinal Impairment Questionnaire" that Dr. Comas-Espinal filled out on May 25, 2016, R. 322-27, he wrote "see copies," "MRI," and "x-rays" in response to a question asking him to "identify the imaging and diagnostic test results which support your diagnoses," R. 322. In the end, it is a close question as to whether the ALJ was obligated to attempt to obtain these records based on these vague statements. But because the case is already being remanded to develop the record, we direct the ALJ to make an effort to obtain from Dr. Comas-Espinal the "copies" he referred to in his questionnaire.
We reject, however, the claim that the ALJ is obligated to obtain more information from Dr. Comas-Espinal based on "the ALJ's perceived paucity of evidence" from Dr. Comas-Espinal. Pl. Mem. at 17. Other than the images, there is no indication that there are any "gaps" in Dr. Comas-Espinal's notes that need to be filled.
Carela argues that the ALJ failed to properly apply the treating physician rule by giving more weight to the opinion of consultative examiner Dr. Mescon over the opinion of treating physician Dr. Comas-Espinal. Pl. Mem. at 9-15. Because we remand this case for further development of the record, we do not address the merits of the parties' arguments as to the treating physician rule. Upon remand, the ALJ will reassess the weight each opinion is entitled to with the benefit of a more fully-developed record.
Carela argues that the ALJ erred by failing to properly evaluate her credibility in determining how much weight to give to her allegations regarding the intensity, persistence, and limiting effects of her symptoms. Pl. Mem. at 18-20. Because we remand this case for further development of the record, we do not address the merits of the parties' arguments on this issue. The ALJ, on remand, is to make a new credibility determination in light of the more fully-developed record.
Carela argues that the ALJ erred by finding that her carpal-tunnel syndrome was "non-severe." Pl. Mem. at 17-18. In her decision, the ALJ states that "carpal tunnel syndrome was not diagnosed until May 2016," and that "[a] review of the record revealed no continuous 12 months of complaints regarding the use of [Carela's] hand." R. 28. The ALJ also noted that a note from May 2016 contained only "a generic description of carpal tunnel syndrome, not the claimant's own symptoms." R. 28. Without providing a citation to the record or other sources, the ALJ also observed that "the claimant should respond to treatment for carpal tunnel syndrome." R. 28. Carela argues that the record shows that her carpal tunnel syndrome was in fact diagnosed much earlier, Pl. Mem. at 18, pointing to a letter written by Dr. Comas-Espinal dated December 26, 2014, which states that Carela "is totally disabled at the present time due to her current medical condition," and listing the conditions of "Herniated Discs in the Lumbar Sacral Spine, Arthritis, and Carpal Tunnel Syndrome," R. 321.
Under the applicable regulations, an impairment is considered to be "non-severe" if it "does not significantly limit [the claimant's] physical or mental ability to do basic work activities." 20 C.F.R. §§ 404.1522(a), 416.921(a) (2017).
Dr. Comas-Espinal's conclusory statement that Carela was "totally disabled," in part due to her carpal tunnel syndrome alone does not constitute substantial evidence of the functional limitations caused by Carela's carpal tunnel syndrome.
At step five in the disability evaluation process, "the Commissioner must determine that significant numbers of jobs exist in the national economy that the claimant can perform," and an "ALJ may make this determination either by applying the Medical Vocational Guidelines or by adducing testimony of a vocational expert."
Here, Carela challenges the ALJ's findings that she graduated high school, and that she was able to communicate and understand English, which in turn determined the grid guidelines used. Pl. Mem. at 21-22. While there was some back-and-forth about the subject during the hearing, substantial evidence does support the ALJ's finding that Carela has at least a high school education. Initially, Carela testified that she completed twelfth grade, but did not graduate high school. R. 50. Later on in the hearing, though, Carela stated to her attorney that she "did finish" high school "in the Dominican Republic," but that she did not know where her high school diploma was. R. 73. In addition, Carela indicated that she completed twelfth grade in her disability questionnaire. R. 252. Carela's statement during the hearing and her assertion in her questionnaire constitute substantial evidence that she completed high school, notwithstanding her initial statement that she did not graduate.
As to her language ability, the evidence suggesting that Carela can communicate in English cannot be fairly characterized as "more than a mere scintilla."
For the foregoing reasons, Carela's motion for judgment on the pleadings (Docket # 13) is granted in part and denied in part and the Commissioner's motion for judgment on the pleadings (Docket # 19) is granted in part and denied in part. This case is remanded to the Commissioner for further proceedings consistent with this opinion. The Clerk is requested to enter judgment.
SO ORDERED.