United States District Court, D. Connecticut
RULING AND ORDER ON MOTION TO AFFIRM AND MOTION TO
REVERSE THE DECISION OF THE ACTING COMMISSIONER
VICTOR
A. BOLDEN UNITED STATES DISTRICT JUDGE
Rosemary
Rainey (“Plaintiff”) filed this administrative
appeal under 42 U.S.C. § 405(g) against Carolyn W.
Colvin, the Acting Commissioner of Social
Security[1] (“Defendant” or “the
Acting Commissioner”), seeking to reverse the decision
of the Social Security Administration (“SSA”)
denying her claim for Title II disability insurance benefits
under the Social Security Act. Complaint, dated May 2, 2016
(“Compl.”), ECF No. 1, at 1.
Accordingly,
Ms. Rainey moves for an order reversing the decision of the
Acting Commissioner. Motion to Reverse the Decision of the
Commissioner, dated Nov. 23, 2016 (“Mot. to
Reverse”), ECF No. 18. The Acting Commissioner moves
for an order affirming her decision. Motion to Affirm the
Decision of the Commissioner, dated Aug. 29, 2017
(“Mot. to Affirm”), ECF No. 25.
For the
following reasons, the motion to reverse the decision of the
Acting Commissioner is DENIED and the motion
to affirm the decision of the Acting Commissioner is
GRANTED.
I.
FACTUAL AND PROCEDURAL BACKGROUND
Ms.
Rainey, a fifty-five year old Connecticut resident, lives
alone on the second floor of a two-story building. She
alleges having been disabled since 2008 and now seeks review
of denial of Title XVI benefits. All factual allegations are
uncontested.
A.
Medical Evidence
Ms.
Rainey's medical history includes degenerative disc
disease of the lumbar spine, depression, a bilateral knee
impairment, HIV/AIDS, hepatitis C, chronic obstructive
pulmonary diseases (“COPD”), heart disease,
obesity, post-traumatic stress disorder (“PTSD”),
and shoulder pain. See, e.g., Transcript of
Administrative Record, filed Aug. 9, 2016
(“Tr.”), annexed as Exs. 1-17 of Defendant's
Answer, ECF Nos. 12-1-12-17, at 483-84, 477, 674-675, 779,
534, 585, 790, 826, 390, 400, 609-210, 391, 401, 389.
Ms.
Rainey has, on multiple occasion, been treated after
complaining of “chronic pain” in her left knee.
Id. at 483, 477-8, 674. In October 2011, Ms. Rainey
was treated for left knee pain and lower back pain. Her
principle complaint was “chronic pain.”
Id. at 483. An examination revealed lower back pain and
muscle spasm, for which she was prescribed Tramadol,
Diclofenac, and discontinued use of Naproxen because it was
deemed ineffective. Id. at 484. In November 2011,
she was again seen for left knee pain and diagnosed with
patellar chondrolmalacia of the left knee. Id. at
477-78. In April and May 2013, Ms. Rainey complained of pain
in her knees and back that registered as an eight out of ten.
Id. at 481-82, 675-76.
Medical
records as early as November 2010 reflect that Ms. Rainey has
a history of left knee pain, and walks with a limp.
Id. at 389-90 (“[Had injury left knee years
ago and now has progressive pain and joint click.”). A
January 2011 x-ray of Ms. Rainey's knee showed
“minimal degenerative change, ” and an MRI
performed in February 2011 revealed: “MCL bursitis,
medial suprapatellar plica, chondromalacia in the median
ridge of the patella, degenerative type thinking of the
medial meniscus and tiny popliteal hernia.”
Id.
In
October 2011, Ms. Rainey was referred to a physiatrist and
prescribed a knee brace. Id. at 484, 839.
Ms.
Rainey was diagnosed as HIV positive in 2010; as of April
2016, Ms. Rainey was asymptomatic with an undetectable viral
load. Id. at 600. She has been diagnosed as having
AIDS, and placed on atovaquone as a prophylaxis against
Pheumocystis jerovencii. Id. at 534, 540, 585, 591,
661-62, 674, 680, 830.
At
least twice, Ms. Rainey has had to discontinue treatment
because of complications due to treatment. Id. at
604-06, 790. From September 2012 to June 2013, Ms. Rainey was
treated with Pegasys, Interferon, and Ribavirin, but the
treatment had to be stopped due to detectable viremia.
Id. at 790. While awaiting a new treatment, almost a
year later, her viral load was more than 800, 000.
Id. at 826. During a second course of treatment, Ms.
Rainey developed generalized pruritus. Id. at 682.
According to a physician who treated Ms. Rainey, Pegasys can
carry side effects of anemia, low energy, and fatigue.
Id. at 601. She was hospitalized in December 2012
due to a number of symptoms and the medical record states:
“the patient's ribavirin and Pegasys were placed on
hold during this admission as she did have acute kidney
injury and diarrhea, initially.” Id. at 605.
Ms.
Rainey was hospitalized due to issues related to COPD and
other bronchial issues. Id. at 602. In addition to
COPD, she also suffers from asthma and chronic bronchitis.
Id. at 390, 403, 475, 609. On at least one occasion,
in 2010, Ms. Rainey was referred to specialists for
consultations regarding asthma and COPD. Id. at 391.
In the beginning of 2013, she was hospitalized from December
29, 2012, and discharged on January 4, 2013. Id. at
602. While hospitalized, Ms. Rainey experienced a number of
pulmonary traumas, which, in combination with other ailments,
lead to her transfer to the intensive care unit. Id.
at 602, 609.
Ms.
Rainey has suffered two heart attacks and, despite taking a
long list of prescriptions, continues to experience
hypertension. Id. at 609, 313, 347-78, 357-58, 366,
836, 496, 498-500, 502.
Ms.
Rainey has been diagnosed as obese. Id. at 391, 401.
As early as 2010, she has been reported as having a BMI of at
least 30. Id. at 149, 433, 438, 448, 456, 462, 466,
827, 832, 843. She has also been referred for nutrition
therapy and intervention and met with a nutritionist.
Id. at 467, 486, 528.
And she
has complained of should pain and examination has shown signs
of degeneration. Id. at 390, 431, 713. On a number
occasions, she visited doctors due specifically due to
reported back and knee pain, id. at 492, 510, and,
at other times, she complained of pain while seeking
treatment for other medical issues, id. at 444, 456,
543.
B.
Procedural Background
On
September 27, 2012, Ms. Rainey applied for Title XVI
benefits, alleging being disabled since January 1, 2008.
Compl. ¶ 4. The application for benefits was first
denied on December 18, 2012, and denied for a second time on
May 3, 2013. Id. ¶ 5.
On
December 17, 2014, the SSA held a hearing; Ms. Rainey
appeared, represented by counsel, before Administrative Law
Judge (“ALJ”) Sharda Singh, as did Steven B.
Sachs, Ph.D., an impartial vocational expert. Tr. at 20.
Ms.
Rainey testified that she is fifty-five years of age,
divorced, and lives alone on the second story of an apartment
building with an elevator. Id. at 81. She receives
cash assistance from State Administered General Assistance
(“SAGA”), which is a state-based disability
benefit program administered by the Connecticut Department of
Social Services (DSS). Id. at 82.
Ms.
Rainey testified that she worked full-time for eleven months
in 1999 as a crew member at McDonalds. Id. at 84.
Her duties would require that she stand, walk, and serve
customers; she received a thirty minute break, which allowed
for her to sit. Id. at 84. The work occasionally
required that she lift twenty-to-thirty pounds. Id.
Lifting items of any significant weight with more frequency
was difficult for Ms. Rainey, because, as she described it:
“the weight goes through my arms down to my back and
knees.” Id. at 85. She further testified that
there is no amount of weight at present that she could carry
with any frequency for five hours in an eight hour day.
Id. at 90.
Dr.
Mauricio Montezuma treats Ms. Rainey for the pain she
experiences in her lower back. Id. at 85. Ms. Rainey
described the pain as constant, with an intermittent muscle
spasm “which can be sometimes excruciating, ”
radiating down to her knees and causing them to burn.
Id. at 86. The pain varies between five and
“over a 10” on a ten point scale, with ten
indicating the highest scaled pain level. Id. at 86.
She would use Cyclobenzaprine to help manage the pain but
testified that it did not help to alleviate the pain.
Id. at 87. Walking up to thirty minutes is
sufficient to cause Ms. Rainey “excruciating”
pain. Id. at 88. Ms. Rainey uses the assistance of a
cane when walking or standing up from a sitting position,
both inside and outside of her home. Id. Similarly,
she stated that, if she stands in one spot for more than
fifteen to twenty minutes, her legs begin to throb, causing
Ms. Rainey to feel as though she may fall. Id. at
89. She experiences pain in her knees, which she described as
registering as eight on the ten point scale; they
“throb with pain” consistently. Id. at
90.
Ms.
Rainey testified that, to the best of her ability, she does
household chores. Id. at 94. She vacuums, does her
laundry, and cooks meals, though she does so while sitting
down to avoid aggravating her back and knees. Id.
She does not receive assistance in completing these chores.
When doing laundry, she uses a “shopping cart” to
transport her laundry to the laundry facilities, which are on
the same floor as her apartment. Id. at 97. Ms.
Rainey also does her own shopping, although there are times,
for example, when she does bulk grocery shopping, in which
she receives assistance from Peter's Retreat, an
organization that provides assistance to individuals living
with HIV/AIDS. Id. at 94. She cleans the bathroom
while on her hands and knees, to avoid standing. Id.
at 98. Although she is able to dress herself, she cannot
stand while putting on her pants. Id.
She is
able to navigate a grocery store with the aid of a cane; she
also uses the shopping cart for support. Id. at
94-95. She also uses public transportation, but there are
times when the pain in her lower back and knees is so
substantial that, approximately two-to-three times monthly,
she will call Peter's Retreat for transportation
services. Id. at 95. Ms. Rainey sometimes also
attends church.
Ms.
Rainey testified that she has been diagnosed with depression
and post-traumatic stress disorder (“PTSD”).
Id. at 91. She described experiencing melancholia,
during which she does not want to speak to others, gets lost
in her thoughts, and avoids social situations. Id.
Because of these feelings, as often as four times weekly, she
will put a sign on her apartment door asking not to be
disturbed. Id. at 92. Once monthly, she meets with
Dr. Matthew Dickinson for talk therapy, where she discusses
with him how she is feeling and the medication he has
prescribed to her. Id. at 92-93.
Ms.
Rainey testified that she has been diagnosed with HIV.
Id. at 100. With medication, her viral load remains
undetectable. Id.
Steven
Saxx also testified as a vocational expert. Id. at
101. He testified that Ms. Rainey's employment with
McDonald's was as a fast food worker, unskilled, and
involved light exertional work. Id. at 102. He
stated that an individual of the same age, with the same
education, and past work experience could lift or carry
twenty pounds occasionally or ten pounds frequently; stand
and walk six hours and sit for up to six hours during an
eight hour day; never climb ladders, ropes, or scaffolds, but
occasionally climb stairs, ramps, or balance, stoop, kneel,
crouch, and crawl; and must be limited to understanding,
remembering, and carrying out simple routine, repetitive,
non-complex tasks could perform the tasks of a fast food
worker. Id. at 104.
Assuming
the same limitations, but also assuming that such an
individual would need to miss work for two days monthly, he
stated that the individual could not perform the tasks of a
fast food worker or any other job. Id. Finally,
assuming the initial limitations and that the individual
would also be “off task” for more than fifteen
percent of a workday, he stated that the individual could not
perform the tasks of a fast food worker or any other job.
Id. at 104-05.
After
the hearing, on January 18, 2015, the Administrative Law
Judge (“ALJ”) found that Ms. Rainey was not
entitled to disability insurance benefits, based on the
following findings:
1. The claimant has not engaged in substantial gainful
activity since September 27, 2012, the application date (20
C.F.R. 416.971 et seq.).
2. The claimant has the following severe impairments:
degenerative disc disease (DDD) of the lumbar spine and
depression (20 C.F.R. 416.690(c)).
3. The claimant does not have an impairment or combination of
impairments that meets or medically equals the severity of
one of the listed impairments in 20 C.F.R. Part 404, Subpart
P, Appendix 1 (20 C.F.R. 416.920(c), 416.925 and 416, 926).
4. 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 C.F.R. 416.967(b) except
she can never climb ladders, ropes, or scaffolds. She can
occasionally climb ramps and stairs, balance, stoop, kneel,
crouch, and crawl. She must avoid hazards. She is limited to
understanding, remembering, and carrying out simple, routine,
and repetitive noncomplex tasks.
5. The claimant is capable of performing past relevant work
as a Fast Food Worker. This work does not require the
performance of work-related activities precluded by the
claimant's residual functional capacity (20 C.F.R.
416.965).
6. The claimant has not been under a disability, as defined
in the Social Security Act, since September 27, 2012, the
date the application was filed (20 C.F.R. 416.920(f)).
Id. at 22-29.
Upon
the Appeals Council's March 3, 2016, denial of Ms.
Rainey's timely request for review of the decision, the
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