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Perez v. Berryhill

United States District Court, D. Connecticut

January 24, 2018

NANCY BERRYHILL, Acting Commissioner of the Social Security Administration, Defendant.



         Plaintiff Anthony Perez alleges that he is disabled and cannot work as a result of a combination of impairments, including both a cluster of mental illnesses such as depression and post-traumatic stress disorder and also physical impairments, chiefly spinal stenosis in his lower back. He has brought this action seeking review of a final decision of defendant Commissioner of Social Security denying his claim for Supplemental Security Income Benefits. For the reasons that follow, I will grant plaintiff's motion to remand the Commissioner's decision (Doc. #16) and deny defendant's motion to affirm the Commissioner's decision (Doc. #26).[1]


         Anthony Perez has struggled with depression for most of his life, and it is not hard to see why. When he was little, as young as six years old, plaintiff was severely abused by his uncles, both physically and sexually. Doc. #12-3 at 86-87; Doc. #12-8 at 77. After he tried to tell his mother, she whipped him rather than taking any action to protect him. Doc. #12-8 at 177. Plaintiff was also physically abused by his father and witness to his father's violence against his mother. Ibid. Unsurprisingly, he has had extraordinary psychological problems ever since. Id. at 77. He began using marijuana at the age of nine, drinking alcohol at the age of fifteen, and taking cocaine at the age of eighteen; by the time he was thirty he had also started using heroin. Id. at 81. He left home at age sixteen, and appears to have essentially been homeless ever since. Id. at 98.[2]

         Over the course of his life, plaintiff has attempted suicide six times, employing a wide variety of different methods. Id. at 177.[3] At least two of these suicide attempts left him in the hospital, once in 1981 (when plaintiff was sixteen or seventeen) and once in 1998. Ibid. During the recent depressive episode that occasioned this application for disability benefits, which episode appears to have begun around March 2014, he has been experiencing nearly constant passive suicidal ideation, as is reflected throughout the record. See, e.g., Doc. #12-8 at 58, 77, 97, 102, 175, 177, 181, 195, 197, 222, Doc. #12-9 at 2, 15, 19, 85, 111, 114. He also actually attempted suicide by cutting his wrists in early May 2014, around the same time that he submitted his application for disability benefits. Doc. #12-8 at 97. Plaintiff has been diagnosed not only with major depressive disorder but also with post-traumatic stress disorder (“PTSD”) and with a generalized anxiety disorder. See, e.g., id. at 176.

         Nor are plaintiff's mental illnesses his only serious medical problems. He has suffered from diabetes mellitus since 2005, id. at 24, and the past medical history section on his recent medical records indicates that he has suffered neuropathy in his feet as a consequence of his diabetes. See Doc. #12-3 at 105, 108; Doc. #12-8 at 21, 175, 178; Doc. #12-9 at 2, 170, 172, 176. He has had serious lower back pain since 1997, which was diagnosed as lumbar spinal stenosis at around the same time he submitted his application for disability benefits. Doc. #12-9 at 97-99. He additionally suffers from hepatitis C, which seems to have been treated successfully, see id. at 123-26. And his medical records also mention hypertension, Doc. #12-8 at 24, 28, asthma, id. at 234, Doc. #12-9 at 173, and syphilis, Doc. #12-8 at 37.

         The record reflects medical treatment for plaintiff's recent bout of depression beginning on March 20, 2014. Doc. #12-8 at 58. He sought care at Catholic Charities in Hartford on April 25, 2014, which completed a detailed intake evaluation of him, id. at 77-91, and on May 14, 2014 went to Hartford Hospital, which discharged him the same day. Doc. #12-9 at 130-43. He was admitted to the Adult Day Treatment program at the Hartford HealthCare Behavioral Health Network on May 22, 2014, and discharged on August 13, 2014. Doc. #12-8 at 233-36. While he was there, his treatment was largely overseen by clinician Traicy A. Garbarino and Dr. Tilla Ruser, MD, who completed an evaluation of his functioning on June 10, 2014, id. at 93-96, and an evaluation for purposes of his application for disability benefits from the State of Connecticut on June 13, 2014, id. at 220-29.

         In early August 2014, plaintiff began treatment at the Wheeler Clinic, where his care was overseen by Peter Rogers, MA, and Dr. Sharon Hasbani, MD. He was briefly discharged from Wheeler Clinic on July 13, 2015, but resumed treatment there eleven days later. Doc. #12-9 at 10, 15. On March 10, 2015, Rogers and Dr. Hasbani completed a medical evaluation in support of plaintiff's application for Connecticut disability benefits. Id. at 83-92.

         The record also contains evidence concerning plaintiff's course of treatment for his back pain, which is discussed in his medical records as far back as February 2013, see Doc. #12-8 at 20. On April 16, 2014, plaintiff saw Dr. Qassem Kishawi, MD, who diagnosed him with spinal stenosis. Doc. #12-9 at 97, 99. At the time plaintiff reported that he had tried physical therapy, which only made the pain worse. Id. at 97. Dr. Kishawi prescribed epidural steroid injections, id. at 99, and three such injections were performed over the next three months. Id. at 100-102. These do not appear to have been very effective either; as of January 28, 2016, plaintiff stated that he was “currently considering recommended back surgery.” Id. at 167.

         Plaintiff has held a number of odd jobs over the years, often working for temp agencies, and was most recently employed assembling cabinets in 2013 and early 2014. Doc. #12-6 at 11- 15; Doc. #12-3 at 57-60. According to plaintiff, he was let go from this cabinet-making job because his physical impairments had made him decreasingly capable of performing his work there. Doc. #12-3 at 60 (“And there came a time when I couldn't even hold a drill anymore because my hands cramp up and I couldn't carry anything. I was falling. I fell like three times in the job. I was dropping the countertops. So he [plaintiff's boss] came to me nicely and he told me that they couldn't have me anymore because of my conditions.”).

         Plaintiff filed a claim for Supplemental Security Income Benefits on May 2, 2014. Doc. #12-6 at 2. His claim was denied initially on July 21, 2014, and then again on reconsideration on September 30, 2014. Id. Plaintiff then requested a hearing before an administrative law judge (“ALJ”), and a hearing was held on May 19, 2016. Id. at 27, 46-99. The ALJ issued his decision denying plaintiff's application on September 21, 2016, id. at 40, and the Social Security Administration's Appeals Council denied plaintiff's appeal of that decision on December 1, 2016. Id. at 2. Plaintiff then filed this civil action on January 12, 2017, Doc. #1, and has moved to reverse the decision of the Commission. Doc. #16. Defendant has cross-moved to affirm the decision of the Commissioner. Doc. #26.


         The Court may “set aside the Commissioner's determination that a claimant is not disabled only if the factual findings are not supported by substantial evidence or if the decision is based on legal error.” Burgess v. Astrue, 537 F.3d 117, 127 (2d Cir. 2008) (internal quotation marks and citation omitted); see also 42 U.S.C. § 405(g). Substantial evidence is “more than a mere scintilla” and “means such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” Lesterhuis v. Colvin, 805 F.3d 83, 87 (2d Cir. 2015) (per curiam). Absent a legal error, this Court must uphold the Commissioner's decision if it is supported by substantial evidence and even if this Court might have ruled differently had it considered the matter in the first instance. See Eastman v. Barnhart, 241 F.Supp.2d 160, 168 (D. Conn. 2003).

         To evaluate a claimant's disability and determine whether he qualifies for benefits, the agency engages in a well-established five-step process. See Cage v. Comm'r of Soc. Sec., 692 F.3d 118, 122-23 (2d Cir. 2012). The claimant bears the burden of proving his case at steps one through four. At step one, the claimant must show that he is not currently engaged in substantial gainful activity. At step two, he must show that he suffers from a “severe impairment” that significantly limits his physical or mental ability to do basic work activities. At step three, if the claimant can show that one or more of his severe impairments meets or medically equals in severity one of the listed impairments in 20 C.F.R. pt. 404, subpt. P, app. 1, then he will be considered disabled without further inquiry. If not, then at step four he must show that he lacks the residual functional capacity ...

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