HUGH B. SCOTT, Magistrate Judge.
Before the Court are the parties' respective motions for judgment on the pleadings (Docket Nos. 18 (plaintiff), 23 (defendant Commissioner)). Having considered the Administrative Record (Docket No. 7), the papers of both sides (Docket Nos. 18, 23, 24), this Court reaches the following decision on the pending motions (Docket Nos. 18, 23).
This is an action brought pursuant to 42 U.S.C. § 405(g) to review the final determination of the Commissioner of Social Security that plaintiff is not disabled and, therefore, is not entitled to disability insurance benefits and Supplemental Security Income benefits.
References noted as "[R. __]" are to the certified record of the administrative proceedings, filed with this Court (Docket No. 7).
The plaintiff ("Roberto Del Valle" or "plaintiff") filed an application for disability insurance benefits on April 21, 2014 [R. 10]. That application was denied initially. The plaintiff appeared before an Administrative Law Judge ("ALJ"), who considered the case
Plaintiff commenced this action on November 10, 2017 (Docket No. 1). The parties moved for judgment on the pleadings (Docket Nos. 18, 23), and plaintiff duly replied (Docket No. 24). This case was scheduled for oral argument and a status conference on February 21, 2019 (Docket No. 25), but due to the failure to enact appropriations, the proceedings were stayed (Docket No. 26). Upon further consideration, this Court then determined that the motions could be decided on the papers.
Plaintiff, a 46-year-old (as of the claimed onset date of February 1, 2014) with a tenthgrade education, last worked as a paint sprayer in an auto shop, window restorer, and mold cutter (Docket No. 18, Pl. Memo. at 4; [R. 41, 59-60, 71-80, 178-216]). The vocational expert later found that these occupations require medium exertion but plaintiff claimed he performed them at a light exertion level [R. 21]. The ALJ later found that plaintiff was unable to perform any past relevant work [R. 21]. Plaintiff reported to consultative examiner Dr. Santarpia that he was laid off in August 2013 and was reported unable to work due to his legs [R. 353].
Plaintiff claims the following impairments deemed severe by the ALJ: obesity, coronary artery disease, persistent congestive heart failure, chronic diastolic heart failure, right ankle fracture with ongoing residuals, osteoarthritis and depression [R. 12]. As for his obesity, plaintiff testified that he weighed 347 pounds [R. 16], once weighed 345 pounds and was 5'9" tall in July 2014 [R. 349, 18;
Plaintiff also claims low back pain as a severe impairment [R. 13] but the ALJ noted that plaintiff completed physical therapy in August 2015 and reported not having pain and that his back was doing well [R. 13, 861]. Thus, the ALJ did not deem this condition to be severe [R. 13].
The ALJ found that plaintiff's severe impairments did not meet or exceed the relevant Listings [R. 13-14], concluding plaintiff's condition did not meet Listings 1.02 (major dysfunction of a joint for ankle or osteoarthritis), 4.02 (chronic heart failure), 4.04C (coronary heart disease), 12.04 (depressive disorder); obesity did not meet Listings 1.00Q (musculoskeletal), 3.00I (respiratory), or 4.00F (cardiovascular) [R. 13-14]. As for plaintiff's claimed mental impairment, the ALJ concluded plaintiff did not meet Listing 12.00 "Paragraph B" or "Paragraph C" criteria, finding that plaintiff had only mild or moderate limitations in the "Paragraph B" criteria [R. 14-15]. As for "Paragraph C" criteria, the ALJ concluded that these criteria were not met, since the record did not show that plaintiff had only a marginal adjustment to changes in plaintiff's environment or to demands not in plaintiff's daily life [R. 15]. At the Fourth Step of the five-step analysis (described below), the ALJ found plaintiff's claims of depression were mitigated by his failure to seek treatment [R. 20].
Plaintiff had heart surgery on July 11, 2016 [R. 602]. His cardiac surgeon, Dr. Janerio Aldridge, in the discharge orders of July 18, 2016, opined that plaintiff's activity be limited to lifting no more than five pounds [R. 604, 877, 18, 20]. The discharge plan limited plaintiff's activities to avoid extreme temperatures, not to smoke, drink alcohol, take tranquilizers or medication not prescribed by the surgeon [R. 604, 877, 20]. Dr. Aldridge also ordered plaintiff not to "travel, drive or return to work till your surgeon clears" [R. 604, 877, 20-21]. The ALJ, however, gave little weight to that opinion because it was time limited opinion following surgery and during plaintiff's recovery [R. 20-21].
On July 29, 2016, plaintiff had a post-operative follow up examination with PA Mary Murphy [R. 876-77, 19, 21]. Plaintiff felt well since his heart surgery, had no new complaints [R. 876, 19] denies any pain and is doing well [R. 876, 877]. Plaintiff then was advised to avoid heavy lifting for eight weeks, of nothing more than ten pounds and was not to drive for four weeks from date of surgery (to mid-August 2016) ([R. 877, 19];
At the September 14, 2016, hearing, plaintiff testified that he had pain, fatigue, cardiac issues, and required rest periods, exertional limitations, and use of hands limitations (Docket No. 24, Pl. Reply Memo. at 8; [R. 41-70, 51 (plaintiff's testimony)]). Plaintiff testified that his heart surgery recovery was expected to take two years and his next cardiology appointment is October 11, 2016 (Docket No. 24, Pl. Reply Memo. at 8; [R. 51, 17]). Looking at the medical evidence, the ALJ found that this record failed to provide support for plaintiff's alleged disabling symptoms and limitations [R. 18]. The ALJ then concluded that plaintiff's statements about that intensity, persistence, and limiting effects of plaintiff's impairments "are not entirely consistent with the medical evidence and other evidence in the record for the reasons stated in this decision" [R. 20], that no objective medical evidence supports some of plaintiff's allegations [R. 20].
The ALJ found that plaintiff had a residual functional capacity to perform sedentary work [R. 15]. The ALJ deemed plaintiff capable of occasionally climbing ramps and stairs; plaintiff could never climb ladders, ropes, and scaffolds; all of plaintiff's ambulation would need to be performed with assistance of cane [R. 15]. Plaintiff could occasionally balance and stoop; never kneel, crouch, and crawl; no work at unprotected heights or around dangerous machinery; frequent but not constant fine and gross manipulation with the right upper extremity and limited to simple routine tasks [R. 15]. Based on this finding and the occupations the vocational expert identified as plaintiff's past relevant work, the ALJ concluded that plaintiff cannot perform this past work [R. 21]. Applying additional limitations to plaintiff's residual functional capacity, the vocational expert opined that a hypothetical claimant with plaintiff's condition, age, and experience could work as a document preparer, printed circuit clerk, and surveillance system monitor, each sedentary exertion occupations [R. 22]. As a result, the ALJ held that plaintiff was not disabled [R. 23].
The only issue to be determined by this Court is whether the ALJ's decision that the plaintiff was not under a disability is supported by substantial evidence.
For purposes of both Social Security Insurance and disability insurance benefits, a person is disabled when unable "to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months." 42 U.S.C. §§ 423(d)(1)(A) & 1382c(a)(3)(A).
Such a disability will be found to exist only if an individual's "physical or mental impairment or impairments are of such severity that [he or she] is not only unable to do [his or her] previous work but cannot, considering [his or her] age, education, and work experience, engage in any other kind of substantial gainful work which exists in the national economy. . . ." 42 U.S.C. §§ 423(d)(2)(A) & 1382c(a)(3)(B).
The plaintiff bears the initial burden of showing that the impairment prevents the claimant from returning to his or her previous type of employment.
In order to determine whether the plaintiff is suffering from a disability, the ALJ must employ a five-step inquiry:
20 C.F.R. §§ 404.1520 & 416.920;
To determine whether an admitted impairment prevents a claimant from performing past work, the ALJ is required to review the plaintiff's residual functional capacity and the physical and mental demands of the work that has done in the past. 20 C.F.R. §§ 404.1520(e) & 416.920(e). When the plaintiff's impairment is a mental one, special "care must be taken to obtain a precise description of the particular job duties which are likely to produce tension and anxiety, e.g. speed, precision, complexity of tasks, independent judgments, working with other people, etc., in order to determine if the claimant's mental impairment is compatible with the performance of such work."
Pertinent to this case is the treating physician's rule (as of April 2014)
In the instant case, the issue is whether the ALJ had substantial evidence to support the decision rendered denying disability coverage. Plaintiff first argues that the ALJ used his own lay opinion rather than medical opinions in the record (Docket No. 18, Pl. Memo. at 15-21). Next, plaintiff faults the ALJ for improperly relying upon the consultative medical examiner Dr. Liu's opinion and that of psychological examiner Dr. Santarpia (
At Step Four of the five-step analysis, plaintiff contends that the ALJ did not properly evaluate the medical record, specifically the opinion of treating cardiac surgeon, Dr. Aldridge (Docket No. 18, Pl. Memo. at 16-21). Plaintiff argues that the ALJ did not give good reason for devaluing the opinion of Dr. Aldridge (
Defendant Commissioner responds that Dr. Aldridge's opinion was rendered one week after plaintiff's surgery (Docket No. 23, Def. Memo. at 10; [R. 604]). The ALJ considered this opinion, gave reasons for giving them little weight in formulating the residual functional capacity (Docket No. 23, Def. Memo. at 10), that plaintiff's subsequent medical examinations found plaintiff's condition was "largely normal" following surgery (Docket No. 23, Def. Memo. at 10-11; [R. 18-19, 685, 688, 741, 743-44, 876-77]), with restrictions increasing plaintiff's capacity over time (
As a treating physician's opinion, Dr. Aldridge's opinion generally is entitled to controlling weight unless it is inconsistent with other substantial evidence or is not supported by medical findings,
Plaintiff next argues that the ALJ inappropriately relied upon the opinions of consultative examiners Dr. Liu and psychologist Dr. Santarpia (Docket No. 18, Pl. Memo. at 17-19, 19-20). He contends that the ALJ favored Dr. Liu's "vague" opinion over the opinion of treating cardiologist, Dr. Aldridge, with Dr. Aldridge's opinion the sole opinion on plaintiff's cardiac condition (
Dr. Liu examined plaintiff on July 18, 2014, prior to plaintiff's 2016 heart surgery and found that plaintiff medically needed a cane, concluding that plaintiff had moderate limitation for prolonged walking, bending, and kneeling [R. 349, 352, 18-19]. The ALJ gave significant weight to this opinion base on the examination and program knowledge ([R. 20]; Docket No. 23, Def. Memo. at 11-12).
Dr. Santarpia found on examination on August 7, 2014, that plaintiff's manner of relating and overall presentation was adequate [R. 353-54, 19-20]. She opined that plaintiff would have moderate limitation with learning new tasks and performing complex tasks independently [R. 355, 20]. The ALJ also gave significant weight to Dr. Santarpia's opinion based upon the examination and program knowledge, as well as that opinion being consistent with the whole record and plaintiff's testimony [R. 21]. Plaintiff faults the ALJ for not adopting the more restrictive limitations in learning new tasks from Dr. Santarpia's assessment (Docket No. 18, Pl. Memo. at 19). He notes Dr. Santarpia was internally inconsistent by finding that stress-related problems may at times interfere with his ability to function daily but did not offer limitations (
Defendant responds that the ALJ properly evaluated all opinion evidence (Docket No. 23, Def. Memo. at 9, 11-12, 14-16), with the ALJ acknowledging plaintiff's cardiac condition which arose after Dr. Liu's evaluation (
As noted above in discussing Dr. Aldridge's opinion, the duration of plaintiff's postsurgery limitation is not stated by that doctor. The ALJ factored in plaintiff's medical condition after Dr. Liu's opinion such that the ALJ did not exclusively rely upon the potentially stale evaluation. Plaintiff's motion on this point is
As for plaintiff's mental evaluation, the ALJ relied heavily upon Dr. Santarpia's evaluation, while also noting the state agency's opinion of Dr. Butensky [R. 20, 91] (
Plaintiff also contends at Steps Two and Three that the ALJ failed to recognize as severe plaintiff's cardiac and lumbar impairments (Docket No. 18, Pl. Memo. at 21-26). Defendant responds that the ALJ fully accounted for plaintiff's cardiac and lumbar conditions (Docket No. 23, Def. Memo. at 18-19; [R. 15-21]).
As for impairments consideration at Step Two, plaintiff bears the burden of establishing that he or she has a severe impairment, "which is `any impairment or combination of impairments which significantly limits [the claimant's] ability to do basic work,'"
This Court agrees with defendant (
As for plaintiff's cardiac limitation, in addition to deeming the condition severe the ALJ reviewed at Step Three plaintiff's heart condition as compared with Listing 4.02 for chronic heart failure and Listing 4.04C for coronary artery disease [R. 14]. Thus, the ALJ did analyze the evidence of his cardiac condition.
Absent Dr. Aldridge's opinion, plaintiff argues that the medical record is incomplete and the ALJ makes her findings with gaps in the record (Docket No. 18, Pl. Memo. at 26-30). Plaintiff argues that the ALJ had a duty to determine from Dr. Aldridge whether his postoperative instructions were of a limited duration and what functional limitations remain (
Plaintiff may have a point. The only ambiguity here is whether the post-op instructions from Dr. Aldridge was limited or remain. When plaintiff had the hearing, it was months after surgery. The hearing concluded with the ALJ awaiting additional records from Dr. Aldridge [R. 79] but plaintiff had not gained further records from Dr. Aldridge. The ALJ closed the record after giving plaintiff the opportunity (at his request for additional time) to supplement.
Where there is a gap in the record, the ALJ must affirmatively develop the evidence,
For the foregoing reasons, plaintiff's motion (Docket No. 18) judgment on the pleadings is
So Ordered.