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Sinclair v. Saul

United States District Court, D. Connecticut

July 22, 2019

ANDREA H. SINCLAIR, Plaintiff,
v.
ANDREW M. SAUL, COMMISSIONER OF SOCIAL SECURITY[1] Defendant.

          RULING ON THE PLAINTIFF'S AMENDED MOTION FOR SUMMARY JUDGMENT AND ON THE DEFENDANT'S MOTION TO AFFIRM THE DECISION OF THE COMMISSIONER

          Robert M. Spector, United States Magistrate Judge

         This action, filed under § 205(g) of the Social Security Act, 42 U.S.C. § 405(g), seeks review of a final decision by the Commissioner of Social Security [“SSA” or “the Commissioner”] denying the plaintiff's application for Social Security Disability Insurance [“SSDI”] benefits.[2]

         I. ADMINISTRATIVE PROCEEDINGS

         On or about February 27, 2014, the plaintiff filed an application for SSDI benefits claiming that she has been disabled since January 1, 2011, due to the following conditions: seizures; opiate and benzodiazepine addiction; “spinal fusion/scoliosis/spondylolisthesis”; chronic migraine headaches; “Lyme [d]isease & co-infections”; Behcet's syndrome; chronic pain, chronic depression; irritable bowel syndrome [“IBS”]; and gastroparesis. (Doc. No. 10 (Certified Transcript of Administrative Proceedings, dated June 6, 2018 [“Tr.”]) 103, 123, 150). The Commissioner denied the plaintiff's application initially and upon reconsideration. (Tr. 103-22, 123-47). On November 4, 2014, the plaintiff requested a hearing before an Administrative Law Judge [“ALJ”]. (Tr. 166-67). On October 4, 2016, a hearing was held before ALJ Mary Beth O'Connor, at which the plaintiff and a vocational expert, Robin L. Generaux, testified. (Tr. 40- 102; see Tr. 227, 251, 257). On November 2, 2016, the plaintiff amended her alleged onset date to March 8, 2011, and requested a closed period of disability, which began on the amended alleged onset date and ended on June 13, 2014.[3] (Tr. 280). On January 9, 2017, the ALJ issued an unfavorable decision denying the plaintiff's claim for benefits. (Tr. 10-34). On August 4, 2016, the plaintiff requested review of the hearing decision (Tr. 258-61; see also Tr. 35-39), and on February 20, 2018, the Appeals Council denied the plaintiff's request for review, thereby rendering the ALJ's decision the final decision of the Commissioner. (Tr. 1-6).

         The plaintiff filed her complaint in this pending action on April 18, 2018. (Doc. No. 1). On July 11, 2018, the defendant filed her Answer and Certified Administrative Transcript, dated June 6, 2018. (Doc. No. 10). On August 2, 2018, the parties consented to the jurisdiction of a United States Magistrate Judge (Doc. Nos. 15 & 16), and the case was reassigned to this Magistrate Judge on August 3, 2018. (Doc. No. 17). On September 10, 2018, the plaintiff filed her Motion for Summary Judgment (Doc. No. 19), with brief in support (Doc. No. 19-1). The parties filed their Joint Statement of Material Facts on December 21, 2018 (Doc. No. 30); and on that same day, the plaintiff filed an amended Motion for Summary Judgment (Doc. No. 32), with brief in support (Doc. No. 32-1 [“Pl.'s Mem.”]). On January 28, 2019, the defendant filed her Motion to Affirm the Decision of the Commissioner (Doc. No. 34), with brief in support (Doc. No. 34-1 [“Def.'s Mem.”]). On February 11, 2019, the plaintiff filed her reply brief. (Doc. No. 35).

         For the reasons stated below, the plaintiff's Amended Motion for Summary Judgment (Doc. No. 32) is denied, and the defendant's Motion to Affirm (Doc. No. 34) is granted.

         II. FACTUAL BACKGROUND[4]

         The Court presumes the parties' familiarity with the plaintiff's medical history, which is thoroughly discussed in the Joint Stipulation of Facts (Doc. No. 30). The Court cites only the portions of the record that are necessary to explain this decision.

         III. THE ALJ'S DECISION

         Following the five-step evaluation process, [5] the ALJ found that the plaintiff had not engaged in substantial gainful activity since her amended alleged onset date of March 8, 2011. (Tr. 15, citing 20 C.F.R. §§ 404.1571 et seq., and 416.971, et seq.). The ALJ concluded that the plaintiff had the following severe impairments: epilepsy; substance addiction; degenerative disc disease; depression; anxiety; migraines; gastroparesis; and IBS.[6] (Tr. 15, citing 20 C.F.R. §§ 404.1520(c) and 416.920(c)). At step three, the ALJ found that the plaintiff did not have an impairment or a combination of impairments that met or medically equaled the severity of one of the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1. (Tr. 16, citing 20 C.F.R. §§ 404.1520(d), 404.1525, 404.1526, 416.920(d), 416.925, and 416.926). The ALJ determined that the plaintiff had the residual functional capacity [“RFC”] to perform light work, as defined in 20 C.F.R. §§ 404.1567(b) and 416.967(b), except that she could occasionally climb ramps and stairs, balance, and crawl; she could never climb ladders, ropes, or scaffolds; she could frequently stoop, kneel, and crouch; she had to avoid concentrated exposure to noise and even moderate exposure to unprotected heights and moving mechanical parts; and she was limited to simple, repetitive, routine tasks. (Tr. 18). At step four, the ALJ stated that the plaintiff was unable to perform any past relevant work. (Tr. 24, citing 20 C.F.R. §§ 404.1565 and 416.965). At step five, after considering the plaintiff's age, education, work experience, and RFC, the ALJ concluded that there were significant numbers of jobs in the national economy that the plaintiff could perform. (Tr. 24, citing 20 C.F.R. §§ 404.1569, 404.1569(a), 416.969, and 416.969(a)). Accordingly, the ALJ found that the plaintiff was not under a disability, as defined in the Social Security Act, at any time from the amended alleged onset date of March 8, 2011, through the date of her decision.[7](Tr. 25, citing 20 C.F.R. §§ 404.1520(g) and 416.920(g)).

         IV. STANDARD OF REVIEW

         The scope of review of a Social Security disability determination involves two levels of inquiry. First, the court must decide whether the Commissioner applied the correct legal principles in making the determination. See Balsamo v. Chater, 142 F.3d 75, 79 (2d Cir. 1998) (citation omitted). Second, the court must decide whether substantial evidence supports the determination. See Id. The court may “set aside the Commissioner's determination that a claimant is not disabled only if the factual findings are not supported by substantial evidence or if the decision is based on legal error.” Burgess v. Astrue, 537 F.3d 117, 127 (2d Cir. 2008) (citation and internal quotations marks omitted); see also 42 U.S.C. § 405(g). Substantial evidence is evidence that a reasonable mind would accept as adequate to support a conclusion; it is more than a “mere scintilla.” Richardson v. Perales, 402 U.S. 389, 401 (1971) (citation omitted); see Yancey v. Apfel, 145 F.3d 106, 111 (2d Cir. 1998) (citation omitted). The substantial evidence rule also applies to inferences and conclusions that are drawn from findings of fact. See Gonzalez v. Apfel, 23 F.Supp.2d 179, 189 (D. Conn. 1998) (citation omitted); Rodriguez v. Califano, 431 F.Supp. 421, 423 (S.D.N.Y. 1977) (citations omitted). However, the court may not decide facts, reweigh evidence, or substitute its judgment for that of the Commissioner. See Dotson v. Shalala, 1 F.3d 571, 577 (7th Cir. 1993) (citation omitted). Instead, the court must scrutinize the entire record to determine the reasonableness of the ALJ's factual findings. See Id. Furthermore, the Commissioner's findings are conclusive if supported by substantial evidence and should be upheld even in those cases where the reviewing court might have found otherwise. See 42 U.S.C. § 405(g); see also Beauvoir v. Chater, 104 F.3d 1432, 1433 (2d Cir. 1997) (citation omitted); Eastman v. Barnhart, 241 F.Supp.2d 160, 168 (D. Conn. 2003).

         V. DISCUSSION

         In this appeal, the plaintiff contends that the ALJ erred in three general regards. First, the plaintiff argues that the ALJ applied improperly the treating physician rule and misconstrued the objective evidence in the record. (Pl.'s Mem. at 18-26). Second, the plaintiff maintains that the ALJ failed to consider adequately the plaintiff's subjective complaints about her condition. (Pl.'s Mem. at 26-31). Finally, the plaintiff claims that the ALJ erred at step five of the sequential analysis by failing to account for certain non-exertional limitations. (Pl.'s Mem. at 31). The defendant responds that substantial evidence supports the ALJ's decision that the plaintiff was not disabled at any time during the closed period of disability. (Def.'s Mem. at 6).

         A. THE ALJ'S EVALUATION OF THE OBJECTIVE MEDICAL EVIDENCE AND APPLICATION OF THE TREATING PHYSICIAN RULE

         The plaintiff claims that substantial evidence does not support the ALJ's conclusions regarding the medical opinion evidence or, alternatively, that such conclusions run contrary to law. (Pl.'s Mem. at 18). The plaintiff relies on several arguments to support this claim. First, the plaintiff contends that the ALJ determined erroneously the length of the plaintiff's treatment with one of her mental health treatment providers and that such error was not harmless. (Pl.'s Mem. at 18-20). Second, the plaintiff asserts that the ALJ failed to address adequately the objective findings and medical opinion of Gaurav Kapur, M.D., regarding the impairments to the plaintiff's lumbar spine. (Pl.'s Mem. at 20-22). Third, the plaintiff maintains that the ALJ failed to address adequately an unsigned, undated medical opinion statement, which she claims was produced by Zeb Ali, M.D. (Pl.'s Mem. at 22-23). Fourth, the plaintiff claims that the ALJ weighed too greatly the opinions of the State agency medical sources. (Pl.'s Mem. at 23-24). Fifth, the plaintiff alleges that the ALJ erred by concluding that an opinion of the plaintiff's mental health providers lacked “expertise and knowledge” to the extent that the opinion discussed the plaintiff's physical impairments. (Pl.'s Mem. at 24-25). Finally, the plaintiff argues that the ALJ afforded too much weight to the opinion of the consultative examiner. (Pl.'s Mem. at 25-26). The defendant responds that the ALJ weighed and evaluated properly the medical opinions of record. (Def.'s Mem. at 6).

         The treating physician rule requires that “the opinion of a claimant's treating physician as to the nature and severity of the impairment is given ‘controlling weight' so long as it ‘is well-supported by medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with the other substantial evidence in [the] case record.'” Burgess, 537 F.3d at 128, (quoting 20 C.F.R. § 404.1527(d)(2)). When the ALJ “do[es] not give the treating source's opinion controlling weight, ” she must “apply the factors listed” in 20 C.F.R. § 404.1527(c)(2), including “(1) the frequency, length, nature, and extent of treatment; (2) the amount of medical evidence supporting the opinion; (3) the consistency of the opinion with the remaining medical evidence; and (4) whether the physician is a specialist.” Selian v. Astrue, 708 F.3d 409, 417 (2d Cir. 2013) (per curiam). Once the ALJ has considered these factors, the ALJ must “comprehensively set forth [her] reasons for the weight assigned to a treating physician's opinion.” Halloran v. Barnhart, 362 F.3d 28, 33 (2d Cir. 2004); see 20 C.F.R. § 404.1527(c)(2) (“We will always give good reasons in our notice of determination or decision for the weight we give [the claimant's] treating source's medical opinion.”). “A failure by the Commissioner to provide ‘good reasons' for not crediting the opinion of a treating physician is a ground for remand.” Hanes v. Comm'r Soc. Sec., No. 11-CV-1991 (JFB), 2012 WL 4060759, at *12 (E.D.N.Y. Sept. 14, 2012) (citing Snell v. Apfel, 177 F.3d 128, 133 (2d Cir. 1999)).

         1. THE LENGTH OF THE PLAINTIFF'S TREATMENT RELATIONSHIP WITH FRANCISCAN LIFE CENTER

         The plaintiff maintains that the ALJ determined erroneously that the plaintiff's treatment relationship with the Franciscan Life Center [“FLC”] began in March 2014, as it actually began in May 2013, and that this error warrants remand. (Pl.'s Mem. at 18-20). Specifically, the plaintiff argues that “application of the correct information would lead as a matter of law to finding the medical opinion entitled to more weight, ” which in turn “would lead to the determination that the [p]laintiff was disabled for the closed period of alleged disability.” (Pl.'s Mem. at 19-20). The defendant concedes that “the ALJ made a mistake when calculating the length of [the] [p]laintiff's treatment at the [FLC, ]” but avers that this error is harmless. (Def.'s Mem. at 6-7). The Court agrees with the defendant.

         “Where . . . an ALJ misreads a critical piece of evidence in the record, and then relies on his error in reaching [her] opinion, the opinion cannot be said to be supported by ‘substantial evidence.'” Joseph v. Astrue, No. 06-Civ-1356 (DCF), 2007 WL 5035942, at *5 (S.D.N.Y. Dec. 28, 2007), Magistrate Judge's Recommended Ruling approved and adopted, No. 06-Civ-1356 (RMB), 2008 WL 850158 (Mar. 20, 2008) (citing Maldonado v. Apfel, No. 98-Civ-9037 (AKH), 2000 WL 23208, at *3-4 (S.D.N.Y. Jan. 13, 2000)); see also McHugh v. Astrue, No. 11-CV-00578 (MAT), 2013 WL 4015093, at *9 (W.D.N.Y. Aug. 6, 2013). “Further, in some cases where the ALJ bases [her] decision on a misinterpretation of the evidence, remand may be warranted to afford the ALJ with an opportunity to re-evaluate the plaintiff's claim in light of what the evidence actually reveals.” Joseph, 2007 WL 5035942, at *5 (citing Lipsman v. Apfel, No. 98-Civ-0743 (HB), 1998 WL 409708, at *6-7 (S.D.N.Y. July 20, 1998)). See Malave v. Sullivan, 777 F.Supp. 247, 253 (S.D.N.Y. 1991) (explaining that, to the extent the ALJ's decision was based on a misreading of the evidence, the decision was “not supported by substantial evidence in the record”); see also Latour-Darch v. Colvin, 14-CV-3000 (SLT), 2017 WL 2964812, at *9 (E.D.N.Y. July 10, 2017) (same). Although remand based on the ALJ's misreading of the record may be appropriate in some cases, “courts in other instances have held the error to be harmless if the ultimate determination is nonetheless supported by substantial evidence.” Howarth v. Berryhill, No. 3:16-CV-1844 (JCH), 2017 WL 6527432, at *16 (D. Conn. Dec. 21, 2017) (citing Trombley v. Colvin, No. 8:15-CV-567 (TWD), 2016 WL 5394723, at *4 n.6 (N.D.N.Y. Sept. 27, 2016)); Coates v. Colvin, No. 5:12-CV-1340 (GLS), 2013 WL 3148222, at *4 (N.D.N.Y. June 19, 2013)).

         Here, the ALJ afforded “partial weight” to an assessment of the plaintiff that a therapist from the FLC completed in March 2014. (Tr. 23). The ALJ reasoned that

[t]he record does support mental health limitations consistent with simple, routine, repetitive work based on her impairments with mental status exams showing impaired judgment, depressed mood and constricted affect. However, the treatment record does not support any other restrictions based on the overall conservative treatment, and normal mental status exams in the closed period. In addition, the undersigned notes that this therapist had a relatively short treating relationship with the claimant, of three months in 2014, and thus she does not have the full picture of the claimant's longitudinal history. She also cannot speak to the majority of the requested closed period, as she was not treating the claimant from 2011 to 2013.

(Tr. 23). As noted above, the defendant concedes that the ALJ determined improperly that the treating relationship between the plaintiff and the FLC was only three months, and that the FLC treated the plaintiff from May 2013 to March 2014. (See Def.'s Mem. at 6-7).

         The Court concludes that a proper understanding of the length of the plaintiff's treating relationship with the FLC would not “lead to the conclusion that the [p]laintiff was disabled for the closed period of alleged disability” (Pl.'s Mem. at 19-20) and, therefore, that the error was harmless. The plaintiff's argument overlooks the fact that the length of the treating relationship was only one factor in the ALJ's decision to afford the FLC opinion partial weight. The ALJ concluded also that, although the record did “support mental health limitations consistent with simple, routine, repetitive work[, ]” it did “not support any other restrictions based on the overall conservative treatment, and normal mental status exams in the closed period.” (Tr. 23). Therefore, even with the knowledge that the plaintiff's treating relationship with the FLC was ten months instead of three months, the plaintiff remains faced with the ALJ's conclusion that the objective medical evidence in the record did not support many of the limitations to which the FLC opined.

         Substantial evidence supports the ALJ's conclusion that the record does not support many of the limitations provided in the FLC opinion. For instance, the FLC opined that the plaintiff had “an obvious problem” caring for her “physical needs (e.g. dressing, eating)” and personal hygiene on a daily basis (Tr. 1938); however, the FLC treatment notes in the record do not suggest “an obvious problem.” The FLC records provide several instances when the plaintiff appeared “well groomed.” (Tr. 2294, 2306-07, 2309-10). And although there was one instance in the FLC treatment records noting that the plaintiff looked “ill physically” (Tr. 2309), there are no treatment notes reflecting problems with the plaintiff's personal hygiene, dress, or eating routines. Moreover, the FLC opinion indicates that the plaintiff had a “very serious problem” with “[p]erforming work activity on a sustained basis (i.e, 8 h[ours] per day, 5 days per week)”; the FLC explained that “[d]ue to chronic pain an 8 [hours per day, 5 days per week job] would be very difficult [and] contribute more to the client's depression.” (Tr. 1939). The FLC records, however, do not indicate that the plaintiff ever complained of chronic pain or discomfort. In fact, the only time the FLC evaluated the plaintiff's musculoskeletal system, the treatment note reflects that the plaintiff had scoliosis, but that her “muscle strength and tone” and “gait and station” were normal. (Tr. 2294). Given the lack of support in the FLC's treatment records for the FLC opinion, the Court cannot conclude that a proper understanding of the length of the plaintiff's treating relationship at the FLC would result in the ALJ affording more weight to the FLC opinion and, ultimately, a finding of disability. Accordingly, the ALJ's misreading of the evidence was harmless error.

         2. THE RECORDS OF DR. KAPUR

         The plaintiff next argues that “[t]he ALJ['s] decision does not address limitations noted in the treatment records arising from the [p]laintiff's spinal fusion surgery[, ]” and that this “failure to account for impairments of the lumbosacral spine, and the recognition by Dr. Kapur that the impairment is not compatible with ‘driving, sleeping, sitting, [or] standing for long periods of time[, ]' is premised on an error of law, is harmful, and should be reversed.” (Pl.'s Mem. at 19- 20). The defendant responds that the “[p]laintiff's argument is nothing more than a transparent attempt to recast her own subjective statements as a medical source opinion, ” and that the ALJ's RFC determination accounts for Dr. Kapur's examination findings. (Def.'s Mem. at 10).

         In addressing the impairments that the plaintiff experienced in her lumbar spine, the ALJ explained that, “[i]n terms of the claimant's alleged degenerative disc disease, examinations in 2011, 2012 and 2014 showed moderate scoliosis and surgical scar, spasm and tenderness, [and] positive lumbar facet loading and straight leg raising.” (Tr. 19). The ALJ cited to records from Dr. Kapur, among others, to support her assertion. (See Tr. 19). The ALJ also cited to Dr. Kapur's treatment notes when stating that the plaintiff was prescribed physical therapy. (Tr. 19). The ALJ concluded that “the record shows the claimant was able to work after her surgery for scoliosis and had good activities of daily living such as hiking and biking. In order to account for her back pain, the undersigned limited the claimant to light work with occasional to frequent postural activities.” (Tr. 19).

         The ALJ did not, as the plaintiff asserts, ignore Dr. Kapur's notation that the plaintiff's “symptoms [were] worse with . . . driving, sleeping, sitting, [or] standing for long periods of time.” (Pl.'s Mem. at 20 (citing Tr. 1575)) (emphasis omitted). Instead, as the defendant points out, the full notation provides that “[t]he patient reports that her symptoms are worse especially with activities involving driving, sleeping, sitting, and standing for long periods of time, working, and weather changes.” (Tr. 1575; see also Def.'s Mem. at 10) (emphasis added). Accordingly, this notation from Dr. Kapur was referencing the plaintiff's subjective complaint of pain, not an objective medical finding. The notes from Dr. Kapur's physical examination from the same day reveal that he observed the plaintiff to have a “slightly antalgic” gait; that, although there were some difficulties, the plaintiff was able to walk on her tiptoes and heels; and that the plaintiff experienced “moderate tenderness” on palpation of certain muscles in her back. (Tr. 1576). Dr. Kapur noted also that a motor examination of the plaintiff “[r]evealed full strength in the upper extremities throughout[, ]” and that “the patient was noted to have 4 strength” in the lower extremities. (Tr. 1576). Dr. Kapur diagnosed the plaintiff with, inter alia, “myofascial pain with trigger points in the trapezius muscles bilaterally” and noted “clinical evidence for right L5 radiculopathy.” (Tr. 1576).

         Moreover, approximately one month later, Dr. Kapur noted that the plaintiff's symptoms were “more or less about the same” after four physical therapy sessions, and that her level of pain ranged “from 3-8 in severity.” (Tr. 1581). Following a neuromuscular examination, Dr. Kapur stated that the plaintiff's “gait [was] slightly antalgic[, ]” that her “lumbar range of motion [was] slightly limited in all directions[, ]”; and that the plaintiff “had difficulty toe and heel walking.” (Tr. 1581). A motor examination revealed that the plaintiff had “full strength throughout except for 4 strength on testing the right foot dorsiflexion, right EHL . . . muscle.” (Tr. 1581). Dr. Kapur concluded that the plaintiff should “continue with physical therapy sessions for her neck and the low back which appears to be helping to some extent.” (Tr. 1582). He added that “if the pain in the low back and right leg continues to persist, then a right L5 transforaminal epidural steroid injection can also be considered to help relieve her symptoms[, ]” and that the plaintiff “would like to consider an injection[.]” (Tr. 1582).

         Following an examination in March 2014, Dr. Kapur noted that the plaintiff's “gait is antalgic[, ]” and that her “lumbar range of motion is moderately limited [by] pain in all directions.” (Tr. 1967). He noted also that the plaintiff reported that “overall with therapy, she feels that she is getting stronger.” (Tr. 1967). In April 2014, the plaintiff stated “that when resting or sitting, her pain level is usually 2 to 3, but with standing, walking, or doing activities it can go up to 6 to 7.” (Tr. 1959). After a physical examination on the same day, Dr. Kapur indicated that the plaintiff's “gait appeared to be slightly antalgic”; that “she had difficulty toe and heel walking with right leg”; that her “lumbar range of motion [was] mild-to-moderately limited in all directions”; and that she was tender on palpation “over the right paralumbar area[.]” (Tr. 1959). Dr. Kapur included findings from an MRI that he had ordered, which showed, inter alia, that the plaintiff “appeare[d] to have slight impingement on the right L5 nerve root on the axial T2 sections.” (Tr. 1959). He noted also that the plaintiff was going to schedule an epidural steroid injection. (Tr. 1960).

         The ALJ's decision addresses adequately the objective findings and opinions of Dr. Kapur. The ALJ mentioned the positive exam findings and degenerative changes in her lumbar spine. (See Tr. 19). Also, in her RFC determination, the ALJ limited the plaintiff to less than light work, noting several postural limitations. (See Tr. 18). Although the ALJ did not explain every detail of Dr. Kapur's treatment records, it is apparent that she reached her decision based on a thorough review of the record before her. See Mongeur v. Heckler, 722 F.2d 1033, 1040 (2d Cir. 1983) (“When, as here, the evidence of record permits us to glean the rationale of an ALJ's decision, we do not require that [s]he have mentioned every item of testimony presented to him or have explained why [s]he considered particular evidence unpersuasive or insufficient to lead h[er] to a conclusion of disability.”).

         3. THE UNSIGNED MEDICAL ...


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