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Smith v. Colvin

United States District Court, D. Connecticut

February 16, 2017




         This is an administrative appeal following the denial of plaintiff Carl Aaron Smith's application for disability insurance benefits (“DIB”) and supplemental security income benefits (“SSI”)[1] It is brought pursuant to 42 U.S.C. §§ 405(g) and 1382(c)(3).

         The 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.

         The 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.

         For the 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 denied.

         I. FACTS

         A. Administrative Proceedings

         An 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.[2] (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.)

         On 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.)

         On 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.

         B. The Treating Physician's Opinions

         Dr. 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).

         As to 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.

         In the 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. (R. 778.)

         C. The ALJ's Decision

         1. The Listings Determination

         The ALJ 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.

         2. RFC

         As to 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 ...

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