Searching over 5,500,000 cases.


searching
Buy This Entire Record For $7.95

Download the entire decision to receive the complete text, official citation,
docket number, dissents and concurrences, and footnotes for this case.

Learn more about what you receive with purchase of this case.

Santiago v. Colvin

United States District Court, D. Connecticut

February 15, 2017

ANGEL LUIS VELEZ SANTIAGO, Plaintiff,
v.
CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant.

          RULING RE: CROSS MOTIONS FOR JUDGMENT ON THE PLEADINGS (Doc. No. 16) AND TO AFFIRM THE DECISION OF THE COMMISSIONER (Doc. No. 20)

          Janet C. Hall United States District Judge

         I. INTRODUCTION

         The plaintiff, Angel Luis Velez Santiago (“Velez”), filed this administrative appeal pursuant to section 405(g) of title 42 of the United States Code. See Complaint (Doc. No. 1) ¶ 1. Velez asks this court to reverse the final decision of the Commissioner of Social Security, defendant Carolyn W. Colvin (“Colvin”), which denied Velez's applications for Disability Insurance Benefits (“DIB”) and Supplemental Security Income (“SSI”) benefits. See Compl. ¶¶ 12-13, Prayer for Relief; see also Mot. for J. (Doc. No. 16). Velez argues that (1) the Administrative Law Judge (ALJ) afforded insufficient weight to the opinion of Velez's treating physician, and (2) the ALJ improperly evaluated Velez's credibility. See Mem. in Supp. of Mot. for J. (Doc. No. 17) at 1, 6. Colvin moves the court to affirm the final decision. See Mot. to Affirm (Doc. No. 20).

         For the reasons that follow, the court GRANTS Velez's Motion for Judgment on the Pleadings (Doc. No. 16), DENIES Colvin's Motion to Affirm (Doc. No. 20), and REMANDS this case to the agency for proceedings consistent with this Ruling.

         II. MEDICAL BACKGROUND[1]

         Velez was born in 1959. See Certified Transcript of the Record (“Tr.”) (Docs. No. 12-3 to 12-9) at 135. He has a seventh grade education. See id. at 137. In the past, he worked as a firefighting equipment tender, a landscape laborer, and a commercial cleaner. See id. at 159.

         A. Dr. Khalid's Notes

         Velez's treating physician is Dr. Haroon Khalid, M.D. (“Dr. Khalid”), at Southwest Community Health Center. Dr. Khalid's treatment notes[2] state, inter alia, the following:

         On June 2, 2009, Velez complained of wrist pain, radiating to his left shoulder. See id. at 567. The pain was at an intensity level of six out of ten. See id. at 567. Dr. Khalid diagnosed Velez with wrist and shoulder pain, and also recorded diagnoses of anxiety and hypertension. See id. at 567. Dr. Khalid's notes from subsequent office visits reflect ongoing diagnoses of anxiety and hypertension. See id. at 521-61, 735- 62. On August 17, 2009, Velez no longer had wrist pain. See id. at 566. On October 27, 2009, however, Velez complained of severe pain in his arm, which had lasted three weeks. See id. at 565. The pain was at an intensity level of ten out of ten. See id. at 565. Dr. Khalid diagnosed shoulder pain. See id. at 565. On January 27, 2010, Velez complained of chest pain, shoulder discomfort, and finger numbness. See id. at 564. Velez's pain was at an intensity level of three out of ten. See id. at 562. Dr. Khalid diagnosed chest pain. See id.at 562. On March 29, 2010, Velez had no pain. See Id. at 563.

         On October 27, 2010, Velez complained of depression, anxiety, and stress. See id. at 559. His mother had died a month before. See id. at 559. Dr. Khalid diagnosed depression. See id. at 559. Dr. Khalid's notes from subsequent office visits reflect an ongoing diagnosis of depression. See id. at 521-55, 735-61.

         On January 27, 2011, Velez complained of back pain and muscle stiffness. See id. at 558. Dr. Khalid diagnosed back pain. See id. at 558. On July 12, 2011, Velez complained of chest pain, radiating to his right shoulder and the right side of his back. See id. at 556. The pain had lasted for a week and was at an intensity level of seven out of ten. See id. at 556. Velez also was experiencing neck stiffness. See id. at 556. Dr. Khalid diagnosed neck and shoulder pain. See id. at 556.

         On September 12, 2011, Velez reported depression and suicidal thoughts as a result of his son's recent death, but he was not in physical pain. See id. at 555.

         On October 3, 2011, Velez reported a recent work injury to his back, and his back pain was of an intensity level of five or six out of ten. See id. at 554. Velez continued to complain of depression. See id. at 554. Dr. Khalid again diagnosed back pain. See id. at 554. Dr. Khalid's notes from subsequent office visits reflect this diagnosis. See id. at 521-53, 735-62. On December 2, 2011, Velez was experiencing chronic back pain with an intensity level of six or seven out of ten, and also complained of anxiety. See id. at 553. On February 2, 2012, Velez stated that he was trying to cope with depression. See id. at 552. Velez also had chronic back pain with an intensity level of three out of ten, and an MRI reported a bulging disc. See id. at 552. On May 2, 2012, Velez presented with anxiety and depression, stating that at times, he was unable to get out of bed. See id. at 551. He also complained of chronic back pain, at an intensity level of three out of ten. See id. at 551.

         On August 29, 2012, Velez presented with right knee pain, which had caused him difficulty walking for the past month, despite Velez not having experienced trauma to the area. See id. at 550. Velez also continued to complain of anxiety. See id. at 550. Dr. Khalid diagnosed knee pain. See id. at 550.

         On May 6, 2013, Velez experienced back pain at an intensity level of seven out of ten, which was aggravated by bending and twisting. See id. at 544-46. Velez's extremities, however, had a “[n]ormal range of motion, muscle strength, and stability [ ] with no pain on inspection.” Id. at 546.

         On September 3, 2013, Velez was not in pain and again had a “[n]ormal range of motion, muscle strength, and stability in all extremities with no pain on inspection.” Id. at 540-42. Velez was experiencing occasional symptoms of anxiety, however. See Id. at 540. On December 3, 2013, Velez felt “increasingly depressed and anxious.” See Id. at 536. Velez still was not in pain, and still had a “[n]ormal range of motion, muscle strength, and stability in all extremities with no pain on inspection, ” except that Velez experienced mild pain when he moved his right hand's middle finger. Id. at 536-38. On December 10, 2013, Velez was not in pain, and had a “[n]ormal range of motion, muscle strength, and stability in all extremities with no pain on inspection.” Id. at 533.

         On February 3, 2014, Velez's back pain was “worsening, ” however, and occurred “persistently.” Id. at 526. Velez described “the pain as an ache, discomforting, piercing, sharp and stabbing.” Id. at 526. Velez's symptoms were “aggravated by bending, changing positions, daily activities, lying/rest, sitting and standing.” Id. at 526. The back pain once again was at an intensity level of seven out of ten. See id. at 528. Velez also complained of “anxiety and depression.” Id. at 526.

         On March 10, 2014, Velez was no longer in pain, and once again had a “[n]ormal range of motion, muscle strength, and stability in all extremities with no pain on inspection.” Id. at 522-23.

         On May 9, 2014, however, Velez presented with “bilateral pain and swelling on both legs and hands, ” which had lasted for the past three weeks. Id. at 735. Velez had “no strength” in his hands-he could not even “hold a gallon of milk.” Id. at 735. Velez also complained of pain on the right side of his head. See id. at 735. Confusingly, however, Dr. Khalid noted that Velez had a “[n]ormal range of motion, muscle strength, and stability in all extremities with no pain on inspection.” See id. at 737.

         On June 20, 2014, pain persisted in Velez's back, right foot, and hand. See id. at 740. Velez experienced “moderate pain” when he moved his spine. See id. at 742. Additionally, Velez's middle finger on his right hand was “lock[ing] up.” Id. at 742. On August 19, 2014, Velez complained that his right foot hurt when he walked. See id. at 745. Velez had experienced this foot problem for the last two weeks. See id. at 745. Velez felt mild pain when he moved his right foot or ankle. See id. at 747.

         On October 14, 2014, and again on January 6, 2015, Velez no longer had any pain, and a physical examination of all four of Velez's extremities produced normal results. See id. at 752, 758.

         On February 3, 2015, however, Velez had back pain with a severity level of eight out of ten. See id. at 761, 764. The problem fluctuated, but occurred persistently. See id. at 761. Velez described “the pain as an ache and throbbing.” Id. at 761. Symptoms were “aggravated by bending, changing positions and lifting.” Id. at 761. The pain had lasted for the past two to three days. See id. at 761. Velez also complained of “shoulder pain, difficulty making a fist [with his] left hand after surgery for [his] trigger finger, feel[ing] depressed, [and being] unable to work and be gainfully employed.” Id. at 761. Velez experienced moderate pain when he moved his lumbar spine, and had a mildly reduced range of motion in his shoulders. See id. at 764.

         Dr. Khalid's treatment notes state that Velez's “[p]rimary language is English, ” id. at 526, 531, 536, 540, 544, but that his “[l]anguage spoken at home is [Castilian] Spanish, ” id. at 526.

         B. Dr. Goccia's Opinion

         On January 15, 2014, Dr. Richard Goccia, MD (“Dr. Goccia”) examined Velez, at the request of the Social Security Administration (SSA). See id. at 516-20. Dr. Goccia wrote that “[t]he claimant states that when he bends his knees far, they crack and are sore, the right more than the left. This has been going on for many years.” Id. at 516. Dr. Goccia also wrote that, “[t]he claimant does his cooking, cleaning, laundry, and shopping. He is able to shower and dress himself.” Id. at 517. Dr. Goccia described Velez as appearing “to be in no acute distress.” Id. at 518. Dr. Goccia stated that Velez had a normal gait, could walk on his heels and toes “without difficulty, ” could squat fully, had a normal stance, “[u]sed no assistive devices, ” and was “[a]ble to rise from [a] chair without difficulty.” Id. at 518.

         Dr. Goccia described the results of a musculoskeletal exam by stating, inter alia, that Velez's cervical and lumbar spine both showed “full flexion, extension, lateral flexion bilaterally, and full rotary movement bilaterally, ” and that Velez had a full range of motion, bilaterally, in his shoulders, elbows, forearms, wrists, hips, knees, and ankles. Id. at 518.

         Dr. Goccia also stated that Velez had a strength level of five-out-of-five in his “upper and lower extremities, ” that his “[h]and and finger dexterity” was “intact, ” and that he had a grip strength level of five-out-of-five, bilaterally. Id. at 519.

         Dr. Goccia diagnosed Velez with conditions including lower back pain, depression, and anxiety. Id. at 519. Dr. Goccia also stated that Velez “is without limitations. However, he should be restricted from more than moderate exertion given his cardiac history.” Id. at 519.

         C. Dr. Khalid's Opinion

         On February 4, 2015, Dr. Khalid filled out a Disability Impairment Questionnaire regarding Velez. See id. at 643. Dr. Khalid diagnosed Velez with back pain, shoulder pain, sleep apnea, artery disease, hypertension, depression, anxiety, and diabetes. See id. at 643. Dr. Khalid noted that these diagnoses were supported by the following clinical and laboratory findings: (1) limited and partial range of motion in Velez's shoulders, (2) painful and decreased flexion in Velez's spine, (3) tiredness, (4) feeling of depression, and (5) the results of an x-ray of Velez's spine. See id. at 643. Dr. Khalid noted that Velez is not “a malingerer.” Id. at 643. Dr. Khalid listed Velez's “primary symptoms” as chronic back pain, bilateral shoulder pain, anxiety, and depression. See id. at 644. Dr. Khalid described the pain as “dull, aching, ” and stated that precipitating or aggravating factors included bending, prolonged standing, and lifting. See id. at 644. The doctor listed the medications prescribed to Velez as including, inter alia, Tramadol, Meloxicam, Xanax, Lovastatin, Metformin, Glimepiride, Cymbalta, and Ambien. See Id. at 644.

         Dr. Khalid estimated that, in an eight-hour workday, Velez could perform one hour of seated work, and less than one hour of work that involves standing, walking, or both. See id. at 645. Dr. Khalid indicated that Velez could “[o]ccasionally” lift or carry up to ten pounds, but not more. Id. at 645. Dr. Khalid also indicated that Velez can “[n]ever, ” or “[r]arely, ” reach overhead; and can only “[o]ccasionally” grab, turn, or twist objects, or use his hands or fingers for fine manipulations. Id. at 646.

         III. PROCEDURAL HISTORY

         On November 14, 2013, Velez applied for DIB and SSI benefits, for an alleged disability beginning August 22, 2011. See id. at 322, 326. On January 31, 2014, the SSA denied Velez's claims. See id. at 219, 224. On May 8, 2014, the SSA denied his reconsideration request. See id. at 232, 236.

         A. Hearing

          Velez thus requested a hearing before an ALJ. See id. at 241. The ALJ held a hearing on March 17, 2015. See id. at 125. During the hearing, the ALJ asked if Velez would like an interpreter. See id. at 130. Velez responded, “Yes, if you can, because I don't-I understand but not that much.” See id. at 130. An interpreter thus assisted with the hearing. See id. at 130-32.

         Velez testified that he sometimes uses a cane to walk, because it is hard for Velez to stand up from sitting down, but that the cane was not prescribed by a doctor. See id. at 137.

         Velez testified that he can dress himself. See id. at 139. He testified that he can also groom and bathe himself, but that he has “a little bit of a problem” doing so, because, on certain days, back pain makes it difficult for him to bend. See id. at 139. Velez testified that he does no “household chores.” Id. at 139-40. Specifically, he stated that he neither cooks nor cleans. See id. at 140. However, he testified that he does do his own laundry. See id. at 140. Velez testified that he has a driver's license and drives when he has an appointment or has “to go to the grocery store to buy something.” Id. at 140. However, Velez then testified that he doesn't do his own grocery shopping. See id. at 140. Velez stated that he has no pets, hobbies, or special interests. See id. at 140.

         Velez stated that he had a “problem with [his] back” as a result of a 2011 “accident at work.” Id. at 141. Velez stated that he suffers from back pain, at an intensity level of seven or eight out of ten. See id. at 142. He testified that the pain usually starts when he returns to an upright position after bending, see id. at 141, and that the pain is worst in the morning, see id. at 142. Velez stated that, from a standing position, he could not bend to touch his toes, and that even bending to touch his knees caused him pain. See id. at 148. He stated that even stooping caused him pain. See id. at 148. Velez testified that “[n]othing” improves his pain, and then stated that even his pain medication does not help much and that physical therapy did not go well. Id. at 142.

         Velez also testified that he suffers from depression, due to losing both his mother and his son within one year. See id. at 143, 151. He stated that he has also been diagnosed with Post Traumatic Stress Disorder. See id. at 151. Velez discussed his intellectual and social abilities and limitations. See id. at 143-46. Velez stated that he is never ...


Buy This Entire Record For $7.95

Download the entire decision to receive the complete text, official citation,
docket number, dissents and concurrences, and footnotes for this case.

Learn more about what you receive with purchase of this case.