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Blackman v. Berryhill

United States District Court, D. Connecticut

December 17, 2018

LEILA BLACKMAN, Plaintiff,
v.
NANCY A. BERRYHILL, ACTING COMMISSIONER OF SOCIAL SECURITY, Defendant.

          ORDER REMANDING CASE

          Alvin W. Thompson, United States District Judge

         For the reasons set forth below, the decision of the Commissioner is reversed and this case is remanded for additional proceedings consistent with this order.

         “A 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).

         The plaintiff contends that the Administrative Law Judge (“ALJ”): “1) failed to properly consider Ms. Blackman's Borderline Personality Disorder under the Listing of impairments and to make specific findings on this issue; 2) failed to make proper weight assignments as to the opinions of Ms. Blackman's treating sources; and 3) failed to properly determine Ms. Blackman's Residual Functional Capacity (“RFC”). Pl.'s Mot. to Reverse (“ECF No. 15-1”) at 2.

         The defendant argues that the ALJ applied the correct legal standards and that substantial evidence supported the ALJ's Decision. See Def.'s Mot. to Affirm (ECF No. 16-1) at 20.

         The court concludes that, at minimum, the ALJ failed to properly apply the treating physician rule to treating psychiatrist Sudha Sreenivasan's opinion that the plaintiff was unable to work in any capacity due to her mental status. This, standing alone, warrants remand.

         The ALJ must evaluate “[e]very medical opinion”. 20 C.F.R. § 404.1527(c). “Medical opinions” are statements from acceptable medical sources that reflect judgments about the nature and severity of a claimant's impairments, including symptoms, diagnosis, prognosis, and restrictions. 20 C.F.R. § 404.1527(a)(1). Medical opinions from acceptable medical sources are entitled to “controlling weight” if “well-supported by medically acceptable clinical and laboratory diagnostic techniques” and “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))(internal quotation marks omitted).

         “[I]f 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).

         In 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 error).

         If the 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.[1] See 20 C.F.R. § 404.1527(f).[2] 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 effective 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).

         This duty to develop the record “is heightened in cases where the claimant is mentally impaired”, as is the case here. Shand v. Colvin, No. 3:15 CV 761 (JGM), 2018 WL 389179, at *14 (citing Robinson v. Colvin, No. 14 CV 1227 (HBF), 2016 WL 7668439, at *6 (D. Conn. Dec. 20, 2016) (citing Dervin v. Astrue, 407 Fed.Appx. 154, 156 (9th Cir. 2010), Magistrate Judge's Recommended Ruling approved and adopted absent objection, No. 3:14 CV 1227 (MPS), 2017 WL 80403 (D. Conn. Jan. 9, 2017))).

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 ...

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