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Minnifield v. Berryhill

United States District Court, D. Connecticut

September 14, 2018



          Donna F. Martinez, United States Magistrate Judge

         The plaintiff, Ronnie Minnifield, seeks judicial review pursuant to 42 U.S.C. § 405(g) of a final decision by the Commissioner of Social Security ("Commissioner") denying his application for Supplemental Security Income ("SSI"). The plaintiff asks the court to reverse the Commissioner's decision or, alternatively, remand for a rehearing. (Doc. #19.) The Commissioner, in turn, seeks an order affirming the decision. (Doc. #20.) For the reasons set forth below, the plaintiff's motion is granted and the defendant's motion is denied.[1]

         I. Administrative Proceedings

         On June 6, 2013, the plaintiff applied for SSI alleging that he was disabled due to auditory hallucinations, schizophrenia, depression, anxiety, PTSD and diabetes.[2] (R. at 82.) His application was denied initially and upon reconsideration. He requested a hearing before an Administrative Law Judge ("ALJ"). On September 9, 2015, the plaintiff, represented by counsel, testified at the hearing. A vocational expert also testified. On December 8, 2015, the ALJ issued a decision finding that the plaintiff was not disabled. On May 16, 2017, the Appeals Counsel denied review, making the ALJ's decision final. In July 2017, the plaintiff commenced this action. On December 4, 2017, the plaintiff filed a motion for reversal or remand and on February 2, 2018, the defendant filed a motion to affirm.

         II. Standard of Review

         This court's review of the ALJ's decision is limited. "It is not [the court's] function to determine de novo whether [the plaintiff] is disabled." Pratts v. Chater, 94 F.3d 34, 37 (2d Cir. 1996). The court may reverse an ALJ's finding that a plaintiff is not disabled only if the ALJ applied the incorrect legal standards or if the decision is not supported by substantial evidence. Brault v. Soc. Sec. Admin., 683 F.3d 443, 447 (2d Cir. 2012). In determining whether the ALJ's findings "are supported by substantial evidence, 'the reviewing court is required to examine the entire record, including contradictory evidence and evidence from which conflicting inferences can be drawn.'" Talavera v. Astrue, 697 F.3d 145, 151 (2d Cir. 2012) (quoting Mongeur v. Heckler, 722 F.2d 1033, 1038 (2d Cir. 1983)). "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." Brault, 683 F.3d at 447 (quotation marks and citations omitted). It is "a very deferential standard of review - even more so than the clearly erroneous standard. . . . The substantial evidence standard means once an ALJ finds facts, [the court] can reject those facts only if a reasonable factfinder would have to conclude otherwise." Id. at 447-48. See also Genier v. Astrue, 606 F.3d 46, 49 (2d Cir. 2010) ("Even where the administrative record may also adequately support contrary findings on particular issues, the ALJ's factual findings must be given conclusive effect so long as they are supported by substantial evidence.") (internal quotation marks omitted).

         III. Statutory Framework

         To be "disabled" under the Social Security Act and therefore entitled to benefits, 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 last for a continuous period of not less than 12 months." 42 U.S.C. § 423(d)(1)(A). The Commissioner uses the following five-step procedure to evaluate disability claims:

First, the [Commissioner] considers whether the claimant is currently engaged in substantial gainful activity. If he is not, the [Commissioner] next considers whether the claimant has a "severe impairment" which significantly limits his physical or mental ability to do basic work activities. If the claimant suffers such an impairment, the third inquiry is whether, based solely on medical evidence, the claimant has an impairment which is listed in Appendix 1 of the regulations. If the claimant has such an impairment, the [Commissioner] will consider him disabled without considering vocational factors such as age, education, and work experience.... Assuming the claimant does not have a listed impairment, the fourth inquiry is whether, despite the claimant's severe impairment, he has the residual functional capacity to perform his past work. Finally, if the claimant is unable to perform his past work, the [Commissioner] then determines whether there is other work which the claimant could perform.

Rosa v. Callahan, 168 F.3d 72, 77 (2d Cir. 1999) (internal alterations and citation omitted). "The applicant bears the burden of proof in the first four steps of the sequential inquiry; the Commissioner bears the burden in the last." Talavera v. Astrue, 697 F.3d 145, 151 (2d Cir. 2012).

         IV. The ALJ's Decision

         Following the five step evaluation process, the ALJ first found that the plaintiff had not engaged in substantial gainful activity since June 6, 2013, his application date. (R. at 14.) At step two, the ALJ determined that the plaintiff had severe impairments of an affective disorder and acute myocardial infarction.[3] (R. at 15.) At step three, the ALJ found that the plaintiff did not have an impairment or combination of impairments that met or medically equaled the severity of one of the listed impairments in 20 CFR Part 404, Subpart P, Appendix 1. The ALJ next determined that the plaintiff had

the residual functional capacity[4] to perform medium work as defined in 20 C.F.R. 416.967(c)[5], except that [he] can have no exposure to extreme heat. He can perform simple, routine repetitive tasks in a setting that does not require strict adherence to time or production quotas. His judgment is limited to simple, work related decisions and he can deal with changes in the work environment limited to simple, work related decisions, He can only have occasional exposure to the public.

(R. at 16.)

         Finally, after considering plaintiff's age, education, work experience and RFC, as well as the testimony of the VE, the ALJ found at step 5 that other jobs existed in significant numbers in the national economy that the plaintiff could perform.[6] (R. at 23.) Accordingly, the ALJ determined that the plaintiff was not under a disability "since June 6, 2013, the date the application was filed." (R. at 23.)

         V. Discussion

         The plaintiff argues that the ALJ erred: (1) in failing to find the plaintiff's diabetes a severe impairment at step 2; (2) in evaluating the opinions of the plaintiff's treating psychiatrist; (3) in weighing the medical evidence and determining his residual functional capacity; and (4) at step 5 because the original ALJ's decision was incomplete and alternatively, in concluding that there was work existing in significant numbers that the plaintiff could perform.

         A. Step 2

         The plaintiff argues that he "suffers from poorly controlled diabetes that should have been found by the ALJ to be a severe impairment." (Doc. #19 at 11.) In support, the plaintiff asserts that his blood sugar readings are "well outside what is considered to be the acceptable range" and demonstrate that his diabetes is "poorly controlled." (Doc. #19 at 12.)

         At step two, "[a] claimant has the burden of establishing that [he] has a 'severe impairment,' which is 'any impairment or combination of impairments which significantly limits [his] physical or mental ability to do basic work." Woodmancy v. Colvin, 577 Fed.Appx. 72, 74 (2d Cir. 2014). "[M]ere diagnosis of an impairment is not sufficient to establish 'severity' under step two." Cobbins v. Comm'r of Soc. Sec., 32 F.Supp.3d 126, 133 (N.D.N.Y. 2012).

         The ALJ determined that the plaintiff's diabetes was not a severe impairment. In so concluding, the ALJ reviewed the medical record, noting that it reflected that the plaintiff had only one case of syncope.[7] (R. at 611.) The ALJ found that although the plaintiff "has some high A1C[8] levels, his diabetes is well managed with medication." (R. at 15.)

         Substantial evidence supports the ALJ's determination. The record demonstrates that the plaintiff generally denied associated symptoms of headache, urinary frequency, polydipsia, [9] feelings of weakness, and/or dizziness. (R. at 318, 323.) When seen by consultative examiner Dr. Kogan in July 2013, the plaintiff reported that he had been diagnosed with diabetes "about 6 years ago." He "deni[ed] any numbness in the distal extremities" and "any history of foot ulcers." (R. at 358, 360.) Upon examination, all the plaintiff's systems were normal. He had no tenderness or swelling and had full range of motion throughout all the joints of his upper and lower extremities bilaterally. (R. at 359.) His motor strength was 5/5[10] and he had normal fine finger movements bilaterally. A sensory examination revealed "intact to light touch and pin prick in the upper and lower extremities bilaterally." (R. at 360.) Deep tendon reflexes ...

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