United States District Court, D. Connecticut
ORDER REMANDING CASE
W. Thompson, United States District Judge.
reasons set forth below, the decision of the Commissioner is
reversed and this case is remanded for additional proceedings
consistent with this order.
district court reviewing a final  decision . . . [of the
Commissioner of Social Security] pursuant to section 205(g)
of the Social Security Act, 42 U.S.C § 405(g), is
performing an appellate function.” Zambrana v.
Califano, 651 F.2d 842, 844 (2d Cir. 1981). The court
may not make a de novo determination of whether a plaintiff
is disabled in reviewing a denial of disability benefits. See
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 Commissioner applied the
correct legal principles in reaching a conclusion and whether
the decision is supported by substantial evidence. See
Johnson v. Bowen, 817 F.2d 983, 985 (2d Cir. 1987).
Substantial evidence is “‘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) (quoting Richardson v.
Perales, 402 U.S. 389, 401 (1971)).
plaintiff contends that the Administrative Law Judge
(“ALJ”): “1) relied on misstatements of
evidence to justify assigning less weight to the consistent
opinions of two treating physicians; and 2) did
not properly formulate Mr. Vandeusen's Residual
Functional Capacity, in light of the numerous statements from
Mr. Vandeusen's treating physicians and Mr.
Vandeusen's own testimony, thereby making a finding for a
higher level of physical capacity, and not determining Mr.
Vandeusen's claim under the Grid rules.” Pl.'s
Mot. to Reverse (“Doc. No. 15-1”) at 2.
defendant argues that the ALJ properly evaluated the medical
opinions and properly assessed the plaintiff's
credibility, and that substantial evidence supported the
ALJ's Decision. See Def.'s Mot. to Affirm (Doc. No.
16-2) at 3-8, 9-12, 12-13, respectively.
court concludes that remand is appropriate because the ALJ
failed to properly apply the treating physician rule.
“[T]he 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.'” Burgess v. Astrue, 537 F.3d 117,
128 (2d Cir. 2008) (quoting 20 C.F.R. § 404.1527(d)(2)).
controlling weight is not given to the opinions of the
treating physician, the ALJ . . . must specifically explain
the weight that is actually given to the opinion.”
Schrack v. Astrue, 608 F.Supp.2d 297, 301 (D. Conn.
2009) (citing Schupp v. Barnhart, No. Civ. 3:02CV103
(WWE), 2004 WL 1660579, at *9 (D. Conn. Mar. 12, 2004)).
“Failure to provide ‘good reasons' for not
crediting the opinion of a claimant's treating physician
is a ground for remand.” Snell v. Apfel, 177
F.3d 128, 133-34 (2d Cir. 1999) (citing Schaal v.
Apfel, 134 F.3d 496, 505 (2d Cir. 1998)). These reasons
must be stated explicitly and set forth comprehensively. See
Burgin v. Asture, 348 Fed.Appx. 646, 649 (2d Cir
2009) (“The ALJ's consideration must be explicit in
the record.”); Tavarez v. Barnhart, 124
Fed.Appx. 48, 49 (2d Cir. 2005) (“We do not hesitate to
remand when the Commissioner . . . do[es] not comprehensively
set forth reasons for the weight assigned . . . .”)
(internal quotation marks and citation omitted); Reyes v.
Barnhart, 226 F.Supp.2d 523, 529 (E.D.N.Y.
2002)(“rigorous and detailed” analysis required).
determining the amount of weight to give to a medical
opinion, the ALJ must consider all of the factors set forth
in § 404.1527(c): the examining relationship, the
treatment relationship (the length, the frequency of
examination, the nature and extent), evidence in support of
the medical opinion, consistency with the record, specialty
in the medical field, and any other relevant factors. See
Schaal, 134 F.3d at 504 (“all of the factors cited in
the regulations” must be considered to avoid legal
opinions are from medical sources other than
“acceptable medical sources”, the ALJ must still
consider the opinions, apply the factors, and explain the
weight given. See 20 C.F.R. § 404.1527(f). Regardless of
whether the opinion is from an acceptable medical source or
an “other source”, the ALJ's explanation
should be supported by the evidence and be specific enough to
make clear to the claimant and any subsequent reviewers the
reasons and the weight given. See 20 C.F.R. §
404.1527(f)(2); SSR 96-2p (applicable but rescinded March 27,
2017, after the date of the ALJ's decision).
[W]here there are deficiencies in the record, an ALJ is under
an affirmative obligation to develop a claimant's medical
history “even when the claimant is represented by
counsel or . . . by a paralegal.” Perez, 77
F.3d at 47; see also Pratts, 94 F.3d at 37
(“It is the rule in our circuit that ‘the ALJ,
unlike a judge in a trial, must  affirmatively develop the
record' in light of ‘the essentially
non-adversarial nature of a benefits proceeding.'[. . .
].”) (citations omitted).
Rosa v. Callahan, 168 F.3d 72, 79 (2d Cir. 1999).
See also Clark v. Comm'r of Soc. Sec., 143 F.3d
115, 118-19 (2d Cir. 1998) (holding that the ALJ should have
sought clarifying information sua sponte because the doctor
might have been able to provide a supporting medical
explanation and clinical findings, that failure to include
support did not mean that support did not exist, and that the
doctor might have included it had he known that the ALJ would
consider it dispositive).
Gaps in the administrative record warrant remand . . . .
Sobolewski v. Apfel, 985 F.Supp. 300, 314
(E.D.N.Y.1997); see Echevarria v. Secretary of Health
& Hum. Servs., 685 F.2d 751, 755-56 (2d Cir. 1982).
. . .
The ALJ must request additional information from a treating
physician . . . when a medical report contains a
conflict or ambiguity that must be resolved, the
report is missing necessary information, or the report does
not seem to be based on medically acceptable clinical and
diagnostic techniques. Id. § 404.1512(e)(1).
When “an ALJ perceives inconsistencies in a
treating physician's report, the ALJ bears an affirmative
duty to seek out more information from the treating physician
and to develop the administrative record
accordingly, ” Hartnett, 21 F.Supp.2d
at 221, by making every reasonable effort to
re-contact the treating source for clarification of
the reasoning of the opinion. Taylor v. Astrue, No.
07-CV-3469, 2008 WL 2437770, at *3 (E.D.N.Y. June 17, 2008).
Toribio v. Astrue, No. 06CV6532(NGG), 2009 WL
2366766, at *8-*10 (E.D.N.Y. July 31, 2009)(emphasis
added)(holding that the ALJ who rejected the treating
physician's opinion because it was broad, “contrary
to objective medical evidence and treatment notes as a
whole”, and inconsistent with the state agency
examiner's findings had an affirmative duty to re-contact
the treating physician ...