United States District Court, D. Connecticut
GLADYS M. LUGO RODRIGUEZ, Plaintiff,
NANCY A. BERRYHILL, ACTING COMMISSIONER OF SOCIAL SECURITY, Defendant.
MEMORANDUM OF DECISION
Vanessa L. Bryant United States District Judge.
Gladys M. Lugo Rodriguez (“Plaintiff” or
“Lugo Rodriguez”) brings this appeal pursuant to
42 U.S.C. § 405(g) and seeks review of the final
decision issued by the Commissioner of Social Security
(“Defendant”) denying her Supplemental Security
Income (“SSI”) under Title XVI of the Social
Security Act. Plaintiff moves to reverse the decision, [Dkt.
21], and Defendant moves to affirm, [Dkt. 22]. For the
foregoing reasons, Plaintiff's motion is GRANTED and
Defendant's motion is DENIED.
following facts are derived from the record provided by the
Social Security Administration (“SSA”). Plaintiff
initially filed an application for SSI on March 23, 2010
alleging an onset disability date of January 1, 2006. [R.
15]. The Social Security Administration (“SSA”)
initially denied the claim on June 9, 2010, and on
reconsideration on October 14, 2010. [R. 15]. Plaintiff filed
a request for a hearing, which was held by Administrative Law
Judge Roy P. Liberman (“ALJ Liberman”) on
September 29, 2011. [R. 15, 23]. Plaintiff was not
represented by counsel at the hearing and testified in
Spanish through an interpreter. [R. 32].
December 19, 2011, ALJ Liberman denied Plaintiff's SSI
claim on December 19, 2011. [R. 23]. ALJ Liberman determined
Plaintiff had not engaged in substantial gainful activity
since March 23, 2010. He then determined Plaintiff to have
the following severe impairments: status post bilateral
carpal tunnel release, hypertension, and obesity. [R. 17].
Because ALJ Liberman found the listed impairments under 20
C.F.R. Part 404, Subpart P, Appendix 1 did not match with
Plaintiff's severe impairments, ALJ Liberman then
evaluated Plaintiff's residual functional capacity
(“RFC”) as able “to perform light
work” with certain limitations. [R. 18]. In
consideration of jobs in the national economy ALJ Liberman
determined Plaintiff could perform, he concluded Plaintiff
was “not disabled.” [R. 23].
filed a request for review with the Appeals Council, which
was denied on July 22, 2013, [R. 1-6]. Thereafter, Plaintiff
filed her appeal in this district. [Dkt. 1 (Compl.)]. On
August 28, 2014, Magistrate Judge William I. Garfinkel issued
a recommended ruling in which he found remand appropriate for
failure to develop the administrative record. [R. 494-98].
Judge Michael P. Shea approved and accepted the recommended
ruling in the absence of an objection from either party.
See Rodriguez v. Colvin, Case No. 3:13-cv-01414-MPS,
Dkt. No. 23. The case returned to the SSA for further
remand, the case was assigned to Administrative Law Judge
Ronald J. Thomas (“ALJ Thomas”). [R. 404-12]. ALJ
Thomas held a hearing on December 7, 2015, and upon request
by counsel he held a supplemental hearing on August 1, 2016.
[R. 404]. Plaintiff testified at both hearings and impartial
vocational experts Albert Sabella and Robert T. Paterwic each
testified at one of the hearings (the former at the first
hearing, the latter at the supplemental hearing). [R. 404].
Plaintiff's counsel obtained and submitted the
outstanding records and ALJ Thomas determined the record to
be fully developed. [R. 404].
October 26, 2016, ALJ Thomas issued a decision denying
Plaintiff's SSI application. [R. 412]. Like ALJ Liberman,
ALJ Thomas determined Plaintiff had not engaged in
substantial gainful activity since March 23, 2010. [R. 407].
However, unlike ALJ Liberman, ALJ Thomas determined Plaintiff
did not have a “severe impairment or combination of
severe impairments.” [R. 407]. ALJ Thomas instead
identified Plaintiff to have certain “medically
determinable impairments”: “status post bilateral
carpal tunnel surgeries; tendinitis of the right hand;
bursitis and bone spur of the right shoulder; depressive
disorder; obesity; plantar faciitis.” [R. 407]. These,
he reasoned, did not significantly limit her “ability
to perform basic work-related activities for 12 consecutive
months.” [R. 407].
Thomas compared Plaintiff's testimony to the medical
evidence in arriving at his opinion. In evaluating
Plaintiff's testimony regarding her symptoms and pain,
ALJ Thomas determined that her “statements concerning
the intensity, persistence, and limiting effects of these
symptoms are not entirely consistent with the medical
evidence and other evidence in the record. . . .” [R.
he concluded that Plaintiff's complaints about pain in
her hand and wrist could not be supported despite several
diagnoses. With respect to carpal tunnel syndrome, ALJ Thomas
observed two main issues: (a) Plaintiff has been taking care
of her grandchild since 2014, she can cook daily, clean, and
shop; and (b) Dr. Cruz, a consultative examiner, evaluated
Plaintiff in May 2010 and determined she had normal fine and
gross manipulation and range of motion, although she felt
tenderness to palpitation of the wrists and could not extend
her third and fourth fingers. [R. 408-09]. ALJ Thomas also
acknowledged Plaintiff obtained a tendinitis diagnosis in
November 2012, but he found her pain to be largely managed
with treatment and observed “she has been able to care
for a toddler full time, and has not had consistent ongoing
treatment.” [R. 409].
ALJ Thomas discussed Plaintiff's complaints of pain in
her right shoulder. [R. 409]. She obtained an MRI of her left
shoulder in November 2010 and was diagnosed with
subacrominal-subdeltoid bursitis, supraspinatous tendinopathy
without a rotator cuff tear, and a subacromonial spur; she
was referred to orthopedics. [R. 409]. ALJ Thomas noted in
November 2012, Plaintiff reported doing well with her right
should pain, but she was again referred to orthopedics for a
bone spur in her shoulder. [R. 409]. ALJ Thomas also
documented that Plaintiff testified she could lift her 23
month old grandchild with difficulty. [R. 409].
ALJ Thomas addressed Plaintiff's diagnosis of plantar
fasciitis in September 2015. [R. 409]. He referred to
treatment notes written by Dr. Liza Goldman Huertas in March
2016, which indicated Plaintiff was caring for her 2 year old
and accordingly stopped exercise classes. [R. 409-10, 1018].
In addition, ALJ Thomas commented Plaintiff did not receive
ongoing treatment for her left leg or heel pain. [R. 409-10].
ALJ Thomas discussed Plaintiff's depression
diagnosis from January 2010. [R. 410, 256]. He
observed Plaintiff refused mental health treatment in March
2010 but did not articulate that the medical note containing
this information also stated Plaintiff's depression was
“poorly controlled.” [R. 250, 410]. Subsequently,
in May 2010 consultative examiner Dr. Lago evaluated
Plaintiff and did not observe vegetative signs of depression,
finding no mental health diagnosis appropriate. [R. 410]. ALJ
Thomas reflected on behavioral health treatment sessions from
May and June 2011 and concluded her mental health issues
caused no more than “minimal limitations, ” she
responded well to medication, and she no longer had
depression. [R. 410].
Thomas concluded that “the claimant's physical and
mental impairments, considered singly and in combination, do
not significantly limit the claimant's ability to perform
basic work activities.” [R. 411]. However, ALJ Thomas
did not reference Plaintiff's obesity diagnosis.
addition to making findings about each “medically
determinable impairment, ” ALJ Thomas also explained
the weight he gave to certain medical experts' medical
opinions. Specifically, ALJ Thomas afforded consultative
examiner Luis R. Cruz, M.D. (“Dr. Cruz”),
“great weight” regarding his “findings of
no limitations with fine or gross manipulation and normal
range of motion.” [R. 409]. With respect to
Plaintiff's mental health impairments, ALJ Thomas
determined the medical opinion of internist and treating
physician Kevin Baran, M.D. (“Dr. Baran”), should
be given less weight than consultative examiner Jesus A.
Lago, M.D. (“Dr. Lago”), because Dr. Baran did
not specialize in mental health, unlike Dr. Lago who was a
psychiatrist. [R. 411]. ALJ Thomas also gave “little
weight” to the medical opinion of J. Grant Thomson,
M.D. (“Dr. Thomson”)-that Plaintiff could not
work on account of her poor prognosis for tendinitis; he made
his determination because Plaintiff began caring for her
grandchild nine months after seeking treatment. [R. 411]. ALJ
did not make any subsequent findings after determining
Plaintiff did not have a “severe impairment.”
respect to Plaintiff's mental health impairments, ALJ
reviewing a final decision of the SSA, this Court is limited
to determining whether the SSA's conclusions were
supported by substantial evidence in the record and were
based on a correct legal standard.” Lamay v.
Comm'r of Soc. Sec., 562 F.3d 503, 507 (2d Cir.
2009) (citing 42 U.S.C. § 405(g)). “Substantial
evidence is more than a mere scintilla. It means such
relevant evidence as a reasonable mind might accept as
adequate to support a conclusion.” Id.
(internal quotation marks and citations omitted). “[A
district court] must consider the whole record, examining the
evidence from both sides, because an analysis of the
substantiality of the evidence must also include that which
detracts from its weight.” Petrie v. Astrue,
412 F. App'x 401, 403-04 (2d Cir. 2011) (quoting
Williams ex rel. Williams v. Bowen, 859 F.2d 255,
258 (2d Cir. 1988)) (internal quotation marks omitted).
“Even if the Commissioner's decision is supported
by substantial evidence, legal error alone can be enough to
overturn the ALJ's decision.” Ellington v.
Astrue, 641 F.Supp.2d 322, 328 (S.D.N.Y. 2009) (citing
Johnson v. Bowen, 817 F.2d 983, 986 (2d Cir. 1987)).
“disabled” under the Social Security Act, a
claimant must demonstrate an “inability to engage in
any substantial gainful activity by reason of any medically
determinable physical or mental impairment which can be
expected to result in death or which has lasted or can be
expected to ...