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Randall v. Berryhill

United States District Court, D. Connecticut

September 4, 2018

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


          MICHAEL P. SHEA, U.S.D.J.

         This is an administrative appeal following the denial of Patricia Ann Randall's application for disability insurance benefits. Ms. Randall contends that the Administrative Law Judge (“ALJ”) erred in: (1) failing to evaluate the medical opinion evidence in the record consistent with the regulations governing the Social Security Administration and Second Circuit precedent; and (2) failing to consider Ms. Randall's work history in assessing her credibility. I agree with Ms. Randall that the ALJ improperly applied the treating physician rule as to opinions issued by her treating primary care physician, Dr. Joseph Fields-Johnson. The case is therefore REMANDED. I do not reach Ms. Randall's remaining argument concerning the ALJ's assessment of her credibility.

         I. Background

         On March 31, 2014, Ms. Randall filed an application for disability benefits for an alleged disability. (ECF No. 17-3 (“Joint Statement of Facts”) at 1.) A disability adjudicator in the Social Security Administration (“SSA”) denied Ms. Randall's application on August 20, 2014 and her claims were thereafter denied upon reconsideration on January 29, 2015. (Id.) On January 21, 2016, Ms. Randall appeared with counsel before ALJ Barry H. Best. (Id.) He denied Ms. Randall's claim on May 23, 2016. (Id. at 2.)

         The ALJ found that Ms. Randall had the severe impairments of pain syndrome, affective disorders, and anxiety-related disorders. (ALJ Decision, Tr. at 22.) The ALJ found that Ms. Randall suffered from “non-severe” impairments related to the following: “irritable bowel syndrome, gastritis, [gastroesophageal reflux disorder (“GERD”)], high cholesterol, headaches, chronic obstructive pulmonary disease, chronic airway obstruction, restless legs syndrome, carpal tunnel syndrome, vasovagal syncope, bursitis, colon polyps, and obstructive sleep apnea. (Id. at 23.) The ALJ rejected Ms. Randall's contention that she suffered from fibromyalgia. (Id.) Next, the ALJ determined that Ms. Randall did not have an impairment or combination of impairments that met or medically equaled the severity of a listed impairment, and had the following Residual Functional Capacity (“RFC”):

to perform less than a full range of light work, as defined in 20 CFR 404.1567(b) and 416.967(b), due to the following limitations. The claimant can lift and carry twenty pounds occasionally and ten pounds frequently. She can stand and walk for six hours in an eight-hour workday. She can sit for six hours in an eight-hour workday. She can occasionally climb, balance, stoop, kneel, crouch, and crawl. She cannot climb ropes, ladders, or scaffolds. She is limited to jobs that are essentially uncomplicated in terms of work tasks. She requires short work breaks on average every two hours. The claimant is able to interact with the public on an occasional basis, provided interaction is limited to the exchange of non-personal work-related information or hand-off of products or materials. She can work in the presence of co-workers and deal with them appropriately on an occasional basis in terms of casual or social contact, but she is unable to work in the context of a work team where ongoing work-related interaction is frequent or continuous. She can deal appropriately with supervisors on an occasional basis, not where monitoring or intervention is frequent or continuous. She can tolerate no more than occasional changes in the job setting. She is unable to perform work requiring travel to unfamiliar places.

(Id. at 23-25.) Finally, the ALJ determined that although Ms. Randall lacked the ability to perform any past relevant work, there were jobs that “exist[ed] in significant No. in the national economy that [she] can perform . . . .” (Id. at 33.) For these reasons, the ALJ concluded that Ms. Randall was not disabled within the meaning of the Social Security Act. (Id. at 36.)

         By letter dated June 22, 2017, the appeals council denied Ms. Randall's request for review of the ALJ's decision, thereby making the ALJ's decision the final decision of the Commissioner. (Joint Statement of Facts ¶ 3.) This appeal followed.[1] Specific facts and portions of the ALJ's decision will be discussed below as necessary.

         II. Standard

         The Social Security Act establishes that benefits are payable to individuals who have a disability. 42 U.S.C. § 423(a)(1). “The term ‘disability' means . . . [an] inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment . . . .” 42 U.S.C. § 423(d)(1). To determine whether a claimant is disabled within the meaning of the Social Security Act, the ALJ must follow a five-step evaluation process as promulgated by the Commissioner.

         The five steps are as follows: (1) the Commissioner considers whether the claimant is currently engaged in substantial gainful activity; (2) if not, the Commissioner considers whether the claimant has a “severe impairment” which limits his or her mental or physical ability to do basic work activities; (3) if the claimant has a “severe impairment, ” the Commissioner must ask whether, based solely on the medical evidence, the claimant has an impairment listed in Appendix 1 of the regulations. 20 C.F.R. § 416.920(a)(4). If the claimant has one of these enumerated impairments, the Commissioner will automatically consider that claimant disabled, without considering vocational factors such as age, education, and work experience. Id. (4) if the impairment is not “listed” in the regulations, the Commissioner then asks whether, despite the claimant's severe impairment, he or she has the residual functional capacity to perform his or her past work; and (5) if the claimant is unable to perform his or her past work, the Commissioner then determines whether there is other work the claimant could perform. Id. To be considered disabled, an individual's impairment must be “of such severity that he is not only unable to do his previous work but cannot . . . engage in any other kind of substantial gainful work which exists in the national economy.” 42 U.S.C. § 423(d)(2)(A). The Commissioner bears the burden of proof on the fifth step, while the claimant has the burden on the first four steps. 20 C.F.R. § 416.920(a)(4).

         “A district court reviewing a final . . . decision pursuant to . . . 42 U.S.C. § 405(g), is performing an appellate function.” Zambrana v. Califano, 651 F.2d 842, 844 (2d Cir. 1981). “The findings of the Commissioner of Social Security as to any fact, if supported by substantial evidence, shall be conclusive.” 42 U.S.C. § 405(g). Accordingly, a district court may not make a de novo determination of whether a plaintiff is disabled in reviewing a denial of disability benefits. Wagner v. Sec'y of Health & Human Servs., 906 F.2d 856, 860 (2d Cir. 1990). Rather, the court's function is to ascertain whether the correct legal principles were applied in reaching the decision, and whether the decision is supported by substantial evidence. Johnson v. Bowen, 817 F.2d 983, 985 (2d Cir. 1987). If the Commissioner's decision is supported by substantial evidence, that decision will be sustained, even where there may also be substantial evidence to support the plaintiff's contrary position. Schauer v. Schweiker, 675 F.2d 55, 57 (2d Cir. 1982). The Second Circuit has defined substantial evidence as “such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” Williams v. Bowen, 859 F.2d 255, 258 (2d Cir. 1988) (citation and quotation marks omitted). Substantial evidence must be “more than a mere scintilla or a touch of proof here and there in the record.” Id.

         III. Discussion

         A. The ALJ's Evaluation of the Medical Opinion Evidence Ms. Randall contends that the ALJ erred in his evaluation of the medical opinion evidence, and in particular in his evaluation of her treating sources. (ECF No. 17-1 at 8.) In particular, she contends that the ALJ improperly disregarded the opinions of two of her treating sources and one of her examining sources who conclude that she had “marked limitations” in various areas. (Id. at 7-8.) Under the treating physician rule, “the opinion of a claimant's treating physician as to the nature and severity of the impairment is given controlling weight so long as it is well-supported by medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with the other substantial evidence in [the] case record.”[2] Burgess v. Astrue, 537 F.3d 117, 128 (2d Cir. 2008) (internal citation and quotation marks omitted). “The regulations further provide that even if controlling weight is not given to the opinions of the treating physician, the ALJ may still assign some weight to those views, and must specifically explain the weight that is actually given to the opinion.” Schrack v. Astrue, 608 F.Supp.2d 297, 301 (D. Conn. 2009). The Second Circuit has made clear that:

To override the opinion of the treating physician . . . the ALJ must explicitly consider, inter alia: (1) the frequency, length, nature, and extent of treatment; (2) the amount of medical evidence supporting the opinion; (3) the consistency of the opinion with the remaining medical evidence; and, (4) whether the physician is a specialist. After considering the above factors, the ALJ must comprehensively set forth his reasons for the weight assigned to a treating physician's opinion.

Greek v. Colvin, 802 F.3d 370, 375 (2d Cir. 2015) (internal citations, quotation marks, and alterations omitted). “The failure to provide good reasons for not crediting the opinion of a claimant's treating physician is a ground for remand.” Id. I now turn to the medical ...

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