Ortiz v. Commissioner of Social Security

          RULING ON THE PLAINTIFF'S MOTION TO REVERSE THE DECISION OF THE COMMISSIONER, OR IN THE ALTERNATIVE, MOTION FOR REMAND FOR A HEARING, AND ON THE DEFENDANT'S MOTION FOR AN ORDER AFFIRMING 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”] denying the plaintiff disability insurance benefits [“SSDI”] and supplemental security income benefits [“SSI”].

         I. ADMINISTRATIVE PROCEEDINGS

         On October 27, 2015, the plaintiff filed applications for SSDI and SSI, claiming that he had been disabled since October 23, 2013, due herniated discs and diabetes. (See Certified Transcript of Administrative Proceedings, dated February 6, 2019 [“Tr.”] 293-310, 341). The plaintiff's applications were denied initially and upon reconsideration. (Tr. 129-30, 151-52). On July 11, 2017, a hearing was held before Administrative Law Judge [“ALJ”] Eskunder Boyd at which the plaintiff and a vocational expert testified. (Tr. 79-114). On August 10, 2017, the ALJ entered a partially favorable decision finding that the plaintiff had performed substantial gainful activity until January 1, 2015 but was disabled from that date through the date of his decision. (Tr. 153-65). On October 6, 2017, the Appeals Council issued its Notice of Appeals Council Action (Tr. 229-37), and on March 23, 2018, the Appeals Council remanded the case back to the ALJ. (Tr. 170-76). The ALJ held a second hearing on August 6, 2018, at which the plaintiff and another vocational expert testified. (Tr. 34-78). On August 22, 2018, the ALJ issued an unfavorable decision denying the plaintiff's claim for benefits. (Tr. 7-20). The plaintiff filed a request for review of the hearing decision (Tr. 290-92), and on October 10, 2018, the Appeals Council denied the request, thereby rendering the ALJ's decision the final decision of the Commissioner. (Tr. 1-5).

         On December 6, 2018, the plaintiff filed his complaint in this pending action (Doc. No. 1), and on February 7, 2019, the defendant filed a certified copy of the Administrative Record. (Doc. No. 15). On March 6, 2019, the parties consented to the jurisdiction of a United States Magistrate Judge, and the case was transferred accordingly. (Doc. No. 18). On April 8, 2019, the plaintiff filed his Motion to Reverse the Decision of the Commissioner (Doc. No. 19), with brief (Doc. No. 19-1 [“Pl.'s Mem.”]), and Statement of Material Facts (Doc. No. 21; see Doc. No. 20) in support. On June 7, 2019, the defendant filed his Motion to Affirm (Doc. No. 22), with brief (Doc. No. 22-1 [“Def.'s Mem.”]) and a Statement of Material Facts (Doc. No. 22-2) in support. On June 21, 2019, the plaintiff filed a reply brief. (Doc. No. 23).

         For the reasons stated below, the plaintiff's Motion to Reverse the Decision of the Commissioner (Doc. No. 19) is GRANTED such that this case is remanded consistent with this Ruling, and the defendant's Motion to Affirm (Doc. No. 22) is DENIED.

         II. FACTUAL BACKGROUND

         The Court presumes the parties' familiarity with the plaintiff's medical and work history, which is thoroughly discussed in the parties' Statement of Facts. (Doc. Nos. 21, 22-2). The Court cites only to the portions of the record that are necessary to explain this ruling.

         III. THE ALJ'S DECISION

         Following the five-step evaluation process, ^[1] the ALJ found that the plaintiff met the insured status requirements through December 31, 2019 (Tr. 13) and has not engaged in substantial gainful activity since October 23, 2013, the alleged onset date. (Tr. 13, citing 20 C.F.R. §§ 404.1571 et seq. and 416.971 et seq.).

         At step two, the ALJ found that the plaintiff had the following severe impairments: plantar fasciitis, chronic right knee instability, multilevel degenerative disc disease, diabetes, and peripheral neuropathy (Tr. 13, citing 20 C.F.R. §§ 404.1520(c) and 416.920(c)), but the plaintiff did not have an impairment or 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. 13-14, citing 20 C.F.R. §§ 404.1520(d), 404.1525, 416.920(d), 416.925 and 416.926).

         The ALJ concluded 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 he could stand/walk up to four hours total and sit for six hours; he required a sit-stand option wherein he could sit for 30 minutes, alternate to a standing position for five minutes, and then resume sitting; and he could not use his lower extremities to operate foot controls and should never climb ladders, ropes, scaffolds, or stairs. (Tr. 14-18). Additionally, he could occasionally climb ramps, balance, stoop, and crouch and should never kneel or crawl. (Id.). He could frequently handle and finger and should not work in exposure to temperature extremes or wetness. (Id.). Additionally, the plaintiff required the use of a cane for ambulation. (Id.).

         At step four, the ALJ concluded that the plaintiff was unable to perform any of his past relevant work (Tr. 18, citing 20 C.F.R. §§ 404.1565 and 416.965), but he retained the RFC to perform other work. (Tr. 30, citing 20 C.F.R. §§ 404.1569, 404.1569(a), 416.969 and 416.969(a)). The ALJ considered the vocational expert's testimony that a person with the RFC adopted by the ALJ could have performed the work of a “[p]arking [l]ot [a]ttendant[, ]” “[t]icket [s]eller [, ]” and “[p]hotocopy [m]achine[]” operator. (Tr. 19). Accordingly, the ALJ concluded that the plaintiff was not under a disability at any time from October 23, 2013, through the date of his decision. (Tr. 31, 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. 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) (citation & internal quotation 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.” 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. 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

         The plaintiff argues that the ALJ's RFC finding was unsupported by substantial evidence because he failed to analyze properly Dr. Seely's opinion evidence in accordance with the Regulations. (Pl.'s Mem. at 3-8; Doc. No. 23, at 1-2). Similarly, the plaintiff claims that the ALJ's RFC finding failed to consider adequately the symptoms of the plaintiff's diabetes and neuropathy, which the ALJ concluded were severe impairments. (Pl.'s Mem. at 8-10). Finally, the plaintiff maintains that, in formulating the RFC, the ALJ failed to develop the record as ordered by the Appeals Council. (Pl.'s Mem. at 10-12).

         Addressing the plaintiff's last argument first, the Court agrees and concludes that the ALJ failed to comply with the Appeals Council's remand order to develop the record. This error was compounded by the ALJ's improper treatment and analysis of Dr. Seely's opinion. As a result, a remand is required.

         A. THE ALJ FAILED TO COMPLY WITH THE APPEALS COUNCIL'S REMAND ORDER AND FAILED TO DEVELOP THE RECORD

         On March 23, 2018, the Appeals Council issued its notice remanding the case to the ALJ [“Remand Order”]. (Tr. 170-76). In the Remand Order, the Appeals Council concluded that “[s]ubstantial evidence does not support the [ALJ]'s [RFC] for the entire period at issue, particularly the standing, walking, and postural limitation.” (Tr. 173). In reaching this conclusion, the Appeals Council noted that, “[i]n support of the [RFC] finding in this case, the [ALJ] gave weight to the medical source opinions of James Seely, M.D., ” but such statements did “not represent his own opinion about [the plaintiff's] work-related abilities[, ]” but rather, were based on the plaintiff's “own reports about what [he could] do.” (Tr. 173). ...