United States District Court, D. Connecticut
RULING RE: MOTION TO REVERSE THE DECISION OF THE
COMMISSIONER (DOC. NO. 20) AND MOTION TO AFFIRM THE DECISION
OF THE COMMISSIONER (DOC. NO. 23)
C. HALL UNITED STATES DISTRICT JUDGE.
Kristin Ellen Moreau brings this action under sections 405(g)
and 1383(c)(3) of title 42 of the United States Code,
appealing from the final decision of the Commissioner of the
Social Security Administration (“SSA”), which
denied her application for Title II disability insurance
benefits and Title XVI supplemental security income.
See Complaint (“Compl.”) (Doc. No. 1) at
1. Moreau seeks either reversal or remand of the Decision
rendered by Administrative Law Judge (“ALJ”)
Louis Bonsangue, which affirms the Commissioner's denial.
See Motion to Reverse or Remand the Decision of the
Commissioner (“Mot. to Reverse”) (Doc. No. 20).
The Commissioner cross-moves for an order affirming that
Decision. See Motion to Affirm the Decision of the
Commissioner (“Mot. to Affirm”) (Doc. No. 23).
reasons set forth below, the Motion to Reverse or Remand the
Decision of the Commissioner is GRANTED. The
Motion to Affirm the Decision of the Commissioner is
DENIED. This case is remanded to the ALJ for
proceedings consistent with this Ruling.
Procedural History 
applied for disability and supplemental security income
benefits on March 20, 2014. See Stipulated Statement
of Facts (“Stip. Facts”) (Doc. No. 21) at 1. The
Commissioner denied Moreau's application initially on
August 29, 2014, and upon reconsideration on December 15,
2014. See id. Moreau requested a hearing with an
ALJ, which was held before ALJ Bonsangue on February 10,
2016. See id.
25, 2016, ALJ Bonsangue issued an unfavorable Decision for
Moreau, affirming the Commissioner's denial and finding
that Moreau was not disabled. See id.; Certified
Transcript of Record (“Tr.”) (Doc. No. 13) at
27-40. Specifically, ALJ Bonsangue found that, while Moreau
cannot perform any past relevant work, there are jobs that
exist in significant numbers in the national economy that
Moreau can perform based on her residual functional capacity.
See Tr. at 38-40. Moreau requested review by the
Appeals Court, and the Appeals Court denied the request on
January 6, 2017. See Stip. Facts ¶ 1. Following
that denial, ALJ Bonsangue's May 25, 2016 Decision became
a final decision reviewable by this court. See id.
at 1-2. Moreau then filed this appeal on March 8, 2017.
court adopts the facts as stated in the Stipulated Statement
of Facts, to which both parties have agreed. See
Stip. Facts. Where the Stipulated Statement of Facts was
incomplete, the court draws additional facts from the
Certified Transcript of the Record. See Tr. Only
those facts relevant to the issues raised in the Motions
before the court are set forth below.
was born in 1971 and was 41 years old at the alleged date of
onset of disability, January 31, 2013. See id. at 1,
3. Her past relevant work includes employment as a server in
a country club, day laborer and landscaper, data entry
specialist and receptionist, resort manager, housekeeper, and
restaurant manager. See id. at 3. The ALJ found that
Moreau suffered from severe impairments including a seizure
disorder, an organic mental disorder, and post-traumatic
stress disorder, as well as a non-severe impairment of
intracranial injury caused by a fall that occurred in 2013.
See Tr. at 30. The parties do not dispute the
ALJ's findings as to Moreau's medically determinable
impairments. Moreau had surgery to perform a right craniotomy
after the intracranial injury in 2013. See id. at
505. In February 2015, the wound was infected, and the bone
flap was removed. See id.
testified that, after the fall, she received physical
therapy, speech therapy, and memory therapy. See
Stip. Facts ¶ 11. She also received mental health
treatment for PTSD and anxiety until November 2015, when her
treating psychiatrist passed away. See id. She
testified that she suffers from seizures approximately once a
month and treats her seizures with anticonvulsant medication.
See id. She also testified that she experiences
“extreme weakness” on her right side and has
difficulty with balance. See id. at 12. She
testified that, as a result, she uses a cane when leaving
home and while at home, but she did not have a cane at the
hearing because she indicated that it was broken. See
Medical Opinion Evidence
received follow-up treatment for her seizures and her
craniotomy from St. Francis Medical Group Stroke Center
(“St. Francis”). See id. at 10. Two of
the doctors who provided her follow-up treatment were Dr.
Bruce Chozick, MD, and Dr. Arjuna Mannam, MD. See
Tr. at 410-33. The record includes progress notes from Dr.
Chozick and Dr. Mannam, but no signed medical opinion from
either. See id. The record does include two unsigned
disability certificates from St. Francis. See Stip.
Facts ¶ 10; Tr. at 419-21.
first disability certificate, dated March 7, 2014, states,
“Kristin had brain surgery and is unable to work untill
[sic] further notice. 12/20/2014 [Patient] had a Stroke and
is taking medication Kepra and Percocet as well.” Tr.
at 419, 421. The second disability certificate, dated August
5, 2014, states, “[Patient] has no neurosurgical
issues, and does not require a follow up. [Patient] is not
currently under the care of neurosurgery, and has not had any
recent surgery. We cannot comment on her ability to take care
of her child.” Tr. at 420. The ALJ accorded partial
weight to both unsigned opinions. See id. at 37.
Moreau underwent two consultative examinations, one by Dr.
Eric Frazer, PsyD, and one by Dr. April McLean, PsyD.
See Stip. Facts ¶ 7-10. Dr. Frazer saw Moreau
on January 14, 2013, as part of a child services case to
determine whether Moreau could act as a guardian for her son.
See id. at 7. Dr. Frazer found that Moreau suffered
from post-traumatic stress disorder and dysthymic disorder
and assigned her a Global Assessment of Functioning
(“GAF”) score of 60, which indicates moderate
symptoms and impairment. See id. at 8. He concluded
that she could be reunited with her son once she obtained
sufficient housing and income. See id. at 8. The ALJ
accorded little weight to Dr. Frazer's opinion.
See Tr. at 37-38.
McLean interviewed Moreau, reviewed her records, and
conducted a psychological assessment on July 23, 2014.
See Stip. Facts ¶ 8-9. Dr. McLean diagnosed
mild neurocognitive disorder due to brain injury and scored
Moreau to be “low average” in immediate memory,
“borderline” in visuospatial/constructional
ability and language, and “extremely low” in
attention and delayed memory. See id. at 9-10. Dr.
McLean opined that Moreau “appeared to have
neurocognitive limitations, including affect lability,
concentration difficulties, and language impairments that
affect her ability to maintain . . . a 40 hour work
week.” Stip. Facts ¶ 10 (quoting Tr. at 407). The
ALJ accorded partial weight to Dr. McLean's opinion.
See Tr. at 36-37.
two non-examining state medical consultants and two
non-examining state psychological consultants reviewed
Moreau's available medical evidence and completed a
residual functional capacity assessment. See Stip.
Facts ¶ 4-7. Dr. Earle Sittambalam, MD, opined that
Moreau had no exertional limitations, could never climb
ladders, ropes, or scaffolds, could frequently balance, could
occasionally crawl, and should avoid concentrated exposure to
noise or vibration and even moderate exposure to hazards.
See id. at 4. Dr. Barbara Coughlin, MD, reached the
same conclusion as Dr. Sittambalam, except that she opined
that Moreau should avoid all exposure to hazards. See
id. Dr. Kirk Johnson, PsyD, opined that Moreau had
moderate limitations in understanding and memory, sustained
concentration and persistence, social interaction, and
adaptation. See id. at 5. Dr. Janine Swanson, PsyD,
concluded that Moreau had the same limitations in
understanding and memory, as well as sustained concentration
and persistence, as Dr. Johnson. See id. Unlike Dr.
Johnson, though, she opined in one part of her report that
Moreau had only mild restrictions in social functioning.
See id. at 6; Tr. at 139. Elsewhere in her report,
she stated that Moreau had no limitations in social
interaction. See Stip. Facts ¶ 7; Tr. at 143,
158. The ALJ accorded partial weight to all four of the state
consultants' opinions without distinguishing between
them. See Tr. at 37.
STANDARD OF REVIEW
section 405(g) of title 42 of the United States Code, it is
not a function of the district court to review de
novo the ALJ's decision as to whether the claimant
was disabled. See Schaal v. Apfel, 134 F.3d 496, 501
(2d Cir. 1998). Instead, the court may only set aside the
ALJ's determination as to social security disability if
the decision “is based upon legal error or is not
supported by substantial evidence.” Balsamo v.
Chater, 142 F.3d 75, 79 (2d Cir. 1998). Substantial
evidence requires “more than a mere scintilla, ”
but is a “very deferential standard of review.”
Brault v. Soc. Sec. Admin., Comm'r, 683 F.3d
443, 447-48 (2d Cir. 2012). It requires “such relevant
evidence as a reasonable mind might accept as adequate to
support a conclusion.” Id. If the
Commissioner's findings of fact are supported by
substantial evidence, those findings are conclusive, and the
court will not substitute its judgment for the
Commissioner's. 42 U.S.C. § 405(g) (2016); see
also Yancey v. Apfel, 145 F.3d 106, 111 (2d Cir. 1998).
404.1520 of title 20 of the Code of Federal Regulations lays
out a five-step sequential evaluation process for determining
whether an individual claimant is disabled. See 20
C.F.R. § 404.1520 (2017).
First, the Commissioner of Social Security considers whether
the claimant is currently engaged in “substantial
gainful activity.” If he is not, the Commissioner
proceeds to the second step and determines whether the
claimant has a “severe medically determinable physical
or mental impairment, ” that “significantly
limits his physical or mental ability to do work
activities.” If the claimant does suffer such an
impairment, the third step is “whether, based on
medical evidence, the claimant has an impairment which is
listed in Appendix 1 of the regulations.” If so, the
claimant is per se “disabled” and thus
presumptively qualified for benefits. If not, the
Commissioner proceeds to the fourth step and examines
whether, “despite the claimant's severe impairment,
he has the residual functional capacity to perform his past
work.” If the claimant is unable to perform his past
work, the Commissioner finally determines whether there is
other work the claimant can perform, taking into
consideration the claimant's RFC, age, education, and
Petrie v. Astrue, 412 Fed.App'x 401, 404 (2d
Cir. 2011) (internal citations omitted).
case, the ALJ found that the first two steps of the
sequential evaluation were satisfied-that Moreau had not
engaged in substantial gainful employment since January 31,
2013, and that Moreau suffered from three severe impairments:
a seizure disorder, an organic mental disorder, and
post-traumatic stress disorder. See Tr. at 29- 30.
The ALJ then found at step three that Moreau's
impairments, though severe, did not meet or medically equal a
listed impairment, specifically considering Listings 11.02,
12.02, and 12.06. See id. at 30-33. The ALJ next
assessed the following residual functional capacity
After careful consideration of the entire record, I find that
the claimant has the residual functional capacity to perform
light work as defined in 20 CFR 404.1567(b) and 416.967(b)
except that the claimant can occasionally climb ramps and
stairs. The claimant can never climb ropes, ladders, or
scaffolds. The claimant can frequently balance. The claimant
can occasionally crawl. The claimant must avoid concentrated
exposure to moderate noise levels and vibration. The claimant
must avoid all exposure to any work hazards such as moving
mechanical parts or unprotected heights. The claimant is
limited to simple, routine, repetitive tasks and not at any
production rate pace with only minimal changes in the work
routine on a day-to-day basis.
Id. at 33. Finally, under steps four and five, the
ALJ determined that Moreau was not able to perform any past
relevant work, but could perform other jobs that exist in
significant numbers in the national economy. See id.
argues that the ALJ's Decision should be reversed or
remanded for a number of reasons relating to the ALJ's
determination of her RFC. First, she argues that the ALJ
failed to adequately develop the administrative record by not
seeking the identity of the unsigned opinions, which she
contends were likely authored by Dr. Mannam, a treating
source. See Memorandum in Support of Mot. to Reverse
(“Mot. to Reverse Mem.”) (Doc. No. 20-1) at 3-6.
Second, Moreau presents several arguments that the ALJ's
weighing of the medical opinion evidence was not supported by
substantial evidence. See id. at 6-9. She argues
that the ALJ failed to articulate good reasons for not giving
controlling weight to the unsigned opinions, which she
contends might have been treating source opinions had the ALJ
contacted St. Francis to identify the author. See
id. at 6-7. She also argues that the ALJ erred in
assigning only partial weight to Dr. McLean's opinion
because the opinion is consistent with the medical record.
See id. at 8-9. She further argues that the ALJ
failed to address the conflict between Dr. Johnson's
opinion and Dr. Swanson's opinion regarding the existence
of limitations in social functioning. See id. at 9.
Third, Moreau argues that, by discounting all of the medical
opinion evidence, the ALJ played doctor in interpreting the
raw medical data on his own. See id. at 7. Finally,
Moreau argues that the RFC was not supported by substantial
evidence because the ALJ failed to account for her use of a
cane. See id. at 10-11.
court focuses its Ruling on Moreau's argument pertaining
to the unsigned opinions and the ALJ's duty to develop
the record. Because the court finds that the ALJ failed to
develop the record, it also suggests that the ALJ revisit the
other issues on remand, without finding it necessary to reach
whether such arguments would themselves constitute legal
error justifying remand on their own. See, e.g.,
Fly v. Colvin, No. 3:14-CV-1840, 2015 WL 5124957, at
*5 (N.D. Ind. Aug. 31, 2015) (requiring the ALJ to inquire
into the availability of low-cost treatment on remand without
reaching whether the failure to do so itself requires remand
because the case was already being remanded for other