Petruck v. Berryhill

          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 ...