LESLIE G. FOSCHIO, Magistrate Judge.
On June 19, 2018, the parties to this action, consented pursuant to 28 U.S.C. § 636(c) to proceed before the undersigned. (Dkt. 7). The matter is presently before the court on motions for judgment on the pleadings filed by Plaintiff on September 10, 2018 (Dkt. 9), and by Defendant on November 9, 2018 (Dkt. 11).
Plaintiff Nathan Bernard Edwards ("Plaintiff"), brings this action under the Social Security Act ("the Act"), 42 U.S.C. § 405(g), seeking judicial review of the Commissioner of Social Security's final decision denying Plaintiff's application filed with the Social Security Administration ("SSA"), on June 23, 2009, for Supplemental Security Income under Title XVI of the Act ("SSI" or "disability benefits"), alleging he became disabled on February 3, 2009, by right hip and low back injury, high blood pressure, gout, and high cholesterol ("initial application"), which conditions caused Plaintiff to stop working on May 28, 2009. AR
On September 10, 2018, Plaintiff filed a motion for judgment on the pleadings (Dkt. 9) ("Plaintiff's Motion"), attaching the Memorandum of Law in Support of Plaintiff's Motion for Judgment on the Pleadings (Dkt. 9-1) ("Plaintiff's Memorandum"). On November 9, 2018, Defendant filed a motion for judgment on the pleadings (Dkt. 11) ("Defendant's Motion"), attaching Defendant's Brief in Support of the Defendant's Motion for Judgment on the Pleadings and in Response to Plaintiff's Brief Pursuant to Local Standing Order on Social Security Cases (Dkt. 11-1) ("Defendant's Memorandum"). On November 30, 2018, Plaintiff filed Plaintiff's Reply Brief (Dkt. 12) ("Plaintiff's Reply"). Oral argument was deemed unnecessary.
Based on the following, Plaintiff's Motion is DENIED; Defendant's Motion is GRANTED.
Plaintiff Nathan Bernard Edwards ("Plaintiff"), born October 5, 1961, was 47 years old as of his asserted disability onset date of February 3, 2009. AR at 113, 156. Plaintiff is a high school graduate and was in regular classes, AR at 33-34, 143, obtained vocational training as a firefighter in the military, AR at 34, and has past relevant work experience as a cable installer, construction worker, cook, ham cutter, and roofer, AR at 139, and served as a firefighter in the military for 16 years. AR at 139. Plaintiff never married and lives with his sister. AR at 161-62, 505.
A claimant is "disabled" within the meaning of the Act and entitled to disability benefits when she is unable "to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which . . . has lasted or can be expected to last for a continuous period of not less than 12 months." 42 U.S.C. §§ 416(i)(1); 1382c(a)(3)(A). A district court may set aside the Commissioner's determination that a claimant is not disabled if the factual findings are not supported by substantial evidence, or if the decision is based on legal error. 42 U.S.C. §§ 405(g), 1383(c)(3); Green-Younger v. Barnhart, 335 F.3d 99, 105-06 (2d Cir. 2003). In reviewing a final decision of the SSA, a district court "is limited to determining whether the SSA's conclusions were supported by substantial evidence in the record and were based on a correct legal standard." Talavera v. Astrue, 697 F.3d 145, 151 (2d Cir. 2012) (internal quotation marks and citation omitted). "Substantial evidence is more than a mere scintilla. It means such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Id. It is not, however, the district court's function to make a de novo determination as to whether the claimant is disabled; rather, "the reviewing court is required to examine the entire record, including contradictory evidence and evidence from which conflicting inferences can be drawn" to determine whether the SSA's findings are supported by substantial evidence. Id. "Congress has instructed . . . that the factual findings of the Secretary,
The applicable regulations set forth a five-step analysis the Commissioner must follow in determining eligibility for disability benefits. 20 C.F.R. §§ 404.1520 and 416.920. See Bapp v. Bowen, 802 F.2d 601, 604 (2d Cir. 1986); Berry v. Schweiker, 675 F.2d 464 (2d Cir. 1982). If the claimant meets the criteria at any of the five steps, the inquiry ceases and the claimant is not eligible for disability benefits. 20 C.F.R. §§ 404.1520 and 416.920. The first step is to determine whether the applicant is engaged in substantial gainful activity ("SGA") during the period for which the benefits are claimed. 20 C.F.R. §§ 404.1520(b) and 416.920(b). The second step is whether the applicant has a severe impairment which significantly limits the physical or mental ability to do basic work activities, as defined in the relevant regulations. 20 C.F.R. §§ 404.1520(c) and 416.920(c). Third, if there is an impairment and the impairment, or its equivalent, is listed in 20 C.F.R. Part 404, Subpart P, Appendix 1 of the regulations ("Appendix 1" or "the Listings"), and meets the duration requirement,
In the instant case, Plaintiff argues the ALJ failed to adhere to the treating physician's rule in explaining the weight given to opinions rendered by Plaintiff's treating sources, Plaintiff's Memorandum at 10-15, the ALJ's determination that Plaintiff can stand for six hours of an 8-hour day is not supported by substantial evidence, id. at 15-17, and, alternatively, the ALJ failed to develop the record and misapplied the "five-day rule." Id. at 17-21.
Plaintiff argues that despite his attorney advising the ALJ by letter dated June 13, 2017 ("June 13, 2017 Letter"), that medical records requested from the Buffalo VA Medical Center and Dr. David Conschafter, DC, had yet to be received, and submitting records to the ALJ on June 22, 2017, ALJ Jones failed to develop the record and issued the Third ALJ Decision ensuring the outstanding VA and chiropractic records had been received, and also improperly relied on the "five-day rule" in failing to consider the records submitted June 22, 2017. Plaintiff's Memorandum at 17-21 (citing AR at 741). In opposition, Defendant argues the ALJ neither misapplied the five-day rule nor failed to develop the record; rather, Plaintiff never attempted to submit the evidence described in the June 13, 2017 Letter, also described the records submitted on June 22, 2017 as "duplicative of prior material," and did not object to the ALJ's response that based on Plaintiff's representation that such records were duplicative, they would not be accepted or reviewed. Defendant's Memorandum at 18-22. Plaintiff further argues the record establishes ALJ Jones relied on the five-day rule in refusing to consider records submitted on June 22, 2017. Plaintiff's Reply at 1-2. There is no merit to Plaintiff's argument.
The so-called "five-day rule" to which the parties refer is a recently enacted SSA regulation requiring, as of May 1, 2017, a disability benefits claimant submit or inform the ALJ of any evidence at least five business days prior to the scheduled administrative hearing. 20 C.F.R. § 416.1435(a). The ALJ may decline to consider or to obtain such evidence unless the claimant was misled by some agency action, a physical, mental, educational, or linguistic limitation, or "[s]ome other unusual, unexpected, or unavoidable circumstance beyond [the claimant's] control" prevented the claimant's compliance with the five-day rule. 20 C.F.R. § 416.1435(b). In the instant case, although the June 13, 2017 Letter was provided more than five business days prior to the third administrative hearing on June 27, 2017, Plaintiff never actually submitted the VA and chiropractic records referenced in the June 13, 2017 Letter. Accordingly, ALJ Jones' failure to consider such records cannot be attributed to improper reliance on the five-day rule. With regard to the records submitted on June 22, 2017 ("the June 22, 2017 records"),
AR at 544 (italics added).
The record thus establishes ALJ Jones provided Plaintiff with more time following the third administrative hearing either to provide the VA and chiropractic records referenced in the June 13, 2017 Letter, or to request additional time to do so. Significantly, to date, no such additional records have been submitted, but such fact is unrelated to application of the five-day rule.
It is settled in the Second Circuit that "`the ALJ, unlike a judge in a trial, must [her]self affirmatively develop the record' in light of `the essentially non-adversarial nature of a benefits proceeding.'" Pratts v. Chater, 94 F.3d 34, 37 (2d Cir. 1996) (quoting Echevarria v. Secretary of HHS, 685 F.2d 751, 755 (2d Cir. 1982)). "This duty arises from the Commissioner's regulatory obligations to develop a complete medical record before making a disability determination, 20 C.F.R. § 404.1512(d)-(f) (1995), and exists even when, as here, the claimant is represented by counsel." Id. (citing Perez v. Chater, 77 F.3d 41, 47 (2d Cir. 1996)). Nevertheless, an ALJ's duty to affirmatively develop the record is discharged when the ALJ agrees to hold the record open to permit the claimant's counsel, who volunteers to do so, to obtain additional relevant records, with the caveat that if counsel fails to provide the records within a specified period of time, the ALJ's decision would be made based on the existing record. See Jordan v. Comm'r of Soc. Sec., 142 Fed.Appx. 542, 543 (2d Cir. Sept. 8, 2005) (affirming district court's holding that no remand to the ALJ was required where, following administrative hearing, ALJ held record open for 30 days to permit Plaintiff's counsel to obtain and submit additional medical records with notice that if such evidence was not timely submitted, a decision would be made based on the record without the additional records). Significantly, in the instant case, the Third ALJ Decision was not issued until September 22, 2017, well beyond the one-week period ALJ Jones advised the record would be held open to provide Plaintiff's counsel time to obtain and submit the records, yet the records were not submitted, nor was a request made by Plaintiff's counsel for additional time or for the ALJ's assistance in securing such records.
Insofar as ALJ Jones failed to consider the June 22, 2017 records, albeit only after Plaintiff's attorney advised the records were "duplicative of prior materials," AR at 500, "`[a]lthough the ALJ has the duty to develop the record, such a duty does not permit a claimant, through counsel, to rest on the record — indeed, to exhort the ALJ that the case is ready for decision — and later fault the ALJ for not performing a more exhaustive investigation.'" Gonzalez v. Colvin, 2018 WL 1040250, at * 3 (W.D.N.Y. Feb. 24, 2018) (quoting Maes v. Astrue, 522 F.3d 1093, 1097 (10
Plaintiff argues remand is required because no medical evidence supports the ALJ's determination that Plaintiff retains the capacity for light work which requires the ability to stand for six hours in an 8-hour workday. Plaintiff's Memorandum at 15-17. Defendant maintains the administrative record contains substantial evidence supporting the ALJ's determination that Plaintiff can stand for six hours in an 8-hour workday, including the consultative opinion of neurologist John Schwab, D.O. ("Dr. Schwab"), that Plaintiff could stand for four hours and walk for four hours in an 8-hour workday. Defendant's Memorandum at 17-18. In reply, Plaintiff argues that equating standing and walking is erroneous. Plaintiff's Reply at 2-4.
Whether Plaintiff can walk for six hours in an 8-hour workday is significant because the ability to stand and walk for six hours is required for work of a "light" as compared to "sedentary" exertion.
SSR 83-10, 1983 WL 31251 at * 5.
In contrast, the walking and standing capability required for "light work" is "frequent" which is defined as
Id. at * 6.
Accordingly, a plain reading of the relevant regulation describing work of a light exertion, i.e., 20 C.F.R. § 416.1567(b), and the pertinent portion of SSR 83-10, establishes light work requires the ability to sit and stand for a combined six hours in an 8-hour workday and not, as Plaintiff argues, to only stand for six hours. Further, substantial evidence in the record supports that Plaintiff can sit and stand for six hours in an 8-hour workday.
In particular, on October 18, 2014, Plaintiff underwent a consultative physical examination by neurologist Dr. Schwab, AR at 816-24, who assessed Plaintiff with the ability to stand for 30 minutes at one time, and to walk for 30 minutes at one time, as well as with the ability to stand for four hours in an 8-hour workday, and also to walk for four hours in an 8-hour workday. AR at 820. Because a plain reading of SSR 83-10 establishes the exertional requirement for light work includes standing and walking for a combined six hours in an 8-hour workday, Dr. Schwab's opinion that Plaintiff can stand and walk for a total of eight hours in an 8-hour workday is consistent with the ALJ's determination that Plaintiff is capable of the exertional requirements for light work. Significantly, the opinion of a consultative examiner assessed after physically examining a claimant can be considered substantial evidence on which the ALJ may rely in assessing a claimant's RFC. See Sloan v. Colvin, 244 F.Supp.3d 315, 324-26 (W.D.N.Y. 2014) (noting "consultative physician's opinion may serve as substantial evidence" and finding no error in ALJ's reliance on consultative examining physician's opinion in assessing the claimant's RFC). As such, substantial evidence in the record supports the ALJ's assessment that Plaintiff retained the ability to stand and walk as required for work at the light exertion level.
Plaintiff maintains ALJ Jones violated the treating physician's rule in determining Plaintiff's RFC by accepting the consultative opinion of Dr. Schwab over the opinions rendered by Plaintiff's treating primary care physician, David Holmes, M.D. ("Dr. Holmes"), and Pretei Lemo, MBBS
Under the so-called "treating physician rule," the opinion of a treating physician is entitled to significant weight where it is supported by medical evidence in the record, and to controlling weight where it is "well supported by medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with other substantial evidence in the case record." 20 C.F.R. § 404.1527(d)(2). Treating physician opinions, however, are not determinative and are granted controlling weight only when they are not inconsistent with other controlling evidence. 20 C.F.R. § 404.1527(d); Halloran v. Barnhart, 362 F.3d 28, 32 (2d Cir. 2004) (citing Veino v. Barnhart, 312 F.3d 578, 588 (2d Cir. 2002)). In the instant case, substantial evidence in the record establishes the ALJ's failure to accord controlling weight to the opinions of Drs. Holmes and Lemo did not violate the treating physician rule.
Specifically, on October 5, 2009, Dr. Lemo completed a disability form on which he circled answers indicating Plaintiff's chronic and moderate right hip pain and back pain limited Plaintiff to standing for 30 minutes at one time, sitting for two hours at one time, could frequently climb stairs, that Plaintiff should never lift any weight, bend, stoop, balance, or climb ladders, but failed to circle the answer corresponding to how many hours Plaintiff could work in one day, and the form did not include any question regarding Dr. Lemo's opinion as to how long Plaintiff could walk. AR at 353-54. The ALJ found Dr. Lemo's opinion was not supported by the medical evidence of record and was inconsistent with treatment notes as well as objective evidence in the record showing Plaintiff with only mild symptoms in his hip, and that Plaintiff ambulated with a normal gait and did not use any assistive devices. AR at 482. This finding is supported by treatment notes in the record indicating Dr. Lemo treated Plaintiff from July 10 through September 3, 2009, at Erie County Medical Center ("ECMC"), in Buffalo, New York. AR at 255-91. In particular, Dr. Lemo's treatment of Plaintiff during this period of time is very limited and largely related to following up with Plaintiff after a brief hospitalization at ECMC from July 10 to 12, 2009 for a back injury, chest pain and and hypertension complications. AR at 239-54. X-rays of Plaintiff's lumbar spine taken July 23, 2009 showed no evidence of fracture or significant degenerative changes. AR at 291. From August 1 to 4, 2009, Plaintiff was again admitted to ECMC, this time complaining about left upper quadrant pain, although "[p]hysical examination was largely within normal limits," and Plaintiff's discharge diagnosis included peptic ulcer disease, acute renal failure, resolved, hypertension, hyperlipidemia, and gout, and Plaintiff was prescribed a home blood pressure cuff, advised to check his blood pressure daily, follow a low-salt and low-fat diet, and to resume activity as tolerated. AR at 256-58. At follow-up with Dr. Lemo on August 6, 2009, Plaintiff reported he felt well and was without any complaints, AR at 275, and Plaintiff's back pain was reported as "stable on Tramadol." AR at 278. On September 3, 2009, Plaintiff had some right heel pain attributed to "gouty arthritis." AR at 273. On both August 6 and September 3, 2009, Dr. Lemo found Plaintiff with normal gait and station, range of motion, stability, muscle strength and tone. AR 273, 278. Accordingly, the ALJ's determination that Dr. Lemo's assessment of Plaintiff as limited to standing for 30 minutes, sitting for two hours, and avoiding all lifting, bending, stooping, balancing, or climbing of ladders, AR at 353-54, is not supported by the scant treatment notes in the record from Dr. Lemo.
Similarly, on May 6, 2014, Dr. Holmes assessed that Plaintiff could stand and walk for ½ hour at a time, and for a total of two hours in an 8-hour workday, frequently lift and carry up to 5 lbs., occasionally lift and carry up to 10 lbs., occasionally lift up to 20 lbs., but never carry more than 10 lbs. nor lift more than 20 lbs., was unable to bend, squat, crawl, or climb, occasionally could reach, and was moderately restricted as to activities involving unprotected heights, being around moving machinery, and driving automotive equipment. AR at 804-05. Dr. Holmes further opined Plaintiff "most likely" unable to engage in "full-time competitive employment five days per week, eight hours per day on a sustained basis," adding "it's unclear what `competitive' means exactly," but also indicated Plaintiff could work seven hours a day before pain prevented the performance of even simple work tasks. AR at 805. Dr. Holmes further found Plaintiff's pain medications did not affect Plaintiff's concentration, that Plaintiff did not need to lie down during an 8-hour workday, that Plaintiff possibly could experience pain symptoms making it impossible to function in a work setting, although this was "unlikely," and that Plaintiff's pain symptoms would be expected to cause Plaintiff to miss work only "0-1 day per month." AR at 805. ALJ Jones correctly found these assessments to be internally inconsistent with the rest of Dr. Holmes's opinion.
Furthermore, the medical record is consistent with Dr. Schwab's assessment of the impact of Plaintiff's impairments on Plaintiff's ability to do work-related activities. See AR at 818-24. Specifically, treatment notes show Dr. Holmes largely followed Plaintiff through the urology clinic at Cleve-Hill Family Health Center ("Cleve-Hill") for treatment of hypertension, hypercholesterolemia, and Type 2 diabetes mellitus, with only occasional mentions of low back and right hip pain. See, e.g., AR at 836-40 (October 11, 2012), 841-44 (November 15, 2012), 774-78 (April 9, 2013), 778-80 (August 19, 2013), 781-84 (September 6, 2013), 785-87 (October 17, 2013), 788-90 (Nov. 16, 2013), 800-02 (February 11, 2014), 869-74 (May 6, 2014), and 883-88 (April 10, 2015). Further, most of the treatment notes for Plaintiff consist of Primary Care Progress Notes ("Progress Notes") from Cleve-Hill where Plaintiff was seen by several health care providers, including Drs. Holmes and Lemo, yet the records largely pertain to Plaintiff's efforts to control his blood pressure, diabetes, ulcers, and gout, with only occasional references to Plaintiff's complaints of hip and low back pain. See, e.g., AR at 330 (July 15, 2009 Progress Note indicating Plaintiff's reason for visit was follow-up from previous hospitalization, hip and low back pain, and possible allergic reaction to medication). Similarly, diagnostic testing, consisting largely of blood tests and radioactive imaging of Plaintiff performed at ECMC show essentially minimal changes. See, e.g., AR at 254 (lumbar spine X-ray taken July 25, 2009 should "no evidence of fracture or significant degenerative changes"). Moreover, the Progress Notes are largely consistent with Dr. Schwab's assessment on October 18, 2016, finding Plaintiff in no acute distress, with normal gait and station, able to walk on heels and toes without difficulty, used no assistive device, tandem walk heel-to-toe was normal, strength in lower extremities was normal, no dysmetria (lack of coordination), reflexes and muscle tone were normal, and no tremors or muscle atrophy was found. AR at 816-17. Dr. Schwab diagnosed Plaintiff with back ache, hypertension, and diabetes mellitus type 2, for which his prognosis was stable, and statement Plaintiff had "no restrictions based on the findings of today's examination." AR at 817.
Accordingly, the ALJ's decision to give the opinion of Dr. Schwab greater weight than those of Drs. Holmes and Lemo did not violate the treating physician rule.
Based on the foregoing, Plaintiff's Motion (Dkt. 9) is DENIED; Defendant's Motion (Dkt. 11) is GRANTED. The Clerk of Court is directed to close the file.
SO ORDERED.
20 C.F.R. § 404.1567(a) and (b).