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Edmonds v. Saul

United States District Court, D. Connecticut

December 4, 2019




         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”] denying the plaintiff disability insurance benefits [“DIB”] and Supplemental Security Income [“SSI”].


         On October 7, 2013, the plaintiff filed applications for DIB and SSI, claiming she had been disabled since June 1, 2007, due to endometriosis, fibromyalgia, arthritis, COPD, high blood pressure, diabetes and a heart murmur. (Certified Transcript of Administrative Proceedings, dated December 6, 2018 [“Tr.”] 343-58, 271). The plaintiff's application was denied initially (Tr. 271-78) and upon reconsideration. (Tr. 283-89). On June 30, 2015, a hearing was held before Administrative Law Judge [“ALJ”] Eskunder Boyd, at which the plaintiff and a vocational expert testified. (Tr. 182-223). The plaintiff was represented by two attorneys at the hearing. (Id.). On September 14, 2015, the ALJ issued an unfavorable decision denying the plaintiff's claim for benefits. (Tr. 7-24). On November 3, 2015, the plaintiff filed a request for review of the hearing decision (Tr. 39), and on December 16, 2016, the Appeals Council denied the request, thereby rendering the ALJ's decision the final decision of the Commissioner. (Tr. 1-6).

         On August 17, 2018, the plaintiff filed her complaint in this pending action (Doc. No. 1), and on October 30, 2018, the defendant filed his answer and administrative transcript. (Doc. Nos. 22, 23). On December 5, 2018, the parties consented to the jurisdiction of a United States Magistrate Judge; the case was transferred to Magistrate Judge Donna F. Martinez. (Doc. No. 27). On December 6, 2018, the defendant filed an amended administrative transcript. (Doc. No. 28). The plaintiff filed her Motion for Judgment on the Pleadings on December 27, 2018, (Doc. No. 29), and brief in support. (Doc. No. 30 [“Pl.'s Mem.”]). On February 19, 2019, the defendant filed his Motion to Affirm (Doc. No. 31), and brief in support. (Doc. No. 31-1 [“Def.'s Mem.”]). The plaintiff filed a Reply to the defendant's Motion to Affirm on February 25, 2019. (Doc. No. 33). On October 10, 2019, this case was reassigned to this Magistrate Judge. (Doc. No. 34).

         For the reasons stated below, the plaintiff's Motion for Judgment on the Pleadings (Doc. No. 29) is denied, and the defendant's Motion to Affirm (Doc. No. 31) is granted.



         As of the date of her hearing in 2015, the plaintiff was forty-four years old, living with her husband, two sons, sister, and her sister's children in a first-floor apartment in Danbury, CT. (Tr. 189). Her average weight was 196 pounds. (Tr. 190). The plaintiff testified that she used a prescribed cane to “keep [her] stable” and “help[] her [] walk.” (Id.). At the time of the hearing, she had been using the cane for “about a year and a half.” (Id.).

         The plaintiff's last job was as a substitute teacher's aide. (Tr. 192). For that job, which she held in 2013, she worked “about 20” hours per week. (Id.). Her last full-time position was in 2012, at which time she worked as a “teacher's aide, and also a gas station clerk.” (Id.). Her normal day, at the time of the hearing, consisted of staying in the house unless she had a doctor's appointment. (Tr. 195). She testified that she could manage her own money, keep a bank account, and pay her bills. (Tr. 191-92). She could groom and bathe herself, although she had difficulty standing in the shower. (Tr. 193). She also tried to perform household chores, such as washing dishes and cooking, but she could only stand for “about two minutes.” (Tr. 193-94). She testified that she wears glasses, but that they did not help with her vision. (Tr. 191). According to the plaintiff, she was in the process of scheduling cataract surgery. (Tr. 205). She was able to see street signs but not the print on a newspaper. (Tr. 190-91). The plaintiff testified that she only drove “maybe about ten miles” a week, (Tr. 194), and could be “behind the wheel” no longer than thirty minutes at a time. (Tr. 195). The plaintiff's sister accompanied her to the grocery store. (Id.). She would remain in the “mobile cart” while her sister pushed the cart of groceries. (Id.).

         According to the plaintiff, she was disabled due to diabetes, neuropathy, and fibromyalgia. (Tr. 196). She testified that her medications made her very tired, and that “everything” aggravated her pain. (Id.). She rated an average day's pain as a nine out of ten, or an eight out of ten with medication. (Tr. 197). The plaintiff testified that she could not sit for a long time, could not stand for a long time, could not walk for a long time without getting shortness of breath, and could not lift. (Id.). She testified that, “on a good day, ” she could lift “maybe a pound, ” (Tr. 200), and that she could carry “maybe about five pounds.” (Tr. 201). She testified that she could not carry a half gallon of milk from the cooler in the grocery store to the cashier. (Id.). According to the plaintiff, she could walk one city block before getting short of breath. (Id.). She could stand for only two minutes at a time and could sit for “maybe twenty minutes” at a time. (Tr. 202). After sitting for twenty minutes, she would have to lay down, and when laying down, would have to wait for fifteen minutes before adjusting her position. (Id.). The plaintiff could not bend over to touch her toes, but she could bend over to touch her knees. (Id.). She could not squat. (Tr. 203). She could climb stairs or ramps with the help of a guardrail. (Id.). She could reach her arms over her head and directly in front of her, as well as use her fingers for both smaller things, i.e., buttons, zippers, and larger things, i.e., an orange. (Id.). She could not shuffle and deal a deck of cards. (Id.). The plaintiff also testified that temperatures, both hot and cold, aggravated her symptoms, as did humidity and rain. (Tr. 203-04). She was also sensitive to odors, fumes and dusts. (Tr. 204).

         A vocational expert (“VE”) testified at the plaintiff's hearing that the plaintiff's past work as a customer service representative in a call center corresponded with a “hybrid” of both order clerk and telephone solicitor, occupations performed at the sedentary exertional level, (Tr. 213), and that her past work as a teacher's aide corresponded with teacher aide II, an occupation typically performed at the light exertional level but performed at the medium exertional level as reported by the plaintiff. (Tr. 214). The ALJ then asked the VE to assume the following hypothetical individual: an individual of the plaintiff's age, education, and vocational background, limited to performing light work, but with limits of standing and walking for two to four hours and sitting for up to six hours. (Id.). Such individual would also require an option where she would be able to sit for thirty minutes, alternate to a standing position for five minutes, and then resume sitting. (Id.). Such individual would have the additional limitations of never climbing ladders, ropes, or scaffolds, never kneeling or crawling, occasionally climbing stairs and ramps, and occasionally balancing, stooping and crouching. (Tr. 215). She could frequently handle and finger, but could not work with exposure to temperature extremes, humidity or wetness. (Id.).

         In response to questioning, the VE testified that the hypothetical individual described above could perform the plaintiff's past work in the call center. (Id.). The ALJ then asked the VE whether the hypothetical individual, if she required a cane for ambulation, could perform the plaintiff's past work. (Id.). The VE again testified that such an individual could perform the plaintiff's past work in the call center. (Id.). For the next hypothetical, the ALJ kept all the limitations described above, but instead of light work, limited the hypothetical individual to sedentary work. (Id.). The VE testified that such an individual could perform the plaintiff's past work in the call center. (Tr. 216). However, if the hypothetical individual, limited to sedentary work, with all the other limitations described above, could only occasionally handle and finger, that individual could not perform the plaintiff's past work or other jobs in the national economy. (Tr. 216-17). Similarly, the VE testified that if the hypothetical individual had to alternate to a reclining position for fifteen minutes after thirty minutes of sitting, the individual could not perform the plaintiff's past relevant work or any other jobs in the national economy. (Tr. 216). Finally, the ALJ asked the VE whether an individual limited to frequent close visual acuity and occasional far visual acuity would be able to perform the plaintiff's past work in the call center. (Tr. 219). The VE answered in the affirmative. (Tr. 220). The VE testified, however, that, if the individual was limited to occasional close visual acuity and occasional far visual acuity, his “understanding . . . is that your near acuity is going to be required at least on a frequent level.” (Tr. 221).


         The Court presumes the parties' familiarity with the plaintiff's medical history, which is discussed in the parties' Joint Statement of Facts. (Doc. No. 30-1). 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.

         The record reflects that the plaintiff frequently visited the Danbury Hospital Emergency Room (“ER”) and the Seifert & Ford Family Community Health Center, which appears to be affiliated with Danbury Hospital. The first medical record is from the plaintiff's visit to the ER on March 23, 2007. (Tr. 494). Treatment notes indicate that she presented “very lethargic” with a history of uncontrolled diabetes. (Id.). Her glucose level was 460. (Tr. 496). Over the next three years, the plaintiff presented at the Danbury Hospital ER on multiple occasions, complaining of abdominal pain, (Tr. 502, 523), pain under her left arm and right groin, (Tr. 515), and a yeast infection and cold. (Tr. 549). Her next visit related to her alleged impairments appears to have been on February 2, 2011, at which time she presented with low blood sugar, blurred vision, tingling fingers, headache, neck pain, abdominal pain and nausea. (Tr. 559). Treatment notes reflect that her chief complaint was abdominal pain. (Tr. 561).

         The plaintiff thereafter returned to the ER for various treatments. She was treated for eye redness in April 2011, (Tr. 571), underwent an endoscopy in May 2011, (Tr. 577), received a gynecological ultrasound in June 2011, (Tr. 580), was treated for chest pain in August 2011, (Tr. 587, 597), and was treated for a benign laryngeal cyst in September and November 2011. (Tr. 612, 703). At her visit to the Seifert & Ford Family Community Health Center on November 4, 2011, the plaintiff did not have any chest or abdominal pain. (Tr. 705). Treatment notes reflect that she had not been compliant with her diabetes medication. (Id.). Due to her complaints of continuing chest pain, the plaintiff had a coronary angiography and LV angiography in January 2012. (Tr. 614). She returned to the Seifert & Ford Family Community Health Center in March 2012 due to chest, knee, abdominal, and pelvic pain. (Tr. 709-10).

         In April and May 2012, the plaintiff went to the ER with complaints of head congestion, (Tr. 618), swelling of her hands and feet, and a sore throat, which she believed might be coxsackie disease. (Tr. 626-27). Treatment notes from the plaintiff's May 21, 2012 visit to Seifert & Ford Family Community Health Center indicate that the plaintiff's fibromyalgia had improved but her diabetes remained uncontrolled. (Tr. 716 (“Poor DM controlled”)).

         The remainder of the plaintiff's medical records from 2012 are for other conditions. In May 2012, the plaintiff had a colonoscopy. (Tr. 635). In July 2012, she twice went to the ER with complaints of chest pain, (Tr. 638, 649), and she had an x-ray, which revealed no evidence of active cardiopulmonary disease. (Tr. 654). In August 2012, she presented to Dr. Jason Gajraj with complaints of a headache and neck ache. (Tr. 753). At that appointment, treatment notes indicate her history of being “fatigued with prolonged activities.” (Tr. 754). In August 2012, she complained of an abscess and chest pressure. (Tr. 666). In September 2012, she reported (and was treated) for a sinus infection, congestion, and chest pain. (Tr. 724). Finally, in October 2012, she again indicated she was experiencing chest pain. (Tr. 728). Treatment notes reflect a diagnosis that the chests pains were likely musculoskeletal and a referral for physical therapy. (Tr. 730).

         After the medical records from October 2012, there is a gap in the plaintiff's treatment until a visit to the Danbury Hospital ER on September 17, 2013. (Tr. 733). At that appointment, the plaintiff presented for evaluation and treatment of “generalized point tenderness over her cervical spine, lumbar spine, knees and ankles.” (Tr. 733-34). Treatment notes indicate her history of fibromyalgia and that she had been maintained on Cymbalta, but that she had not been on that medication for one year after moving to South Carolina in October 2012. (Tr. 734).[2] The treatment notes also reflect that the plaintiff had been off her diabetes and anti-hypertensive medications except for Lisinopril for the past year. (Tr. 734). Dr. Jason Gajraj prescribed medication. (Tr. 735).

         At an endocrine consultation for the plaintiff's diabetes with Dr. Guillermo Pons, M.D., on September 30, 2013, the plaintiff complained of foot pain while walking. (Tr. 487). Treatment notes reflect that the plaintiff “is afraid of needles and is reluctant to start on insulin.” (Id.). The plaintiff had blurred vision but no dryness, no neck pain, no chest pain, no back pain, no muscle weakness, no muscle aches, no headache, no tremors, no numbness, and no burning sensation. (Id.). An examination revealed that she had normal muscle strength and no arthropathy. (Tr. 489). Her “[feet were] onychomycosis, but not swollen, not tender, not erythematous” and had “no ulcerations.” (Id.). A “sensory exam [for both feet] showed normal vibratory sensation at the level of the toes and normal position sense at the level of the toes.” (Id.). The plaintiff's motor exam was also normal, with normal deep tendon reflexes and no tremors. (Id.). Dr. Pons noted that “leg pain is unusual in a patient who does not exhibit any signs of peripheral neuropathy”; “[i]n fact there is no evidence to suggest pseudo claudication syndrome.” (Tr. 490).

         That same day, the plaintiff presented at the Danbury Hospital ER complaining of chest pain, beginning in her left chest area and radiating to her left arm. (Tr. 695). On examination, the plaintiff had no myalgia, muscle weakness, joint pain, back pain, or abdominal pain. (Tr. 697). She had a regular heart rate and rhythm, no murmurs, positive reproducible tenderness to her left mid to lower sternal border, and no edema in her bilateral lower extremities. (Tr. 697, 701).

         Approximately one week later, the plaintiff saw Dr. Gajraj for her diabetes. (Tr. 743-44). Treatment notes reflect that the plaintiff has a severe phobia of needles and had not taken the Lantus Solostar, an insulin pen, prescribed to her. (Id.). Dr. Gajraj recommended that the plaintiff try using the Novolog Flexpen, a different insulin pen; the Diabetes Education department also recommended alternative medications, but the record does not reflect whether their recommendations also required needles. (Tr. 744). Treatment notes indicate that the plaintiff had generalized body aches related to fibromyalgia that had improved with use of Robaxin. (Tr. 744). The plaintiff returned to Dr. Gajraj on October 22, 2013, complaining of bilateral leg, knee, and ankle pain. (Tr. 738-39). Treatment notes indicate her history of fibromyalgia, which had been maintained on Cymbalta; the plaintiff discontinued her use of Robaxin due to drowsiness. (Tr. 738). As to the plaintiff's diabetes, her cousin had been administering her Novolog Flexpen twice daily. (Tr. 739). The plaintiff rated her pain level at ten out of ten; her hips, ankles, knees and feet were tender upon examination. (Tr. 740).

         On November 12, 2013, the plaintiff presented to Dr. Gajraj with bilateral lower extremity pain, numbness and tingling. (Tr. 133-34). The plaintiff reported decreased sensation of both feet. (Id.). Treatment notes indicate that the plaintiff had issues administering insulin due to needle phobia but did well with a trial of Auto Shield pen needles. (Tr. 134). Because those needles were not covered by the plaintiff's insurance, however, the physician recommended that the plaintiff start back on Lantus Solostar. (Tr. 135). The plaintiff returned to the ER on December 3, 2013, for weakness, (Tr. 865), and again on December 30, 2013, for severe pain and buckling of her right knee. (Tr. 100). An x-ray revealed “mild mexlial tibiofemoral joint narrowing.” (Id.).

         Throughout 2014, the plaintiff continued to visit the Danbury Hospital ER and Seifert & Ford Community Health Center. On January 30, 2014, the plaintiff reported bilateral knee pain, which radiated to her right calf and ankle; she rated her pain as a ten out of ten. (Tr. 108-09). Treatment notes reflect that the plaintiff reported she was still able to walk independently but had to change position “all the time.” (Tr. 108). The pain interfered with her sleep, was worse with movement, and was mildly relieved with rest. (Id.). On examination, the “appearance” of the plaintiff's knees was normal, with no swelling or warmth. (Tr. 109). The plaintiff's knees were tender upon palpation, and her range of motion was restricted, though “hard to tell as the patient ...

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