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Baldwin v. Colvin

United States District Court, D. Connecticut

December 1, 2016



          Joan Glazer Margolis United States Magistrate Judge

         This action, filed under ' 205(g) of the Social Security Act, 42 U.S.C. §§ 405(g) and 1383(c)(3), as amended, seeks review of a final decision by the Commissioner of Social Security [“SSA”] denying plaintiff Disability Insurance Benefits ["DIB"] and Supplemental Security Income ["SSI"] benefits.


         On April 22, 2013, plaintiff filed an application for DIB and SSI benefits claiming that he has been disabled since August 1, 2004, which date was later amended to September 6, 2012, due to heart failure and low back pain. (Certified Transcript of Administrative Proceedings, dated November 13, 2015 [“Tr.”] 94, 247-63, 355; see also Tr. 110, 305, 322, 330). Plaintiff's applications were denied initially and upon reconsideration (Tr. 137-70; see Tr. 108-09, 130-31), and on January 6, 2014, plaintiff filed his request for a hearing before an Administrative Law Judge ["ALJ"]. (Tr. 171-72; see Tr. 173-79). A hearing was held on April 21, 2015, before ALJ Alexander Peter Borré, at which plaintiff and vocational expert Stephen Sachs testified. (Tr. 37-93; see Tr. 193-246; see also Tr. 353-54). Plaintiff has been represented by counsel. (Tr. 133, 135). On May 12, 2015, ALJ Borré issued his decision finding that plaintiff has not been under a disability from September 6, 2012 through the date of his decision. (Tr. 17-32). On July 14, 2015, plaintiff filed his request for review of the hearing decision (Tr. 7; see also Tr. 8-16), and on August 26, 2015, the Appeals Council denied plaintiff's request for review, thereby rendering the ALJ's decision the final decision of the Commissioner. (Tr. 1-3).

         On October 7, 2015, plaintiff filed his complaint in this pending action. (Dkt. #1).[1]On October 22, 2015, the parties consented to jurisdiction before this Magistrate Judge, and the case was transferred accordingly. (Dkt. #13). On December 8, 2015, defendant filed her answer, along with a copy of the 1, 186 page administrative record. (Dkt. #14).[2]Thereafter, on February 22, 2016, plaintiff filed his Motion to Reverse the Decision of the Commissioner, with brief in support (Dkt. #18), along with a Stipulation of Facts (Dkt. #19), and on April 22, 2016, defendant filed her Motion to Affirm, with brief in support. (Dkt. #21).

         For the reasons stated below, plaintiff's Motion to Reverse the Decision of the Commissioner (Dkt. #18) is granted such that this case is remanded consistent with this Ruling, and defendant's Motion to Affirm the Decision of the Commissioner (Dkt. #21) is denied.



         At the time of his hearing, plaintiff was living with his fiancée[3] and stepson; he also has a teenage son who lives with the son's mother. (Tr. 48, 50). Plaintiff was homeless for a period of time, but with the help of others, plaintiff and his family eventually moved into an apartment. (Tr. 52-53). His fiancée does the cleaning and shopping (Tr. 83-84, 315), and plaintiff cooks and washes dishes, vacuums and makes his bed. (Tr. 314-15). During a typical day, plaintiff does crossword puzzles and watches television. (Tr. 316).

         Plaintiff is a high school graduate. (Tr. 54). At the time of the hearing, plaintiff was working three days a week at Denny's as a dishwasher. (Tr. 52-55; see Tr. 289). He works between four and five hours a shift, "because [he cannot] do much more than that without hurting." (Tr. 52-53, 55). According to plaintiff, his employer is "pretty good with [him] because . . . they know [his] situation, " and they are "kind of working with [him]." (Tr. 53). The waitresses bring him the dishes, and at most he carries four or five plates within his small work area that he described as a "square[.]" (Tr. 66). Plaintiff testified that he can lift "[m]aybe" five or ten pounds. (Tr. 71). According to plaintiff, when he lifts or carries items, he experiences shooting pain and his arm will just drop. (Tr. 69, 72). He cannot clean the parking lots, take out grease, or fill the ice machine, but he can clean the bathrooms, although not the toilets. (Tr. 55). Prior to working for Denny's, he worked as a janitor (Tr. 54; see Tr. 288), in maintenance at a car dealership, as an assembly worker, and as a cook. (Tr. 306).

         According to plaintiff, he "sometimes[]" takes fifteen minute breaks and he cannot work sitting down because of his "[b]ack issues." (Tr. 56). For the same reason, he does not drive often. (Tr. 57). During a four hour shift, he sits down probably three times for ten or fifteen minutes at a time. (Tr. 79). He also testified that he can sit for "maybe five, [ten] minutes[]" (Tr. 67), can stand for ten or fifteen minutes (Tr. 70), and can walk for ten or fifteen minutes before having to stop to rest. (Tr. 318). He provided his employer with a doctor's note that says he should take more frequent breaks. (Tr. 79). Additionally, he takes frequent bathroom breaks due to his medication. (Tr. 80).

         He rates his back pain as a ten on a scale to ten, and reported that sleeping "is very hard[]" due to his back pain. (Tr. 57; see also Tr. 60-61 (back pain is "always there"), 313 (has a "sleep disorder")). He cannot stoop or bend because of his back. (Tr. 74-75). He finds it "hard to really constantly stand up or walk far or climb stairs without [his] heart feeling like it's beating out [his] chest." (Tr. 57). Plaintiff testified that he has pain in his feet, for which he needs surgery, and it is "painful to stand[.]" (Tr. 58). When walking, he stops and leans on something to rest. (Tr. 67). Sometimes he has to leave work early because after three hours, it is just "too much for" him (Tr. 78), and he cannot stand as long as he needs to. (Id.). According to plaintiff, his impairments affect his ability to lift, squat, bend, stand, reach, walk, sit, kneel, climb stairs, complete tasks, remember, understand, follow instructions, use his hands, and concentrate. (Tr. 317).

         Additionally, plaintiff is seen by doctors for heart issues and he experiences dizziness which causes him to need to take breaks at work. (Tr. 59-60; see Tr. 313 (dizzy spells, out of breath)).[4] He also experiences dizzy spells when doing household chores. (Tr. 315). He has a defibrillator. (Tr. 68). Plaintiff also has shortness of breath (Tr. 60), and at times, he feels sharp pain or fluttering in his chest. (Tr. 82; see Tr. 318). He testified that he has a "little bit of asthma going on[]" but he stopped using an inhaler; he "didn't pursue it." (Tr. 63). Plaintiff smokes a pack of cigarettes every two to three days (id.), but he is bothered by fumes and heat, the latter of which makes him dizzy. (Tr. 64-65). According to plaintiff, if it gets too hot when he is working, they send him home. (Tr. 65).

         The vocational expert testified at plaintiff's hearing that plaintiff's past work as a janitor was semi-skilled medium level work, as a server was light work, as a dishwasher was medium work, and as a food prep worker was light work. (Tr. 86). The vocational expert then testified that a person can perform the work of a server and could perform food prep work if the individual is limited to light work, but is not able to climb ladders, ropes and scaffolding, must avoid hazards such as open, moving machinery and temperature extremes, and is limited to occasional climbing of ramps and stairs, occasional balancing, stooping, kneeling, crouching and crawling. (Tr. 86-87). Additionally, a person with such limitations could also perform the work of a hand packer, production worker, or production inspector. (Tr. 87). If such a person was limited to sedentary work, he could perform the work of a hand packager or production worker (Tr. 88), and if such a person was off task approximately fifteen percent of the workday for unscheduled breaks due to either back pain, or just to catch their breath, such a person could not work. (Tr. 88-89). Similarly, if such a person were absent two or more days a month, such a person could not work. (Tr. 89).

         B. MEDICAL RECORDS[5]


         Plaintiff was first diagnosed with cardiomegaly and congestive heart failure ["CHF"] ¶ 2002-03, when plaintiff was seen at the Hospital of Central Connecticut ["HCC"](formerly known as New Britain Hospital) Emergency Department on several occasions. (See Tr. 544-58, 573, 574, 576, 596; see generally Tr. 591-95, 797). Most of plaintiff's care has been through HCC's Emergency Department, its Medical Clinic, or its Cardiology Clinic. On October 20, 2002, plaintiff was diagnosed with cardiomegaly. (Tr. 596). Less than two months later, on December 8, 2002, plaintiff presented to the Emergency Department with pneumonia (Tr. 646-48; see Tr. 883-87); he was admitted and over the course of the next three days (see Tr. 649-76), he was found to have dyspnea (Tr. 655-56), acute CHF (Tr. 573, 655, 881; see Tr. 574), a severely reduced left ventricular ejection fraction ["LVEF"](Tr. 658), systolic dysfunction of major proportion (Tr. 657), systemic hypertension (id.), and morbid obesity (id.). Three days later, he was noted again to have an enlarged heart and interval decrease in CHF. (Tr. 574, 661). He was discharged with diagnoses of acute congestive heart failure, cardiomyopathy, upper respiratory viral syndrome, and hypertension. (Tr. 881-82).

         On February 10 and 11, 2003, plaintiff was found to have CHF, in part due to medication noncompliance, dilated cardiomyopathy, morbid obesity, and hypertension. (Tr. 566, 839-40; see Tr. 567-69, 841-55). On April 29, 2003, he presented to the Emergency Department with shortness of breath. (Tr. 548).

         On July 2, 2004, he underwent a Treadmill Exercise Study (Tr. 386-87), the results of which were "[a]bnormal." (Tr. 387). At that time, he had a diagnosis of biventricular cardiomyopathy with severe reduction of left ventricle ["LV"] function, as well as both mitral and tricuspid regurgitation. (Tr. 386). An echocardiogram ["ECG"] performed on July 8, 2004 revealed dilated cardiomyopathic LV with biatrial dilation. (Tr. 388).

         Plaintiff was hospitalized with bronchitis, dilated cardiomyopathy, and obstructive sleep apnea ["OSA"] from January 16 to January 18, 2005. (Tr. 856-80; see Tr. 799-802). The results of an ECG taken January 17, 2005 revealed severe dilated cardiomyopathy with severe LV dysfunction. (Tr. 868). On October 5 and 6, 2005, plaintiff was again diagnosed with CHF, hypertension, hyperlipidemia, and OSA, with a past history of cocaine use and then current marijuana use. (Tr. 815-16; see Tr. 817-38).[6]

         Plaintiff presented to the Emergency Department on February 1, 2009 (see Tr. 375-85) with chest pain; his LVEF was moderately decreased to an estimate of 30-35%, with LV cavity moderately to severely increased. (Tr. 375).

         On September 6, 2012, plaintiff was admitted to HCC from the Emergency Department with chest pain (Tr. 406, 412, 624; see Tr. 403-15, 505, 508-18, 623-29, 692-703), [7] for what would be the start of more regular medical treatment for his cardiac and other conditions. At that time, he was morbidly obese with a BMI of 38. (Tr. 514, 516, 626, 628). The record includes reference to an ejection fraction [“EF”] by echocardiogram in 2010 of less than 20%. (Tr. 510, 622). He was diagnosed with chronic systolic congestive heart failure, cardiomyopathy in a setting of a remote history of myocarditis, with an EF of approximately 20%, with hypertension. (Tr. 510, 515, 622, 627). The next day, plaintiff underwent a cardiac catheterization; his doctors concluded that he had "[s]evere cardiomyopathy[.]" (Tr. 506-07, 618-19; see Tr. 807). An echo 2-D doppler test performed the same day revealed that the LVEF was severely decreased globally with regional disparities, the LVEF was estimated to be 25-30%, the left ventricular cavity size was severely increased, there was mild concentric left ventricular hypertrophy, and mild mitral regurgitation with mildly dilated left atrium. (Tr. 518-20, 630-32).

         Plaintiff was seen in the Cardiology Clinic on September 14, 2012 (see Tr. 501-04, 613-16) for resumption of care; he reported feeling "generally well[]" and denied any chest discomfort or shortness of breath. (Tr. 501, 613). Catherine Callan, APRN, saw him in the clinic on September 27, 2012 (see Tr. 497-500, 609-12), at which time he could walk two blocks without shortness of breath, and he denied any chest pain, palpitations, presyncope, syncope, orthopnea, night-time shortness of breath, edema, or claudication. (Tr. 497, 609). The catheterization showed LVEDP of 26, and EF less than 20%, and APRN Callan assessed nonischemic cardiomyopathy and New York Heart Association ["NYHA"] Class II heart failure. (Tr. 498, 610). On October 15, 2012 (see Tr. 494-96, 606-08), plaintiff reported that he was feeling "very well[]" overall. (Tr. 494, 606). His walking limit without shortness of breath was still two blocks; an examination revealed regular heart rate and rhythm, with no murmurs, rubs, gallops, or thrills, and no edema in his extremities, and APRN Callan assessed chronic systolic dysfunction and NYHA Class II heart failure. (Tr. 495, 607; see Tr. 491-93, 603-05).

         On April 10, 2013, when seen at the Cardiology Clinic (Tr. 487-89, 597-99, 951-53), plaintiff again reported difficulties with insurance. (Tr. 487, 597, 951). He had run out of his medications for a time, but reported that once he resumed his medications, he regained his energy. (Id.). He had shortness of breath climbing two flights of stairs as well as tying his shoes. (Id.). On examination, his heart rate and rhythm were regular, and there were no murmurs, rubs, ...

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