United States District Court, D. Connecticut
CHELE D. PETRUCK, 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 and the defendant agree that the Administrative Law
Judge (“ALJ”) failed to apply the correct legal
principles. See Pl.'s Brief (ECF No. 23) (improper
evaluation of treating sources, improper credibility
assessment, improper determination of residual functional
capacity, improper actions on behalf of an impartial
adjudicator); Def.'s Brief (ECF No. 22) at 2 (incomplete
record).
The
plaintiff contends that the ALJ's decision should be
either (1) reversed and benefits awarded, or (2) reversed and
remanded solely for the award and calculation of benefits
because “substantial evidence does not exist”,
“the record is complete”, and “the evidence
of record is overwhelming that the Plaintiff is disabled and
that no alcoholism or drug addiction materially contributed
to that disability.” Pl.'s Brief at 2-3.
The
defendant contends that “the record . . . is
incomplete” and the case should be remanded so the ALJ
can “assess whether plaintiff's mental impairments
independently caused disabling functional limitations and
cite evidence in the record from her alleged onset date of
May 27, 2009 through her date of abstinence, June
2015.” Def.'s Brief at 2, 4.
The
court concludes that, at minimum, the ALJ failed to properly
apply the treating physician rule to the opinions of Colleen
Piccone, LCSW, co-signed by psychiatrist Dr. Rachwal. This,
standing alone, warrants remand.
Medical
opinions from acceptable medical sources[1] 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), 416.927(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) 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).
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 ...