Caruso v. Saul

          RULING ON THE PLAINTIFF'S MOTION TO REVERSE THE DECISION OF THE COMMISSIONER 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 disability insurance benefits [“DIB”].

         I. ADMINISTRATIVE PROCEEDINGS

         The plaintiff filed her application for DIB on February 4, 2015, claiming that she has been disabled since January 26, 2015, due to major depressive disorder, anxiety, asthma, sleep apnea and chronic neck, back and shoulder pain. (Certified Transcript of Administrative Proceedings, dated January 11, 2019 [“Tr.”] 89-99, 195-198).^[2] The plaintiff's application was denied initially (Tr. 89-99), and upon reconsideration. (Tr. 101-115). On March 28, 2016, the plaintiff requested a hearing before an Administrative Law Judge [“ALJ”] (Tr. 131-132), and on October 3, 2017, a hearing was held in Hartford, Connecticut before ALJ Alexander P. Borré, at which the plaintiff and a vocational expert testified. (Tr. 45-74). The ALJ subsequently issued an unfavorable decision on December 6, 2017, denying the plaintiff's claims for benefits. (Tr. 25-44). The plaintiff appealed to the Appeals Council, which, on November 19, 2018, denied the plaintiff's request for review, rendering the ALJ's decision the final decision of the Commissioner. (Tr. 1-5).

         On November 26, 2018, the plaintiff filed her complaint in this pending action (Doc. No. 1).^[3] The parties consented to the jurisdiction of a United States Magistrate Judge on November 28, 2018, and this case was transferred to the undersigned. (Doc. No. 9). On February 11, 2019, the defendant filed his answer and administrative transcript, dated January 11, 2019. (Doc. No. 11). On April 5, 2019, the plaintiff filed her Motion to Reverse the Decision of the Commissioner (Doc. No. 13), with a Statement of Facts (Doc. No. 13-1), and brief in support (Doc. No. 13-2 [“Pl.'s Mem.”).^[4] On July 15, 2019, the defendant filed his Motion to Affirm (Doc. No. 17), with a Statement of Material Facts (Doc. No. 17-2), and brief in support. (Doc. No. 17-1).

         For the reasons stated below, the plaintiff's Motion to Reverse the Decision of the Commissioner (Doc. No. 13) is GRANTED, and the defendant's Motion to Affirm the Decision of the Commission (Doc. No. 17) is DENIED.

         II. FACTUAL BACKGROUND

         The Court presumes the parties' familiarity with the plaintiff's medical history, which is discussed in the plaintiff's Statement of Facts (Doc. No. 13-1) and the defendant's Statement of Material Facts. (Doc. No. 17-2). Though the Court has reviewed the entirety of the medical record, it cites only the portions of the record that are necessary to explain this decision.

         At the plaintiff's October 3, 2017 hearing, the plaintiff was fifty-eight years old (Tr. 49), and during the relevant period at issue, she lived with her adult son and a roommate in a house in Meriden, Connecticut. (Tr. 49-51). She graduated high school but did not complete any additional education or vocational training. (Tr. 52).

         From 1977 to 2009, the plaintiff worked for Blue Cross Blue Shield in enrollment and billing. (Tr. 52-53). In 2011, she was employed as the office manager for Comprehensive Orthopedics. (Tr. 53-54). In 2014, she worked at the Middletown DSS office (a job she obtained through the staffing agency Hallmark Total Tech) in a “filing position.” (Tr. 54). The plaintiff testified that she had problems completing her tasks at the Middletown DSS office because it involved “so much up and down and pulling out files” and hurt her back and neck. (Tr. 55). She would “go in [her] car [and] turn on [her] heated seat to be a heating pad.” (Id.). She had to carry a 10-pound file box for that position. (Id.). She testified that, although she did not leave that job because of her back and neck problems, she could not have kept doing it. (Tr. 56).

         The plaintiff also testified that she was able to drive but did not “drive far.” (Tr. 51). She explained that she could drive for approximately 45 minutes before her lower back began to hurt. (Tr. 52). She tried to walk “every day just a little.” She explained that she was able to walk the length of eight houses and back, and that it took her less than ten minutes to do so, but she needed to rest afterwards. (Tr. 59-60). She noted that she needed to “to walk on level ground.” (Tr. 59). The plaintiff estimated that she could lift twelve pounds, an estimate based on the fact that she was able to pick up her lighter grandchildren. (Tr. 60). Additionally, the plaintiff's ability to concentrate and focus “changed drastically.” (Tr. 61). She had “lists for everything” to “try to keep on top of things.” (Id.). She did not like going out in crowds, and she would order groceries online because it was “hard for [her] to grocery shop.” (Tr. 62). She testified that she completed one chore a day and “focus[ed] on setting [her] alarm [for] 9:00.” (Tr. 63). She did, however, “try to go out to dinner once a month” and sometimes watched her grandkids. (Tr. 64). She had panic attacks once every four months and issues with her sons triggered her anxiety. (Tr. 67).

         A vocational expert testified that the plaintiff's past work as an office manager and enrollment clerk were both semi-skilled jobs performed at the sedentary level. (Tr. 70). The plaintiff's past work as a file clerk was a semi-skilled job performed at the light exertional level. (Id.). All three of the plaintiff's past jobs could be performed by a person limited to the light exertional level who could frequently climb ladders, ropes, and scaffolds, stoop, kneel, crouch, and crawl, and who was further limited to only occasional exposure to temperature extremes and extreme humidity and no concentrated exposure to fumes, dust, or gases. (Id.). If such a person was further limited to simple and repetitive tasks, those additional limitations would “eliminate” the plaintiff's past three jobs. (Tr. 71). Similarly, according to the vocational expert, if such a person were “off-task 15 percent of the workday due to symptoms of either back pain or anxiety-type symptoms [that] would cause that individual to leave the work area, ” such a person would not be employable at “any exertional level.” (Id.).

         III. THE ALJ'S DECISION

         Following the five-step evaluation process, ^[5] the ALJ found that the plaintiff met the insured status requirements through December 31, 2018, (Tr. 30), and that the plaintiff had not engaged in substantial gainful activity since January 26, 2015, her alleged onset date. (Tr. 31, citing 20 C.F.R. § 404.1571 et seq.).

         At step two, the ALJ concluded that the plaintiff had the severe impairments of cervical spine and lumbar spine degenerative disc disease and asthma, (Tr. 31, citing 20 C.F.R. § 404.1520(c)), but that the plaintiff did not have an impairment or combination of impairments that met or medically equaled the severity of a listed impairment in 20 C.F.R. Part 404, Subpart P, Appendix 1. (Tr. 32-33, citing 20 C.F.R. §§ 404.1520(d), 404.1525 and 404.1526). Specifically, the ALJ concluded that the plaintiff's spinal conditions did not meet Listing 1.04 (Disorders of the Spine), and that the plaintiff's asthma did not meet Listing 3.02 (Chronic Respiratory Disorders) or Listing 3.03 (Asthma). (Tr. 32-33). The ALJ also found that the plaintiff's mental impairments, as well as the plaintiff's obstructive sleep apnea, were non-severe. (Tr. 31-22).

         At step three, the ALJ found that, “[a]fter careful consideration of the entire record, ” the plaintiff had the residual functional capacity [“RFC”] to perform light work, as defined in 20 C.F.R. § 404.1567(b), except she could frequently climb ramps and stairs and occasionally climb ladders, ropes, and scaffolds. (Tr. 33). The ALJ stated that the plaintiff could occasionally stoop, kneel, crouch, and crawl; she could occasionally be exposed to temperature extremes and extreme humidity; and, she could have no concentrated exposure to dust, gases, or fumes. (Id.).

         The ALJ concluded that the plaintiff was capable of performing her past relevant work as a clerk, secretary, and file clerk. (Tr. 38, citing 20 C.F.R. § 404.1565). Accordingly, the ALJ found that the plaintiff was not under a disability at any time from January 26, 2015, the alleged onset date, through December 6, 2017, the date of the ALJ's decision. (Tr. 39).

         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. Second, the court must decide whether the determination is supported by substantial evidence. See Balsamo v. Chater, 142 F.3d 75, 79 (2d Cir. 1998) (citation omitted). 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) (internal quotation marks & citation 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.” Gonzalez v. Apfel, 23 F.Supp.2d 179, 189 (D. Conn. 1998) (citing Rodriguez v. Califano, 431 F.Supp. 421, 423 (S.D.N.Y. 1977)). 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. Further, 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

         The plaintiff contends that the ALJ erred in five respects. First, the plaintiff argues that the ALJ failed to develop the record by not contacting Drs. Lorenzo Galante, Alessandra Buonopane, and/or the treating clinicians at Perspective Center for Care [“PCC”] to obtain medical source statements, and, in the case of PCC, treatment notes and records. (Pl.'s Mem. at 1-9). Second, the plaintiff argues that the ALJ was not properly appointed and thus lacked authority to hear and decide the plaintiff's claim. (Id. at 9-12). Third, the plaintiff argues that the ALJ erred at step four, in that the RFC determination was not supported by substantial evidence. (Id. at 13-18). Fourth, the plaintiff argues that the ALJ failed to assess properly the plaintiff's complaints of pain. (Id. at 18-20). Lastly, the plaintiff argues that the ALJ “[m]isconstrued the [e]vidence.” (Id. at 20-24).

         Whether an ALJ has satisfied his obligation to develop the record “must be addressed as a threshold issue.” Downes v. Colvin, No. 14-CV-7147 (JLC), 2015 WL 4481088, at *12 (S.D.N.Y. July 22, 2015). “Even if the ALJ's decision might otherwise be supported by substantial evidence, the Court cannot reach this conclusion where the decision was based on an incomplete record.” Moreau v. Berryhill, No. 17-CV-396 (JCH), 2018 WL 1316197, at *4 (D. Conn. Mar. 14, 2018). Upon a thorough review of the administrative record, the Court concludes that the ALJ failed to adequately develop the record to include treating physician opinions as to the plaintiff's physical and mental functional limitations, as well as the plaintiff's treatment records from PCC. See Rosa v. Callahan, 168 F.3d 72, 80 (2d Cir. 1999) (holding that an ALJ's failure to “fulfill his affirmative obligation to develop the administrative record” constitutes legal error).

         A. THE ALJ DID NOT SATISFY HIS DUTY TO DEVELOP THE RECORD AS TO THE ...