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Belton v. Berryhill

United States District Court, D. Connecticut

March 9, 2017



          Dominic J. Squatrito United States District Judge.

         This is an administrative appeal following the denial of an application filed by the plaintiff, Sharyl A. Cummings Belton (“Belton”), for disability insurance benefits (“DIB”).[2] It is brought pursuant to 42 U.S.C. §§ 405 (g) and 1383 (c)(3).

         Belton now moves for judgment on the pleadings, seeking an order reversing the decision of the Commissioner of the Social Security Administration (“Commissioner”). In the alternative, Belton seeks an order remanding her case for a rehearing. The Commissioner, in turn, has moved for an order affirming her decision.

         The issues presented are whether the ALJ: (1) properly determined that Belton did not have a condition that met or exceeded the severity requirements of an impairment listed in the pertinent regulations; (2) properly applied the treating physician rule; and (3) properly evaluated Belton's credibility with regard to her symptoms. For the following reasons, Belton's motion for judgment on the pleadings is denied, and the Commissioner's motion for an order affirming her decision is granted.


         An examination of the record discloses the following: On July 19, 2012, Belton filed an application for DIB.[3] for an alleged disability that commenced on March 15, 2012.[4] On October 24, 2012, her application was denied, and on April 17, 2013, her request for reconsideration was denied.

         On May 16, 2014, Belton appeared with counsel for a hearing before an ALJ. On June 3, 2014, the ALJ issued a decision denying benefits. On September 24, 2015, the Appeals Council denied Belton's request for review of that decision thereby making the ALJ's decision the final decision of the Commissioner. This appeal followed.

         Belton, who was born on March 18, 1961, has a high school diploma plus one year of college. Her past relevant work was as an administrative assistant, retail manager, newspaper layout designer, cashier, take-out food clerk, personal care assistant, and teaching assistant. According to Belton, she left her most recent job, a teaching assistant position, in 2011 because “I had got an attack and I was sick, very sick, for three days and I didn't call. I didn't show up. So, about in the third day, I listened to my messages, and they pretty much told me if I didn't show up or call, that I was terminated. So, I never went to fight for my job, because I didn't know if I was going to get sick again or be out, and it was part time anyway. . . .” (Doc. # 9-3, at 85, p. 84).[5]

         Medical Evidence

         A. Dr. Samuel Bridgers

         In early 2012, Belton's primary care physician, Dr. Babu Kumar, referred her to a neurologist, Dr. Samuel Bridgers, due to her history of migraine headaches. Dr. Bridgers' initial consultation note, dated January 26, 2012, reflects Belton's statements to him about her migraines:

She will probably experience a half a dozen headaches a year, most of which can be controlled by taking Excedrin Migraine at the onset. About twice a year, the Excedrin Migraine won't work and the patient will go on to experience a severe headache with nausea, vomiting, photophobia and phonophobia. When headaches progress to this point, they usually last a few days.
She denies . . . nausea and vomiting other than with headaches, . . . joint problems, depression or anxiety.

         (Doc. # 9-8, at 44, p. 293).

         Regarding a follow-up visit on July 6, 2012, Dr. Bridgers noted that over the course of the previous six months “[s]he has had 6 migraines. . . . They usually respond to a combination of Maxalt 10 mg and a Compazine suppository. . . . I will see her again in one year.” (Id. at 46, p. 295). A report by Dr. Bridgers dated February 17, 2014, states the following:

The patient returns for reevaluation approximately 1 ½ years after I had last seen her. She still does average one migraine [a] month, although in some months she may get none and in some months she may get two in a row. Her headaches generally respond to a combination of Maxalt MLT and a Compazine suppository.

(Id. at 77, p. 326).

         B. Arthritis & Osteoporosis Center, P.C.

         In 2012 Dr. Kumar also referred Belton to the Arthritis & Osteoporosis Center, P.C. (“AOC”) due to joint pain. Belton first saw an AOC rheumatologist, Dr. Jennifer Becker, on March 26, 2012. Her chief complaint was noted as “Joint Pain.” (Id. at 47, p. 296). It was further noted that the “[p]atient denies systemic symptoms . . . .” (Id.). Belton was diagnosed as having “Discoid Lupus, ” and it was noted that “[s]he is without . . . manifestations of Systemic Lupus Erythematosus.”[6] (Id. at 48, p. 297). At a follow-up visit on April 19, 2012, she was again diagnosed as having “Discoid Lupus, ” and it was also noted that there were indicators of “probable SLE [Systemic Lupus Erythematosus].” (Id. at 51, p. 300).

         On July 20, 2012, Dr. Becker listed a diagnosis of “SLE” as well as a diagnosis of “Discoid Lupus.” (Id. at 54, p. 303). A notation in Dr. Becker's report indicated that certain lab results were “fitting for Undifferentiated Connective Tissue Disease, probable SLE. I discussed SLE with patient.” (Id.). A report from a visit on October 15, 2012 indicates that Beltons's joints were “feeling good” and that she had “[n]o new issues.” (Id. at 68, p. 317).

         An office visit report from Dr. Becker dated March 15, 2013 is largely unremarkable. As is the case with other AOC reports, this record indicates that the “[p]atient denies systemic symptoms specifically denying fever, chest pain, SOB [shortness of breath].” (Id. at 74, p. 323). On July 12, 2013, Belton returned to AOC, where she was seen by APRN [Advanced Practice Registered Nurse] Anita DeAngelo and reported that “she has been well overall except for arm stiffness. . . . Some days she is more fatigued than others.” (Id. at 94, p. 343).

         On September 24, 2013, Belton was seen by AOC rheumatologist Dr. Sonia Gordon-Dole[7] for the first time. The report of that visit indicates that during the period of her treatment by Dr. Becker, Belton “had intermittent join pain, ” and that “[h]er main concern is the scarring from her skin.” (Id. at 89, p. 338). At an AOC office visit on December 6, 2013, she was seen again by APRN DeAngelo and “[d]eni[ed] joint symptoms, pain or swelling” and “report[ed] no new skin or other symptoms.” (Id. at 85, p. 334 and at 87, p. 336).

         On March 20, 2014, Belton was seen for a second time by Dr. Gordon-Dole. The chart note from that visit again refers to “intermittent joint pain” and states that “[h]er main concern is the scarring from her skin.” (Id. at 78, p. 327). Under the heading “Lifestyle” the note states, “Vigorous activity level. Exercises daily.” (Id. at 81, p. 330).

         Dr. Gordon-Dale wrote a letter to plaintiff's counsel, dated May 14, 2014, in response to a letter from counsel “which indicated that you represent Sharyl Belton in her claim for social security disability insurance benefits.” (Id. at 137, p.386). Dr. Gordon-Dale's letter included the following statements:

Mrs. Belton has Systemic Lupus erythematosus and features of a mixed connective tissue disease. She has constitutional symptoms, involvement of skin, hair, and joints and laboratory evidence of lupus . . . . She has severe depression which is most likely due to central nervous system involvement and has been limited by disabling daily refractory migraines and severe malaise and fatigue, despite ongoing treatments. She has difficulty with activities of daily living and cannot complete tasks necessary to maintain employment.
She meets criteria for Listing 14.02 Systemic lupus erythematosus. She was diagnosed with systemic lupus and placed on systemic treatment 4/19/2012 and therefore it is evident that she met criteria before and on March 31 2013.

(Id. at 137, p. 386).

         C. Agency Consulting Physicians

         In addition to reports from treating providers, the record also contains the determinations of two state agency consulting physicians that Belton's “[a]llegations of total disability due to impairments are not fully supported by the objective evidence in [the] file.” (Doc. # 9-4, at 7, p. 101 and at 19, p. 113). One of the consulting physicians found that Belton was capable of performing past relevant work (layout designer) with some limitations. The other consultant determined that she was capable of performing work at a light exertional level with some climbing limitations.

         Hearing Testimony

         At the May 16, 2014 hearing before the ALJ, Belton testified that in the year or two before she first saw Dr. Becker she was “extremely depressed . . . [and] was sick all the time.” (Doc. # 9-3, at 44, p. 43). With regard to that same time period, she stated that she “could have [migraines] a couple times a day. I could have them a couple times a week.” (Id.). She testified further that she knew these headaches were migraines “because immediately I get ...

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