MEMORANDUM DECISION & ORDER
KATHERINE B. FORREST, District Judge.
Plaintiff Merys Urena seeks review, pursuant to 42 U.S.C. § 405(g), of the decision by defendant Commissioner of Social Security ("Commissioner"), finding that she was not disabled and not entitled to Disability Insurance Benefits under Title II of the Social Security Act and Supplemental Security Income benefits under Title XVI of the Social Security Act. The parties have filed cross-motions for judgment on the pleadings. Plaintiff argues that the Commissioner made several errors in her decision and requests that the decision be reversed and plaintiff's claim be remanded for an award and calculation of benefits or, in the alternative, for further proceedings. The Commissioner opposes, arguing that the decision was legally correct and supported by substantial evidence.
For the reasons set forth below, the Court GRANTS plaintiff Urena's motion for judgment on the pleadings and DENIES the Commissioner's cross-motion for judgment on the pleadings. The Court finds that there are gaps in the administrative record that were not properly developed by the ALJ—specifically, those concerning Dr. Nunez's treatment notes and Mental Status Examination ("MSE") findings. Accordingly, as described below, this case is remanded for further proceedings consistent with this Opinion.
Plaintiff Merys Urena filed applications for Disability Insurance Benefits ("DIB") under Title II of the Social Security Act ("Act") and Supplemental Security Income ("SSI") under Title XVI of the Act on October 28, 2010, alleging disability since January 1, 2009, because of depression, low back pain, and arthritis. (Tr. 60-61, 163-73, 196.) The Social Security Administration ("SSA") denied the applications. Plaintiff then requested an administrative hearing, which took place before an administrative law judge ("ALJ") on January 13, 2012. (Tr. 20-59.) The ALJ, before whom plaintiff and her attorney appeared, issued a decision finding that plaintiff was not disabled and not eligible for DIB and SSI. (Tr. 26-34.) The Appeals Council denied plaintiff's request for review (Tr. 1-8), and plaintiff thereafter filed a civil action. On February 11, 2015, the district court remanded the case for further administrative proceedings to consider plaintiff's mental impairments. (Tr. 403-36.)
Upon remand, a second hearing was held before an ALJ on January 27, 2016. (Tr. 345-69.) Plaintiff, who was represented by an attorney, appeared and testified; a vocational expert also testified. (Tr. 345-69.) On March 31, 2016, the ALJ again found that plaintiff was not disabled under the Act. (Tr. 370-95.) The ALJ's decision became the final decision of the Commissioner of Social Security ("Commissioner"), and plaintiff filed this instant action on June 6, 2016. (ECF No. 1.) The period at issue is from January 1, 2009—plaintiff's alleged disability onset date—through the Commissioner's March 31, 2016, final decision.
Plaintiff's Instant Motion
Plaintiff filed her instant motion "to contest the decision of the Commissioner of Social Security. . . . that she is not disabled as a result of a severe psychiatric illness." (Memorandum of Law in Support of Plaintiff's Motion for Judgment on the Pleadings ("Plaintiff's Mem. in Supp."), ECF No. 16, at 1.) First, plaintiff argues that the ALJ's decision should be reversed because the ALJ violated the treating physician rule. (
The Commissioner has opposed plaintiff's motion and has filed a cross-motion for judgment on the pleadings. The Commissioner argues that "the Commissioner's decision is supported by substantial evidence in the record, and is based upon the application of correct legal standards." (Memorandum of Law in Support of the Commissioner's Cross-Motion for Judgment on the Pleadings and in Opposition to Plaintiff's Motion for Judgment on the Pleadings ("Commissioner's Mem. in Supp."), ECF No. 21, at 1.) Specifically, the Commissioner argues that the ALJ properly considered the medical evidence and opinions in the record and appropriately evaluated plaintiff's credibility. (
II. APPLICABLE LEGAL PRINCIPLES
Judgment on the Pleadings
"After the pleadings are closed—but early enough not to delay trial—a party may move for judgment on the pleadings." Fed. R. Civ. P. 12(c). "The same standard applicable to Fed. R. Civ. P. 12(b)(6) motions to dismiss applies to Fed. R. Civ. P. 12(c) motions for judgment on the pleadings."
The Disability Standard
The Commissioner will find a claimant disabled under the Act if he or she demonstrates an "inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months." 42 U.S.C. § 423(d)(1)(A). The claimant's impairment must be "of such severity that he is not only unable to do his previous work but cannot, considering his age, education, and work experience, engage in any other kind of substantial gainful work which exists in the national economy."
The Commissioner uses a five-step process when making disability determinations.
Review of the ALJ's Judgment
The Commissioner and ALJ's decisions are subject to limited judicial review. The Court may only consider whether the ALJ applied the correct legal standard and whether his or her findings of fact are supported by substantial evidence. When these two conditions are met, the Commissioner's decision is final.
Substantial evidence means "more than a mere scintilla. It means such relevant evidence as a reasonable mind might accept as adequate to support a conclusion."
While the Court must consider the record as a whole in making this determination, it is not for this Court to decide
Finally, it is the function of the Commissioner, not the Court, "to resolve evidentiary conflicts and to appraise the credibility of witnesses, including the claimant."
The Treating Physician Rule
"[T]he treating physician rule generally requires deference to the medical opinion of a claimant's treating physician," although an ALJ need not afford controlling weight to a treating physician's opinion that is "not consistent with other substantial evidence in the record, such as the opinions of other medical experts."
Although the ALJ will consider a treating source's opinion as to whether a claimant is disabled or able to work, the final responsibility for deciding those issues is reserved to the Commissioner, and the treating source's opinion on them is not given "any special significance." 20 C.F.R. § 416.927(d)(3);
The ALJ's Duty to Develop the Record
Although "[t]he claimant has the general burden of proving that he or she has a disability within the meaning of the Act," "the ALJ generally has an affirmative obligation to develop the administrative record."
Plaintiff advances two arguments in support of her position that the ALJ erred in finding that she was not disabled: (1) the ALJ improperly failed to give "controlling weight" to plaintiff's treating psychiatrist, Dr. Giovanny Nunez; and (2) the ALJ's assessment of the credibility of plaintiff's testimony was legally deficient. (
The ALJ's Decision
The ALJ evaluated plaintiff's claim pursuant to the five-step sequential evaluation process and concluded that plaintiff has not been under a disability within the meaning of the Act since January 1, 2009, the date of plaintiff's application. At step one, the ALJ found that plaintiff had not engaged in substantial gainful activity since January 1, 2009 (the application date). (Tr. 378.) At step two, he determined that plaintiff had the following severe impairments: major depressive disorder, hypertension, hypothyroidism, obesity, gastritis, degenerative joint disease of the right knee, a history of vertigo, and migraines. (Tr. 379.) The ALJ determined at step three that none of plaintiff's impairments, nor any combination of those impairments, was of a severity to meet or medically equal one of the listed impairments in Appendix 1 of the regulations. (Tr. 379)
Before proceeding to step four, the ALJ determined that plaintiff had the residual functional capacity to perform "medium work" as defined in the regulations, except that she must avoid working at unprotected heights or around hazardous machinery; the ALJ further determined that plaintiff perform the full range of only repetitive unskilled work that requires no more than occasional close interpersonal contact with supervisors and coworkers and no close interpersonal contact with the general public. (Tr. 380.) In making this finding, the ALJ considered plaintiff's symptoms, objective medical evidence and other evidence, as well as opinion evidence. The ALJ concluded that plaintiff's "medically determinable impairments could reasonably be expected to cause the alleged symptoms, but further concluded that plaintiff's "statements concerning the intensity, persistent and limiting effects are these symptoms are not entirely consistent with the record." (Tr. 385.) The ALJ also noted that his finding reflected "significant weight" given to the opinion of Dr. Gonzales; "significant weight" to the opinion of Dr. Matthew; "little weight" to the opinion of Dr. Gerhart; "substantial weight" to the opinion of Dr. Brewer; "partial, but not controlling weight" to the opinion of Dr. Nunez; "partial weight" to the opinion of Dr. Alexander; "partial weight" to the opinion of Dr. Mahony; and "limited weight" to the opinion of the DDS reviewing psychologist. (Tr. 386-87.)
At step four, the ALJ found that plaintiff was unable to perform any past relevant work. (Tr. 388.) Proceeding to step five, the ALJ determined that considering plaintiff's "age, education, work experience, and residual functional capacity, there are jobs that exist in significant numbers in the national economy that [plaintiff] can perform." (Tr. 388.) Thus, the ALJ found that plaintiff was not disabled under the Act and denied her claims. (Tr. 388-89.) The ALJ relied on the Medical-Vocational Guidelines as a framework for his decision and utilized a vocational expert. (Tr. 388.)
Application of the Treating Physician Rule
Plaintiff's principal claim is that the ALJ failed to properly weigh the opinion evidence in the record. (Mem. in Supp. at 15-24.) Specifically, plaintiff claims that the ALJ failed to apply the treating physician rule in giving "partial, but not controlling weight" to Dr. Nunez plaintiff's treating psychiatrist. (
The ALJ did not assign Dr. Nunez's opinion controlling weight primarily because, in the ALJ's view, Dr. Nunez's opinion and clinical findings were in conflict with her office notes. (Tr. 387.) The ALJ explained that "opinions by treating sources must be supported by substantial evidence, the best evidence of which are contemporaneous treatment notes, which in this case, do not support the medical source statements." (Tr. 387.) The ALJ further stated that "[i]f office notes are defective, the onus is on the provider to document actual defects." (Tr. 387.)
Plaintiff acknowledges that the sections of Dr. Nunez's notes that record plaintiff's findings on mental status examination ("MSE") are mostly normal. (Plaintiff's Mem. in Supp. at 14.) However, plaintiff explains that this is based, in part, on the computer program Dr. Nunez used for progress notes. (
The Court has already noted that while "[t]he claimant has the general burden of proving that he or she has a disability within the meaning of the Act," "the ALJ generally has an affirmative obligation to develop the administrative record."
The Social Security Act directs that "[t]he court shall have power to enter, upon the pleadings and transcript of the record, a judgment affirming, modifying, or reversing the decision of the Commissioner of Social Security, with or without remanding the cause for a rehearing." 42 U.S.C. § 405. The Second Circuit has explained that "where the administrative record contains gaps, remand to the Commissioner for further development of the evidence is appropriate."
The Court has noted the gaps in the administrative record that were not properly developed by the ALJ—specifically, those concerning Dr. Nunez's treatment notes and MSE findings. The Court thus remands this case to the ALJ for further proceedings consistent with this Opinion & Order.