United States District Court, D. Connecticut
RULING ON THE PLAINTIFF'S MOTION TO REVERSE OR
REMAND AND THE DEFENDANT'S MOTION TO AFFIRM THE DECISION
OF THE COMMISSIONER
W. THOMPSON UNITED STATES DISTRICT JUDGE.
an administrative appeal following the denial of plaintiff
Carl Aaron Smith's application for disability insurance
benefits (“DIB”) and supplemental security income
benefits (“SSI”) It is brought pursuant to 42
U.S.C. §§ 405(g) and 1382(c)(3).
plaintiff now moves for an order reversing the decision of
the Commissioner of the Social Security Administration
(“Commissioner”), or in the alternative, an order
remanding the case for a rehearing. The Commissioner, in
turn, has moved for an order affirming the decision.
plaintiff claims that the ALJ improperly concluded that the
plaintiff did not have an impairment that meets or equals a
listed impairment and improperly applied the treating
physician rule when making the Listings and Residual
Functional Capacity (“RFC”) determinations.
reasons set forth below, the plaintiff's motion for
remand is being granted, and the Commissioner's motion
for an order affirming the ALJ's decision is being
examination of the record discloses the following: On July
19, 2011, the plaintiff filed an application for DIB and SSI
benefits for an alleged disability that commenced on November
1, 2009 and continued through December 31, 2011, the date on
which he was last insured. (R. 11-12, 254, 261.) The alleged onset
date was amended to October 25, 2011 at a hearing on October
16, 2013. (R. 11, 39.)
March 2, 2012, a disability adjudicator denied the
plaintiff's initial request for DIB and SSI benefits (R.
11, 95, 114.) and on June 27, 2012 denied his request for
reconsideration. (R. 11, 159-172.)
October 16, 2013, the plaintiff appeared with counsel for a
hearing before an ALJ. (R. 33-77.) On January 27, 2014, the
ALJ issued a decision denying benefits. (R. 8-32.) On June 5,
2015, the appeals council denied the plaintiff's request
for review thereby making the ALJ's decision final. (R.
1-7.) This appeal followed.
The Treating Physician's Opinions
Kristin Giannini is a general practice family physician and
the plaintiff's primary treating physician. In evidence
are her records dated 1/1/06 to 8/18/11 (R. 470-710), 9/6/11
to 3/13/12 (R. 748-69) and the Medical Source Statement of
Ability to Do Work Related Activities (Physical)
(“MSS”) dated 9/26/13 (R. 773-79, 784-88).
ambulation, Dr. Giannini's 9/26/13 MSS indicates under
“Sitting/Standing/Walking” that the plaintiff can
walk for zero minutes but also that he does not require the
use of a cane to ambulate. (R. 774, 785.). With regard to
these opinions, the MSS asks the physician to
[i]dentify the particular medical or clinical findings (i.e.,
physical exam findings, x-ray findings, laboratory test
results, history, and symptoms including pain, etc.) which
support [the] assessment or any limitations and why the
findings support the assessment.
(R. 774, 785.) Dr. Giannini left this area blank. Dr.
Giannini states in the MSS that the
plaintiff cannot “walk a block at a
reasonable pace on rough or uneven
surfaces”. (R. 786 (emphasis added).) The MMS
asks the physician to “identify the medical findings
that support this assessment and why the finding[s] support
the assessment”. (R. 778.) Dr. Giannini also left this
area blank. She did not identify any medical or clinical
findings or rationale to support these assessments.
same MSS, Dr. Giannini noted that the plaintiff could shop,
travel independently, use public transportation, and climb a
few steps at a reasonable pace with the use of a hand rail.
The ALJ's Decision
The Listings Determination
found that the plaintiff did “not present with an
impairment that, either singly or in combination, medically
meets or equals the severity requirements of any listed
impairments”. (R. 15.) He reasoned that
[a]lthough there is evidence of a gross anatomical ankle
deformity with chronic joint pain/stiffness and joint space
narrowing, there is no documentation in the medical evidence
of record that the claimant's impairment involves one
major peripheral weight bearing joint, resulting in the
inability to ambulate effectively. . . . [T]he claimant's
physical examinations show that he presented with tenderness
and swelling of his left ankle, requiring the use of a brace.
However, the claimant does not require the use of a cane.
Although he has an antalgic gait, he is able to ambulate
independently. Therefore, the undersigned finds that the
claimant's ankle impairment does not meet or medically
equal the criteria of listing 1.02. . . .
(R. 15.) (emphasis added). Also, the ALJ concluded that the
plaintiff had “mild restriction in his activities of
daily living.” (R. 16.) He reasoned that
a typical day involve[ed] taking a shower, cleaning his room,
watching Sports Center on television, helping his mother
around the house, helping her to the front door, and driving
her to the store. . . At a February 23, 2012 psychological
consultative evaluation, the claimant reported that he was
able to shower daily, brush his teeth daily, cook for
himself, go grocery shopping, and clean his room. Exhibit 9F.
He admitted that he was independent in his personal care
skills. He also admitted to watching sports, fishing, and
hunting shows. He stated the he drives twice a week to go
grocery shopping and also drove himself to the hearing. As
the claimant “is able to independently care for himself
and help his elderly mother at times, the undersigned finds
that he has no more than a mild restriction in his activities
of daily living.”
(R. 16.) In making the Listings determination, the ALJ did
not identify the treating physician's opinions or the
factors considered in weighing those opinions, and the ALJ
did not give the required “good reason” for
rejecting her Listings opinions.
the RFC determination the ALJ found that the plaintiff
has the residual functional capacity to perform light work as
defined in 20 CFR 404.1567 (b) and 416.967(b) except he can
stand/walk for up to 4 hours in an 8-hour workday, sit for up
to 6 hours in an 8-hour workday, and requires a sit/stand
option as well as the use of a cane when walking on uneven
surfaces. He can occasionally climb ramps and stairs,
balance, stoop, kneel, crouch and crawl, and never climb
ladders, ropes or scaffolds. He should avoid ...