Shapleigh v. Saul

          RULING AND ORDER

          Robert N. Chatigny, United States District Judge

         Norma Shapleigh appeals the denial of her applications for disability insurance benefits and supplemental security income benefits by the Commissioner of the Social Security Administration (“Commissioner”).^[1] Plaintiff moves for an order reversing the decision or, in the alternative, remanding the case for further proceedings. The Commissioner, in turn, has moved for an order affirming the decision. The principal issue on appeal is whether the ALJ correctly discounted the weight to be given the opinion of a treating physician. I agree with the plaintiff that a remand is necessary to ensure compliance with the treating physician rule.

         I. Background

         On August 5, 2014, plaintiff filed an application for disability benefits claiming she had been disabled for about two months.^[2] A disability adjudicator denied plaintiff's request for disability benefits and thereafter denied a request for reconsideration. On March 30, 2016, plaintiff appeared with counsel for a hearing before an ALJ. Several weeks later, the ALJ issued a decision denying benefits. The appeals council denied plaintiff's request for review of the decision. This appeal followed.

         I assume the parties' familiarity with the facts and therefore provide only a brief summary.

         At the hearing before the ALJ, plaintiff testified that severe pain restricts her ability to work because she cannot stand, sit, or crouch for very long. She described experiencing pain resulting from reaching and manipulating small items. She acknowledged being able to engage in daily activities of self- care and manipulate small objects like buttons, zippers, fruit and cigarettes.

         Plaintiff first complained of significant neck and lower back pain after a rear-end motor vehicle collision in July 2009. She was eventually seen by Dr. Cloutier, a family practitioner, and reported a continuing history of chronic back pain. Dr. Cloutier began treating plaintiff in March 2014 and was continuing to treat her at the time of the hearing in March 2016.

         Dr. Cloutier's treatment notes indicate that plaintiff had scoliosis and chronic back pain, as well as a relatively mild neck injury that was expected to improve. The notes show that she had a normal range of motion and no weakness. Between November 2014 and January 2016, plaintiff was seen by other treatment providers for chronic back pain, scoliosis and carpal tunnel symptoms.

         Dr. Cloutier has completed several medical source statements. The first, dated March 16, 2015, states that plaintiff was limited to lifting no more than ten pounds, standing or walking for up to two hours per day, and sitting for up to two hours per day, and that she was to avoid repetitive pushing/pulling and bilateral rotation of the hands, as well as repetitive bending, climbing, carrying, pushing, pulling, and overhead reaching. The other source statements completed by Dr. Cloutier describe similar limitations. For instance, a statement dated January 7, 2016, described plaintiff as limited to twenty minutes of sitting during a work day.

         On September 19, 2014, a consultative examination was performed by Herbert Reiher, MD. He noted that plaintiff experienced back and neck pain. However, he placed significantly less restrictive conditions on her ability to work. He found that she could sit, walk and stand for six hours and frequently lift fifteen pounds. Two state-agency medical consultants also submitted findings based on their review of the record, which are generally consistent with Dr. Reiher's findings.

         II. Legal Standard

         “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 findings of the Commissioner of Social Security as to any fact, if supported by substantial evidence, [are] conclusive . . . .” 42 U.S.C. § 405(g). Accordingly, the court may not make a de novo determination of whether a plaintiff is disabled in reviewing a denial of disability benefits. Id.; 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, and whether the decision is supported by substantial evidence. Johnson v. Bowen, 817 F.2d 983, 985 (2d Cir. 1987); Berry v. Schweiker, 675 F.2d 464, 467 (2d Cir. 1982). Substantial evidence means “‘such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.'” Williams v. Bowen, 859 F.2d 255, 258 (2d Cir. 1988) (quoting Richardson v. Perales, 402 U.S. 389, 401 (1971)). Substantial evidence must be “more than a mere scintilla or a touch of proof here and there in the record.” Id.

         The Social Security Act establishes that benefits are payable to individuals who have a disability. 42 U.S.C. § 423(a)(1). “The term ‘disability' means . . . [an] inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment . . . .” 42 U.S.C. § 423(d)(1). In order to determine whether a claimant is disabled within the meaning of the Social Security Act, the ALJ must follow a five-step evaluation process as promulgated by the Commissioner.^[3]

         In order to be considered disabled, an individual's impairment must be “of such severity that [s]he is not only unable to do h[er] previous work but cannot . . . engage in any other kind of substantial gainful work which exists in the national economy.” 42 U.S.C. § 423(d)(2)(A). “[W]ork which exists in the national economy means work which exists in significant ...