Searching over 5,500,000 cases.

Buy This Entire Record For $7.95

Download the entire decision to receive the complete text, official citation,
docket number, dissents and concurrences, and footnotes for this case.

Learn more about what you receive with purchase of this case.

Walters v. Berryhill

United States District Court, D. Connecticut

June 11, 2018

NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.


          Stefan R. Underhill United States District Judge.

         In the instant Social Security appeal, Jessie James Walters, Jr. moves to reverse the decision by the Social Security Administration (SSA) denying him disability insurance benefits. The Commissioner of Social Security moves to affirm the decision. Walters raises two arguments of error in the decision of the Administrative Law Judge (“ALJ”), arguing that the ALJ failed to properly weigh the medical opinion evidence, and that the ALJ inappropriately determined that Walters' own testimony was not completely credible. For the reasons set forth below, I agree with some of Walters' arguments regarding the ALJ's failure to properly weigh the medical opinion evidence, and I remand to the ALJ for reconsideration in light of this ruling. The ALJ appears to have discounted the opinions of Walters' treating physicians primarily based on the inconsistency of those opinions with the opinion of a single consulting physician, on which the ALJ placed great weight. Although that inconsistency might justify failing to accord controlling weight to the opinions of the treating physicians, it would be circular for that inconsistency to itself provide the basis for preferring the assessment of the consulting physician over the assessments of Walters' treating physicians.[1] Absent further explanation from the ALJ, I am unable to properly evaluate his preference for the consulting physicians' opinions. I therefore grant Walters' motion to reverse or remand and deny the Commissioner's motion to affirm.

         Because I remand for reconsideration of the medical opinion evidence, it is unnecessary for me to consider whether the ALJ properly evaluated Walters' credibility, which must, in any event, be determined in light of the appropriately weighted medical evidence.

         I. Standard of Review

         The SSA follows a five-step process to evaluate disability claims. Selian v. Astrue, 708 F.3d 409, 417 (2d Cir. 2013). First, the Commissioner determines whether the claimant currently engages in “substantial gainful activity”. Greek v. Colvin, 802 F.3d 370, 373 n.2 (2d Cir. 2015) (citing 20 C.F.R. § 404.1520(b)). Second, if the claimant is not working, the Commissioner determines whether the claimant has a “‘severe' impairment”, i.e., an impairment that limits his or her ability to do work-related activities (physical or mental). Id. (citing 20 C.F.R. §§ 404.1520(c), 404.1521). Third, if the claimant does have a severe impairment, the Commissioner determines whether the impairment is considered “per se disabling” under SSA regulations. Id. (citing 20 C.F.R. §§ 404.1520(d), 404.1525, 404.1526). If the impairment is not per se disabling, then, before proceeding to step four, the Commissioner determines the claimant's “residual functional capacity” based on “all the relevant medical and other evidence of record”. Id. (citing 20 C.F.R. §§ 404.1520(a)(4), (e), 404.1545(a)). “Residual functional capacity” is defined as “what the claimant can still do despite the limitations imposed by his [or her] impairment.” Id. Fourth, the Commissioner decides whether the claimant's residual functional capacity allows him or her to return to “past relevant work”. Id. (citing 20 C.F.R. §§ 404.1520(e), (f), 404.1560(b)). Fifth, if the claimant cannot perform past relevant work, the Commissioner determines, “based on the claimant's residual functional capacity”, whether the claimant can do “other work existing in significant numbers in the national economy”. Id. (20 C.F.R. §§ 404.1520(g), 404.1560(b)). The process is “sequential”, meaning that a petitioner will be judged disabled only if he or she satisfies all five criteria. See id.

         The claimant bears the ultimate burden to prove that he or she was disabled “throughout the period for which benefits are sought”, as well as the burden of proof in the first four steps of the inquiry. Id. at 374 (citing 20 C.F.R. § 404.1512(a)); Selian, 708 F.3d at 418. If the claimant passes the first four steps, however, there is a “limited burden shift” to the Commissioner at step five. Poupore v. Astrue, 566 F.3d 303, 306 (2d Cir. 2009). At step five, the Commissioner need only show that “there is work in the national economy that the claimant can do; he need not provide additional evidence of the claimant's residual functional capacity.” Id.

         In reviewing a decision by the Commissioner, I conduct a “plenary review” of the administrative record but do not decide de novo whether a claimant is disabled. Brault v. Soc. Sec. Admin., Comm'r, 683 F.3d 443, 447 (2d Cir. 2012); see Mongeur v. Heckler, 722 F.2d 1033, 1038 (2d Cir. 1983) (“[T]he reviewing court is required to examine the entire record, including contradictory evidence and evidence from which conflicting inferences can be drawn.”). I may reverse the Commissioner's decision “only if it is based upon legal error or if the factual findings are not supported by substantial evidence in the record as a whole.” Greek, 802 F.3d at 374-75. The “substantial evidence” standard is “very deferential”, but it requires “more than a mere scintilla”. Brault, 683 F.3d at 447-48. Rather, substantial evidence means “such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.'” Greek, 802 F.3d at 375. Unless the Commissioner relied on an incorrect interpretation of the law, “[i]f there is substantial evidence to support the determination, it must be upheld.” Selian, 708 F.3d at 417.

         II. Facts

         Walters was born in 1968, completed one year of college, and worked as a fire safety director and a building manager prior to the onset of his alleged disability. (Joint Stipulation of Facts, Doc. # 15 [hereinafter, “Facts at ”], at 1.)

         Walters applied for Social Security Disability Benefits on November 6, 2013 and Social Security Income Benefits on November 8, 2013, alleging a period of disability beginning June 4, 2013. (Facts ¶ 1.) Following denial of Walters' claims, he requested a hearing before an Administrative Law Judge (“ALJ”) on March 5, 2014. (Facts ¶ 1.) A hearing was held before ALJ Michael Friedman on June 2, 2015, subsequent to which ALJ Friedman found Walters not disabled within the meaning of sections 216(i), 223(d), and 1614(a)(3)(A) of the Social Security Act. (Facts ¶ 1; Transcript of the Certified Administrative Record, Doc. # [hereinafter, “Tr. at ”], at 13.) Walters requested review of the ALJ's decision by the Appeals Council on August 18, 2015, and the Appeals Council denied Walters' request on October 25, 2016. (Facts ¶ 1.)

         Pursuant to the first four steps of the five-step evaluation process, the ALJ found, first, that Walters did not currently engage in substantial gainful activity (Tr. at 15); second, that Walters had the severe impairments of systemic lupus erythematosus, diabetes with peripheral neuropathy and a history of retinopathy, hand pain/reflex sympathetic dystrophy/diabetic hand syndrome, cubital tunnel syndrome, mild cervical spondylosis, and rheumatoid arthritis (Tr. at 16); third, that Walters' severe impairments were not per se disabling (Tr. at 16-18); and, fourth, that Walters was unable to perform any past relevant work (Tr. at 24). However, pursuant to the fifth step of the five-step evaluation process, and based on a determination of Walters' residual functional capacity, the ALJ found that Walters was able to engage in light work with certain exceptions (Tr. at 18-24) and that Walters could therefore perform jobs existing in significant numbers in the national economy (Tr. at 24-25). Specifically, the ALJ found that Walters could perform the requirements of the jobs of Usher and Counter Clerk. (Tr. at 25.) Because the ALJ determined that Walters could perform jobs existing in significant numbers in the national economy, the ALJ found Walters not disabled within the meaning pertinent to the Social Security Act. (Tr. at 25.)

         In determining Walters' residual functional capacity, the ALJ reviewed the medical opinions of Walters' treating orthopedic surgeon, Dr. Seneviratne, Walters' treating orthopedist, Dr. Diaz, Walters' treating rheumatologist, Dr. Lipschitz, and Walters' treating internist, Dr. Prabhakar, as well as consulting examiner Dr. Salon and non-examining consultant Dr. Putcha.[2](Tr. at 18-24.) The ALJ also considered Walters' own testimony regarding his conditions and degree of impairment. (Tr. at 18-24.)

         Dr. Seneviratne began treating Walters in March 2013, performed surgery on Walters in August 2013, and last saw Walters on January 29, 2014. (Facts ¶ 2-5.) Dr. Seneviratne saw Walters repeatedly during that period. (Facts ¶ 2-5.) The ALJ noted that Dr. Seneviratne had opined in an October 2013 report that Walters' was precluded from doing any fine motor grasping, typing or any gross motor activities with his left hand. (Tr. at 22 (citing Tr. at 255).) In such report, Dr. Seneviratne stated that it was possible that further joints in Walters' body would be affected by his systemic lupus condition, and thus that it was “more than reasonable to expect [Walters] to be permanently disabled”. (Tr. at 255.) The ALJ also noted a February 6, 2014 opinion from Dr. Seneviratne, in which the doctor noted that Walters was limited to standing or walking for less than two hours and sitting for less than six hours in an eight-hour workday. (Tr. at 22 (citing Tr. at 261).) In such report, Dr. Seneviratne also stated that Walters was unable to lift any weight. (Tr. at 260.) The ALJ gave Dr. Seneviratne's opinions only “partial weight”, apparently giving the February 2014 opinion something less than controlling weight, because such opinion was “inconsistent with the objective medical record”. (Tr. at 22.) In explaining his finding that Dr. Seneviratne's opinion was inconsistent with the record, the ALJ cited exclusively to Dr. Salon's opinion. (Tr. at 22.)

         Dr. Lipschitz began treating Walters in October 2013, saw Walters again on May 4, 2015, and sent Walters for multiple intervening x-rays. (Facts ¶ 5-7; Tr. at 334-40.) On May 4, 2015, Dr. Lipschitz diagnosed Walters with an overlap of lupus and rheumatoid arthritis, and, in a “Lupus Impairment Questionnaire” filled out on the same day, Dr. Lipschitz observed evidence of malar rash, photosensitivity, oral ulcers, non-erosive arthritis, abnormal laboratory tests that documented anti-DNA in abnormal titer, positive findings of antiphospholipid antibodies, and a positive ANA test. (Facts ¶ 6-7; Tr. at 278-82, 340.) In the Lupus Impairment Questionnaire, Dr. Lipschitz opined that Walters would only be able to sit for less than one hour and stand or walk for less than one hour in an eight-hour workday. (Facts ¶ 7-8; Tr. at 280.) Dr. Lipschitz also opined that, with either hand, Walters could “never/rarely” lift up to five pounds, grasp, turn, or twist objects, perform fine manipulations, or reach, that Walters would have attention and concentration problems for one-third to two-thirds of an eight-hour workday, and that Walters would miss work more than three times a month due to his impairments or treatment. (Facts ¶ 8; Tr. at 22, 280-82.) The ALJ accorded Dr. Lipschitz's opinions little weight, explaining that the symptoms Dr. Lipschitz had recorded in the Lupus Impairment Questionnaire were insufficient to render Walters as disabled as Dr. Lipschitz had indicated in the same questionnaire. (Tr. at 23.) The ALJ also observed that the degree of disability Dr. Lipschitz indicated in the questionnaire was inconsistent with Dr. Seneviratne's observations in October 2013 and Dr. Salon's observations in January 2014 (Tr. at 23 (citing Tr. at 237-38, 312)) and Walters' own testimony that he could use a tablet (Tr. at 23).

         Dr. Prabhakar began treating Walters in December 2000, and last saw him on March 21, 2015. (Facts ¶ 9.) The ALJ noted that Dr. Prabhakar purportedly saw Walters four to eight times per year during that interval, but observed that Dr. Prabhakar provided no diagnostic or treatment records from that period. (Tr. at 23.) The ALJ did not document any attempts to contact Dr. Prabhakar in his decision, but the Commissioner appears to have attempted to contact Dr. Prabhakar twice in January 2014 and received no response to either attempt. (Tr. at 349-50.) Dr. Prabhakar did provide a “Multiple Impairment Questionnaire” dating from June 2015, in which he indicated that Walters would be unable to push, pull, kneel, bend, or stoop at work on a sustained basis (Tr. at 347) and that Walters would need to be absent from work “much” more than three times a month (Tr. at 347). The ALJ gave Dr. Prabhakar's opinions little weight, justifying his decision on the lack of ...

Buy This Entire Record For $7.95

Download the entire decision to receive the complete text, official citation,
docket number, dissents and concurrences, and footnotes for this case.

Learn more about what you receive with purchase of this case.