MEDINA v. COMMISSIONER OF SOCIAL SECURITY
OPINION. Signed by Judge William J. Martini on 6/26/15. (gh, )
NOT FOR PUBLICATION
UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF NEW JERSEY
Civ. No. 2:14-cv-06241 (WJM)
MARIBEL CARABALLO MEDINA,
CAROLYN W. COLVIN
ACTING COMMISSIONER OF
WILLIAM J. MARTINI, U.S.D.J.:
Plaintiff Maribel Caraballo Medina brings this action seeking review of a final
determination by the Commissioner of Social Security (the “Commissioner”) denying her
Title II application for a period of disability and disability insurance benefits, and Title
XVI application for supplemental security income. For the reasons that follow, the
Commissioner’s decision is AFFIRMED.
A. The Five-Step Sequential Analysis
Under the authority of the Social Security Act, the Social Security Administration
has established a five-step evaluation process for determining whether a claimant is entitled
to benefits. 20 C.F.R. §§ 404.1520, 416.920. In the first step, the Commissioner
determines whether the claimant has engaged in substantial gainful activity since the onset
date of the alleged disability. Id. §§ 404.1520(b), 416.920(b). If not, the Commissioner
moves to step two to determine if the claimant’s alleged impairment, or combination of
impairments, is “severe.” Id. §§ 404.1520(c), 416.920(c). If the claimant has a severe
impairment, the Commissioner inquires in step three as to whether the impairment meets
or equals the criteria of any impairment found in the Listing of Impairments. 20 C.F.R.
Part 404, Subpart P, Appendix 1, Part A. If so, the claimant is automatically eligible to
receive benefits (and the analysis ends); if not, the Commissioner moves on to step four.
Id. §§ 404.1520(d), 416.920(d). In the fourth step, the Commissioner decides whether,
despite any severe impairment, the claimant retains the Residual Functional Capacity
(“RFC”) to perform past relevant work. Id. §§ 404.1520(e)-(f), 416.920(e)-(f). The
claimant bears the burden of proof at each of these first four steps. At step five, the burden
shifts to the Social Security Administration to demonstrate that the claimant is capable of
performing other jobs that exist in significant numbers in the national economy in light of
the claimant’s age, education, work experience and RFC. 20 C.F.R. §§ 404.1520(g),
416.920(g); see Poulos v. Comm’r of Soc. Sec., 474 F.3d 88, 91-92 (3d Cir. 2007) (citations
B. Standard of Review
For the purpose of this appeal, the Court conducts a plenary review of the legal
issues. See Schaudeck v. Comm’r of Soc. Sec. Admin., 181 F.3d 429, 431 (3d Cir. 1999).
The factual findings of the Administrative Law Judge (“ALJ”) are reviewed “only to
determine whether the administrative record contains substantial evidence supporting the
findings.” Sykes v. Apfel, 228 F.3d 259, 262 (3d Cir. 2000). Substantial evidence is “less
than a preponderance of the evidence but more than a mere scintilla.” Jones v. Barnhart,
364 F.3d 501, 503 (3d Cir. 2004) (citation omitted). Substantial evidence means “such
relevant evidence as a reasonable mind might accept as adequate to support a conclusion.”
Id. When substantial evidence exists to support the ALJ’s factual findings, this Court must
abide by the ALJ’s determinations. See id. (citing 42 U.S.C. § 405(g)).
Plaintiff Maribel Caraballo Medina is a fifty-four year-old resident of Clifton, New
Jersey, who seeks a finding of disability due to diabetes mellitus and depression.
Administrative Transcript (“Tr.”) 8, 55, 73. She has a high school education, speaks
English, and has no past relevant work experience as defined by the Social Security
Regulations. Tr. 59.
On September 3, 2010, Plaintiff applied for a period of disability and disability
insurance benefits (“DIB”) under Title II. Tr. 53. Plaintiff then filed a Title XVI
application for supplemental security income on September 17, 2010. Id. Plaintiff alleged
that she could no longer work due to symptoms of depression and diabetes. Tr. 73.
According to Plaintiff, her disability began in April 2008 after she lost her job and became
depressed. 1 Id.
Plaintiff requested a hearing before the ALJ after her initial application and Request for
Reconsideration were both denied. Tr. 100, 106, 114. After conducting a hearing, the ALJ
denied Plaintiff’s claim on December 14, 2012. Tr. 50. The ALJ found that, subject to
While she provided contradictory reasons for why she was terminated, Plaintiff does not claim
that her disability was the cause. Tr. 28, 299.
certain non-exertional restrictions, Plaintiff’s residual functional capacity (“RFC”) enabled
her to perform light work, as defined in 20 C.F.R. §§ 404.1567(b), 416.967(b). Tr. 57.
Consequently, the ALJ concluded that there existed a significant number of jobs – both
regionally and nationally – that Plaintiff was capable of performing. Tr. 60. On August 22,
2014, the Appeals Council denied Plaintiff’s request for a review of the ALJ’s decision.
Tr. 1. Plaintiff now appeals.
A. Summary of the Record
The record includes medical records from treating physicians Drs. Patrick Beaty,
M.D. and Brett Freirna D.O., reports from two consultative examiners, Drs. Alexander
Hoffman, M.D. and Kim Arrington Psy.D., case analyses from two non-examining
physicians, Drs. Joseph Micale, M.D. and Pamela Foley, Ph.D., interrogatory responses
from vocational expert (“VE”) Rocco Meola, and Plaintiff’s own testimony.
Plaintiff’s treating physician, Dr. Beaty, began treating Plaintiff in May 2010. Tr.
328. On September 9, 2010, Dr. Beaty noted in a letter that he was treating Plaintiff for
diabetes mellitus, post-cataract surgery, and “mild depression.” Tr. 292. Treatment notes
from 2012 further indicate that Plaintiff continued to suffer from diabetes and depression.
Tr. 354-61, 368-75. Dr. Beaty’s records also noted that Plaintiff’s diabetes was without
complication, and that Plaintiff did not experience any eye symptoms, blurry vision,
tingling, burning, or numbness. Id. On March 7, 2012, Dr. Beaty completed an impairment
questionnaire indicating that because Plaintiff could not sit, stand or walk for more than
two hours at a time she was unable to perform sedentary work as defined by the
Regulations. 20 C.F.R. §§ 404.1567(a), 416.967(a). Tr. 330-34. The report also included
supporting diagnostic results, and stated that Plaintiff suffered from fatigue, weakness,
impaired vision, numbness in her extremities, burning neuropathic pain, and a variety of
affective disorders. Tr. 328-29.
On October 21, 2010, consultative physician Dr. Hoffman performed an orthopedic
examination of Plaintiff. Tr. 293. Dr. Hoffman’s report indicated that Plaintiff walked
normally, had “no difficulty getting on and off the table,” demonstrated a “good range of
motion at the wrist, elbow, and shoulder,” and was able to “balance on either leg, do a deep
knee bend, flex fully at the waist, [sic] walk on heels and toes.” Tr. 293-94. Dr. Hoffman
concluded that Plaintiff suffered from diabetes without major complication, and that she
suffered primarily from depression. Tr. 294.
Consultative physician Dr. Kim Arrington examined Plaintiff on October 22, 2010.
Dr. Arrington reported that Plaintiff was coherent, but that she had trouble sleeping, and
was limited in attention, concentration, and memory. Tr. 299-300. Dr. Arrington also
found that Plaintiff was of average intelligence and could live independently. Tr. 301. She
opined that despite limited attention and concentration, Plaintiff was “able to follow and
understand simple directions and instructions … perform many simple tasks independently
… [and] maintain a regular schedule.” Id. The report concluded that Plaintiff suffered
from adjustment disorder “with mixed anxiety and depressed mood.” Id.
While not examining Plaintiff in person, Social Security Administration physician
Dr. Joseph Micale reviewed Plaintiff’s disability claim. Dr. Micale’s report stated that
Plaintiff suffered from diabetes without major complications, and that her vision had been
restored. Tr. 303. Concluding that Plaintiff’s medical impairments were not severe, the
report noted that she was independent, fully capable of lifting and squatting, but was unable
to walk more than two blocks at a time. Id.
In addition, Social Security Administration physician Dr. Pam Foley evaluated
Plaintiff’s psychiatric record. Dr. Foley found that Plaintiff had “mild” restrictions in daily
activities, “moderate difficulties in maintaining social functioning,” and “moderate
difficulties in maintaining concentration, persistence, or pace.” Tr. 314.
Plaintiff testified at the hearing. She stated that her disability began when she
became depressed after losing her job in 2008, Tr. 73, which caused her to become isolated
and withdrawn. Tr. 79-80. Plaintiff complained of impaired vision, memory loss, poor
concentration, and some combination of pain, numbness and tingling in her hands and feet
as a result of her diabetes. Tr. 73-75. With regards to her eyesight, Plaintiff testified that
she continued to have blurred vision in her right eye despite undergoing cataracts surgeries
in 2009 and 2010. Tr. 74. Plaintiff further testified that she experienced numbness, pain
and tingling in her feet four to five times a week, and that the symptoms subsided if she sat
or lay down for approximately twenty minutes. Tr. 76-78. Plaintiff also stated that she
experienced pain in her right index finger roughly three times a week, which made it
difficult to lift or hold things. 2 However, Plaintiff’s testimony indicated that she was
capable of driving and shopping, Tr. 80, while a self-completed function report showed
that she routinely cooked and cleaned for herself. Tr. 222-23.
Finally, VE Rocco Meola concluded that someone of Plaintiff’s RFC (as determined
by the ALJ), age, education, and work experience has the ability to work as a sorter, bagger,
or produce weigher. Tr. 272.
B. The ALJ’s Decision
At step one, the ALJ determined that Plaintiff did not engage in substantial activity
since the alleged onset date. Tr. 55. At step two, the ALJ found that Plaintiff had the
following severe impairments: diabetes mellitus and adjustment disorder. Id. At step three,
the ALJ found that the severity of Plaintiff’s impairments, individually or combined, did
not meet or medically equal any of the listed impairments in 20 C.F.R. Part 404, Subpart
P, Appendix 1, Part A. Tr. 56.
Plaintiff is right-handed. Tr. 294.
At step four, the ALJ found that Plaintiff has the RFC to perform light work,
meaning she could lift or carry twenty pounds occasionally and ten pounds frequently, walk
or stand for a substantial portion of the workday, and push or pull controls within the given
weight restriction. 20 C.F.R. §§ 404.1567(b), 416.967(b); Tr. 57. The ALJ’s RFC finding
also included three non-exertional limitations: Plaintiff was capable of work that involved
only (1) simple instructions; (2) occasional interaction with others; and (3) occasional
changes in “essential job functions.” Id. At step five, the ALJ relied on the VE’s
interrogatory answers to conclude that given her RFC, age, education, and occupational
history, Plaintiff was capable of performing work as a sorter, bagger, or produce weigher.
Tr. 59-60. The ALJ found that these positions existed in “significant numbers” in the
national economy, as well as in the region where Plaintiff resides. Tr. 60. In light of these
findings, the ALJ concluded that Plaintiff was not disabled under the Act and therefore not
entitled to benefits. Id.
In determining that Plaintiff was capable of light work, the ALJ primarily relied on
medical reports from the Social Security Administration’s consultative examiners. Tr. 5759. The ALJ cited Dr. Hoffman’s conclusion that Plaintiff had diabetes without
complications, 20/20 vision, and no physical limitations. Tr. 58. In addition, the ALJ
referenced Dr. Arrington’s report, which found that Plaintiff possessed average intellectual
functioning, such that she was capable of maintaining a schedule, following simple
directions, and performing simple tasks without supervision. Id.
The ALJ further ruled that Plaintiff’s testimony regarding the severity of her
symptoms was not credible. Tr. 57. In particular, the ALJ found that Plaintiff’s statements
were inconsistent with the reports submitted by Drs. Hoffman and Arrington, as well as the
fact that she had received only conservative treatment for her ailments. Id. Furthermore,
the ALJ noted that Plaintiff’s stated capacity to perform daily tasks conflicted with her
description of the “intensity, persistence and limiting effects” of her symptoms. Id.
The ALJ assigned little weight to the opinion of the treating physician, Dr. Beaty,
because it was not supported by “any objective medical evidence.” Tr. 59. Specifically,
the ALJ concluded that Dr. Beaty’s report was inconsistent with the consultative
examiners’ reports, the treatment that Plaintiff received, and any other “signs or medical
Plaintiff challenges the ALJ’s finding that she was not disabled under the Social
Security Act. Specifically, Plaintiff argues that: (1) the ALJ did not properly weigh the
treating physician’s opinion; (2) the ALJ did not properly determine the credibility of
Plaintiff’s testimony; and (3) the ALJ relied on flawed testimony from the VE. The Court
will address these arguments in turn:
A. Step Four: Failure to Properly Weigh The Treating Physician’s Opinion
Plaintiff argues that the ALJ erred when it assigned little weight to the opinion of
Dr. Beaty. The Court disagrees.
When determining a claimant’s RFC, an ALJ will analyze and assign weight to
medical opinions. 20 C.F.R. §§ 404.1527, 416.927. A treating source’s opinion of the
nature and severity of an individual’s impairment must be given controlling weight if the
opinion is well-supported by medically acceptable clinical and laboratory diagnostic
techniques and is not inconsistent with other substantial evidence. 20 C.F.R. §§
404.1527(c)(2), 416.927(c)(2); Fargnoli v. Massanari, 247 F.3d 34, 43 (3d Cir. 2001);
Social Security Ruling (SSR) 96-2p. Otherwise, a treating source’s medical opinion must
be weighed according to the factors defined in 20 C.F.R. §§ 404.1527(c)(2)-(6),
416.927(c)(2)-(6). SSR 96-2p.
Here, Dr. Beaty’s opinion was inconsistent with substantial evidence on record. For
example, Dr. Beaty’s treatment notes indicate that Plaintiff did not have eye problems,
blurry vision, tingling, burning sensations, or numbness. Tr. 355, 358, 369, 372.
Furthermore, Dr. Beaty’s medical opinion also conflicts with that of the Social Security
Administration’s consultative examiner, Dr. Hoffman, who concluded that the Plaintiff had
diabetes without complications, and 20/20 eyesight. Tr. 294. These inconsistencies are
sufficient grounds for rejecting a treating physician’s opinion. See Lyons-Timmons v.
Barnhart, 147 F. App'x 313, 316 (3d Cir. 2005). Therefore, the ALJ did not err in granting
Dr. Beaty’s opinion less than controlling weight.
Moreover, in declining to give Dr. Beaty’s opinion controlling weight, the ALJ
properly considered all of the factors listed in 20 C.F.R. §§ 404.1527(c), 416.927(c).
Specifically, the ALJ noted the length of the treatment relationship, the frequency of visits,
and the type of treatment received. Tr. 59. More significantly, the ALJ’s decision to
discount Dr. Beaty’s opinion was specifically predicated on the opinion’s lack of objective
support and its inconsistency with the record. Id. The ALJ also concluded that Dr. Beaty
is “less knowledgeable than state Agency doctors about the SSA definition of disability.”
Id. See 20 C.F.R. §§ 404.1527(c)(6), 416.927(c)(6) (stating that a medical source’s
understanding of the disability program is a relevant consideration). Finally, because Dr.
Beaty is a primary care physician, Tr. 81, specialization is not a relevant factor in this case.
See 20 C.F.R. §§ 404.1527(c)(5), 416.927(c)(5). Thus, substantial evidence supported the
ALJ’s decision to grant Dr. Beaty’s opinion little weight was not erroneous.
B. Step Four: The ALJ’s Credibility Assessment
Plaintiff challenges the ALJ’s decision not to credit Plaintiff’s testimony describing
the intensity, persistence and limiting effects of her symptoms. While a plaintiff’s
testimony of subjective pain and inability to perform even light work is normally entitled
to great weight, an ALJ may reject those claims if he or she explains why they are
inconsistent with the medical evidence of record. See, e.g., Harkins v. Commissioner of
Social Security, 399 Fed.Appx. 731, 735 (3d Cir. 2010) (citing Matullo v. Bowen, 926 F.2d
240, 245 (3d Cir. 1990)). Moreover, when determining the credibility of a plaintiff’s
testimony, an ALJ may consider a plaintiff’s medical treatment and ability to perform daily
tasks. See Harkins, 399 Fed.Appx. at 735; Hartranft v. Apfel, 181 F.3d 358, 362 (3d Cir.
1999). In this case, the ALJ gave several well-supported reasons for his decision. First,
the ALJ determined that Plaintiff’s allegation of complete disability was inconsistent with
the State’s consultative examiner reports. Tr. 58. In addition, Dr. Arrington’s
psychological evaluation concluded that Plaintiff was a person of average intellectual
functioning who could follow simple directions, perform simple tasks independently, and
maintain a regular schedule. Id. The ALJ also relied on the Plaintiff’s admission that she
is able to carry out daily tasks. Tr. 57. Finally, the ALJ noted that Plaintiff’s allegations
of disability were inconsistent with the fact that her treatment was limited to medication.
Id. For these reasons, the Court finds that substantial evidence supports the ALJ’s
assessment of Plaintiff’s credibility.
C. Step Five: Flawed Vocational Expert Testimony
Finally, Plaintiff argues that the VE’s testimony was flawed. Specifically, Plaintiff
argues that the testimony relied on a hypothetical question that did not account for her
moderate limitations in concentration, persistence or pace. Tr. 56. Generally, a VE may
testify about a plaintiff’s capacity to work by responding to a hypothetical describing
someone with the plaintiff’s mental and physical limitations. 20 C.F.R. §§ 404.1560(b)(2),
416.960(b)(2). However, a VE’s response to the hypothetical constitutes substantial
evidence only if it accurately reflects all of the plaintiff’s credibly established impairments.
See Rutherford v. Barnhart, 399 F.3d 546, 554 (3d Cir. 2005). Plaintiff argues that the
ALJ’s hypothetical in this case failed to account for her moderate limitations in
concentration, persistence, or pace. However, the Third Circuit has held that a hypothetical
limiting a plaintiff to “simple routine tasks” adequately accounts for such limitations.
McDonald v. Astrue, 293 F. App'x 941, 946 (3d Cir. 2008); Menkes v. Astrue, 262 F. App'x
410, 412-13 (3d Cir. 2008). See also Padilla v. Astrue, No. 10-CV-4968 ES, 2011 WL
6303248, at *10 (D.N.J. Dec. 15, 2011) (holding that an RFC limiting the plaintiff to
“simple, unskilled work” accounted for moderate limitations in terms of concentration,
persistence or pace); Padilla v. Comm'r of Soc. Sec., No. CIV.09-2897 (WJM), 2010 WL
2346650, at *6 (D.N.J. June 9, 2010) (holding that an ALJ’s hypothetical limiting the
plaintiff to “simple, routine repetitive jobs in a low stress setting” sufficiently conveyed
“difficulties in maintaining concentration and pace.”). Here, the ALJ’s hypothetical
contained a non-exertional limitation analogous to the one given in McDonald and Menkes,
as it described someone who could “understand, remember and carry out simple
instructions.” Tr. 271. Consequently, the Court finds that the ALJ’s hypothetical
accurately reflected all of Plaintiff’s credibly established limitations.
For the foregoing reasons, the Commissioner’s decision is AFFIRMED. An
appropriate order follows.
/s/ William J. Martini
WILLIAM J. MARTINI, U.S.D.J.
Date: June 26th, 2015
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