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).
plaintiff contends that the Administrative Law Judge
(“ALJ”) erred in the following ways:
First, the Defendant improperly rejected the opinion of the
treating physician Dr. Timell, because it was not based on
objective medical evidence of impairment. Secondly, the
Defendant weighed the evidence and found in favor of state
agency consultants, but failed to follow the regulations in
weighing the evidence. Third, the Defendant furthermore found
that the Plaintiff's “impairments could reasonably
be expected to cause symptoms, but “..[.], the
claimant's statements concerning the intensity,
persistence and limiting effects of these symptoms are not
entirely consistent with the medical evidence and other
evidence in the record for the reasons explained in this
decision.” R. at 27. . . . The last error assigned is
that the Defendant arrived at an RFC that did not honor the
evidence of impairment because of the errors throughout this
Pl.'s Mot. to Reverse (“ECF No. 17-2”) at
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.
18, 18-1) at 1 and 13, respectively.
court concludes that, at minimum, the ALJ failed to properly
apply the treating physician rule to Dr. Timell's
opinions. This, standing alone, warrants remand.
must evaluate “[e]very medical opinion”. 20
C.F.R. §§ 404.1527(c), 416.927(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), 416.927(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). See also 20 C.F.R. § 416.927(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).
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), 416.927(f)(2); SSR 96-2p
(applicable but rescinded effective March 27, 2017, after the
date of the ALJ's decision).
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) and § 416.927(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).
[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 to obtain clarification of his opinion
that plaintiff was “totally incapacitated”).
determining whether there has been “inadequate
development of the record, the issue is whether the missing
evidence is significant.” Santiago v. Astrue,
2011 WL 4460206, at *2 (D. Conn. Sept. 27, 2011) (citing
Pratts v. Chater, 94 F.3d 34, 37-38 (2d Cir. 1996)).
“[T]he burden of showing that an error is harmful
normally falls upon the ...