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Garcia v. Berryhill

United States District Court, D. Connecticut

May 8, 2019

NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.



         This is an administrative appeal following the denial of Plaintiff, Elena Perez Garcia's, application for Title XVI supplemental security income benefits (“SSI”). It is brought pursuant to 42 U.S.C. § 405(g).[1] Plaintiff now moves for an order reversing the decision of the Commissioner of the Social Security Administration (the “Commissioner”), or in the alternative, an order remanding her case for a rehearing. [Doc. # 18]. The Commissioner, in turn, has moved for an order affirming her decision. [Doc. # 19]. For the reasons set forth below, Plaintiff's motion is granted and the Commissioner's motion is denied.


         1. Facts

         Plaintiff filed her SSI application on November 20, 2014. Her claim was denied at both the initial and reconsideration levels. Plaintiff then requested a hearing. On December 22, 2016, a hearing was held before Administrative Law Judge Ellen Parker Bush (the “ALJ”). Plaintiff, who was represented by counsel, and a vocational expert (“VE”) testified at the hearing. On May 30, 2017, the ALJ issued a decision denying Plaintiff's claim. Plaintiff timely requested review of the ALJ's decision by the Appeals Council. On May 30, 2018, the Appeals Council denied review, making the ALJ's decision the final determination of the Commissioner. This action followed.

         Plaintiff has alleged disability based primarily on the conditions of diabetic neuropathy and degenerative disc disease. She was forty-six years old on the date of the hearing. She has an associate degree and past work experience as an accounting assistant. Plaintiff's complete medical history is set forth in the Joint Stipulation of Facts filed by the parties. [Doc. ## 18-1, 19-2]. The Court adopts this stipulation and incorporates it by reference herein.

         2. The ALJ's Decision

         The Commissioner must follow a sequential evaluation process for assessing disability claims. The five steps of this process are as follows: (1) the Commissioner considers whether the claimant is currently engaged in substantial gainful activity; (2) if not, the Commissioner considers whether the claimant has a “severe impairment” which limits his or her mental or physical ability to do basic work activities; (3) if the claimant has a “severe impairment, ” the Commissioner must ask whether, based solely on the medical evidence, the claimant has an impairment which “meets or equals” an impairment listed in Appendix 1 of the regulations (the Listings). If so, and it meets the durational requirements, the Commissioner will consider the claimant disabled, without considering vocational factors such as age, education, and work experience; (4) if not, the Commissioner then asks whether, despite the claimant's severe impairment, he or she has the residual functional capacity to perform his or her past work; and (5) if the claimant is unable to perform his or her past work, the Commissioner then determines whether there is other work in the national economy which the claimant can perform. 20 C.F.R. § 416.920(a)(4)(i)-(v). The claimant bears the burden of proof on the first four steps, while the Commissioner bears the burden of proof on the final step. McIntyre v. Colvin, 758 F.3d 146, 149 (2d Cir. 2014).

         In this case, at Step One, the ALJ found that Plaintiff has not engaged in substantial gainful activity since the SSI application date. (R. 23). At Step Two, the ALJ found the following severe impairments: diabetes; peripheral neuropathy; left-sided carpal tunnel syndrome, status post right-sided carpal tunnel release; and degenerative disc disease of the lumbar spine. (Id.). At this second step, the ALJ also discussed Plaintiff's obesity, and concluded that there is no evidence it impacted her ability to perform basic work activities. (R. 23-24). At Step Three, the ALJ found Plaintiff's severe impairments, alone or in combination, do not meet or medically equal the severity of one of the listed impairments. (R. 24). Next, the ALJ determined Plaintiff retains the following residual functional capacity[2]:

Plaintiff can perform light work with the following limitations: she can occasionally climb ramps, stairs, ladders, ropes, and scaffolds. She can occasionally stoop, crouch, and crawl. She can frequently balance and crouch.[3]She should avoid concentrated exposure to respiratory irritants and hazards.

(R. 25).

         In formulating this RFC, the ALJ considered three medical opinions. First, Dr. Colb, a State Agency Medical Consultant, reviewed the record and provided an opinion dated November 20, 2015. He opined that Plaintiff could occasionally lift and carry twenty pounds and frequently lift and carry ten pounds, and could sit, stand, and walk for six hours in an eight-hour workday. (R. 96). He found Plaintiff had limited ability to push and pull with the left upper extremity. (Id.). Dr. Colb stated Plaintiff could occasionally climb ramps, stairs, ladders, ropes, and scaffolds; occasionally stoop, crouch, and crawl; and frequently balance and kneel. (R. 97). Dr. Colb concluded that Plaintiff could think, communicate, care for her own needs, and perform usual daily activities. (R. 99). He noted that although Plaintiff may experience pain and discomfort, she can “move about … in a satisfactory manner.” (Id.). The ALJ gave Dr. Colb's opinion partial weight. (R. 28).

         Second, Dr. Dodenhoff provided an opinion dated June 3, 2016 based on his consultative examination of Plaintiff. He noted that Plaintiff's pain medications “let her function” to perform activities of daily living. (R. 820). He opined she can sit, stand, walk, lift, carry, and handle objects. (R. 821). In addition, Dr. Dodenhoff stated Plaintiff's hearing and speaking are intact, and she can understand, remember, and carry out instructions. (Id.). He found she should be able to respond appropriately to supervision, coworkers, and the pressures in a work setting. (Id.). The ALJ gave Dr. Dodenhoff's opinion great weight. (R. 28).

         Third, Dr. Borgonos, Plaintiff's treating physician, completed a medical source statement in December 2016. He noted that he has seen Plaintiff every three months for two years. (R. 815). He listed her diagnoses as diabetes, diabetic neuropathy, hypothyroidism, depression, and GERD. (Id.). He assessed a fair prognosis. (Id.). Plaintiff's symptoms were identified as chronic pain, specifically “moderate pain that is constant mostly involving her legs, ” and back pain from degenerative disease. (Id.). Dr. Borgonos found Plaintiff could walk three city blocks without rest or pain, could sit for more than two hours at a time, and could stand for thirty minutes at a time. (R. 816). He stated that, in an eight-hour workday, Plaintiff could sit for four hours total, and stand/walk for less than two hours total. (Id.). He opined she could frequently lift and carry ten pounds; could occasionally lift ...

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