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Lugo Rodriguez v. Berryhill

United States District Court, D. Connecticut

March 2, 2018



          Hon. Vanessa L. Bryant United States District Judge.

         Plaintiff 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.


         The 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].

         On 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].

         Plaintiff 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 administrative proceedings.

         On 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].

         On 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].

         ALJ 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. 408].

         First, 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].

         Second, 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].

         Third, 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].

         Fourth, ALJ Thomas discussed Plaintiff's depression diagnosis[1] 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].

         ALJ 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.

         In 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 Thom


         “In 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)).

         To be “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 ...

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