MADERA v. COMMISSIONER OF SOCIAL SECURITY
OPINION. Signed by Judge Claire C. Cecchi on 15-7619. (JB, )
NOT FOR PUBLICATION
UNITED STATES DISTRICT COURT
DISTRICT OF NEW JERSEY
JOSE SANCHEZ MADERA,
Civil Action No.: 2:15-cv-7619 (CCC)
COMMISSIONER Of SOCIAL SECURITY,
CECCHI, District Judge.
Before the Court is Plaintiff Jose Sanchez Madera’s (“Plaintiff’) appeal seeking review of
Commissioner of the
(“Commissioner”) denying his application for supplemental social security income (“SSI”) under
1614(a)(3)(A) of the Social Security Act (“SSA”). The issue to be decided is whether the
Commissioner’s denial of benefits is supported by substantial evidence. for the reasons set forth
below, the decision of the Administrative Law Judge (“AU”) is affirmed in part and vacated in
part and the matter is remanded for further proceedings consistent with this Opinion.
Plaintiff applied for SSI on August 22, 2012, alleging disability as of June 15, 2008. Tr.’
at 29. The applications were denied initially on February 25, 2012, and upon reconsideration on
February 26, 2013. Id. A hearing was held before AU U. Rogall on January 17, 2014. Id. AU
“Tr.” refers to the certified record of the administrative proceedings. ECf No. 7.
Rogall issued a decision on April 15, 2014, finding Plaintiff was not disabled, as defined by the
$SA. Id. at 38 (citing 20 C.F.R.
§ 416.920(g)). Plaintiff requested review of the decision and the
Appeals Council denied the request on August 25, 2015. Tr. at 1. On October 20, 2015, Plaintiff
instituted this action. ECF No. 1.
Plaintiff was born on September 12, 1974. Tr. at 134. Plaintiff has completed his GED,
id. at 307, is divorced, and currently lives alone in an apartment. Id. at 48-49. Plaintiff has work
experience as a clerk in various factories and as a server in a bakery. Id. at 307. Plaintiff testified
he last worked in a factory, and stopped working because of panic attacks, anxiety, and depression.
Id. at 34. Plaintiff testified that he hears voices which tell him to attack other people, that he has
never acted upon these voices, but that they frighten him. Id.
In December 2011, Plaintiff was hospitalized with suicidal ideation. Id. Plaintiff was
discharged with medication and was diagnosed with schizoaffective disorder bipolar type and a
global assessment functioning (“GAF”) of 70. Id. In September 2012, Plaintiff was examined by
psychological consultative examiner Paul Fulford, Ph.D. Id. at 35. Dr. Fulford diagnosed Plaintiff
with alcohol abuse in full remission, drug use in early full remission, and major depression with a
GAF of 60. Id. At this examination, Plaintiff also reported auditory hallucinations of a command
nature. Id. In November 2012, Plaintiff was admitted to the Community Psychiatric Institute with
schizoaffective disorder and a GAF of 45. See Id. at 435.
In September 2012, Plaintiff underwent an internal consultative examination with Dr.
Ramhbai Patel. Id. at 35. Dr. Patel diagnosed Plaintiff with obesity, uncontrolled hypertension,
hyperlipidemia, seizer disorder, anxiety, and depression. Id. Dr. Patel noted Plaintiffs gait was
normal without any walking device and there were no gross sensory or motor deficits. Id. In
December 2012, Plaintiff underwent a second internal consultative examination with Dr. Rahel
Dr. Eyassu diagnosed Plaintiff with diabetes mellitus, hypertension, and severe
depression, but the physical examination was otherwise unremarkable. Id. at 35-36. In November
2013, Plaintiff underwent an examination by Dr. Frank Ostella, who completed a questionnaire
regarding Plaintiffs mental impairments. Id. at 36. Dr. Ostella indicated Plaintiff suffered from
auditory hallucinations, paranoia, and insomnia. Id at 491. Dr. Ostella opined Plaintiff was
“seriously limited, but not precluded,” “unable to meet competitive standards,” or had “no useful
ability to function” in each work related skill on the questionnaire. See Id. at 493-94.
Standard of Review
This Court has jurisdiction to review the Commissioner’s decision under 42 U.s.c.
§ 405(g) and 13$3(c)(3). The Court is not “permitted to re-weigh the evidence or impose [its]
own factual determinations,” but must give deference to the administrative findings. Chandler v.
Comm ‘r ofSoc. Sec., 667 F.3d 356, 359 (3d Cir. 201 1); see also 42 U.S.C.
§ 405(g). Nevertheless,
the Court must “scrutinize the record as a whole to determine whether the conclusions reached are
rational” and supported by substantial evidence. Gober v. Matthews, 574 F.2d 772, 776 (3d Cir.
1978) (citations omitted). Substantial evidence is more than a mere scintilla, and is “such relevant
evidence as a reasonable mind might accept as adequate to support a conclusion.” Chandler, 667
F.3d at 359 (citing Richardson v. Ferales, 402 U.S. 389, 401 (1971)). If the factual record is
adequately developed, substantial evidence “may be ‘something less than the weight of the
evidence, and the possibility of drawing two inconsistent conclusions from the evidence does not
prevent an administrative agency’s finding from being supported by substantial evidence.”
Daniels v. Astrue, No. 4:08-1676, 2009 WL 1011587, at *2 (M.D. Pa. Apr. 15, 2009) (quoting
Consolo v. Fed. Mar. Comm
383 U.S. 607, 620 (1966)). In other words, under this deferential
standard of review, the Court may not set aside the AU’s decision merely because it would have
come to a different conclusion. Cruz v. Comm ‘r ofSoc. Sec., 244 F. App’x 475, 479 (3d Cir. 2007)
(citing Harlranft V. Apfel, 181 f.3d 358, 360 (3d Cir. 1999)).
Pursuant to the SSA, in order to be eligible for benefits, a plaintiff must show he is disabled
by demonstrating 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 twelve months.”
423(d)(1)(A), 13$2c(a)(3)(A). Taking into account the plaintiffs age, education,
and work experience, disability will be evaluated by the plaintiffs ability to engage in his previous
work or any other form of substantial gainful activity existing in the national economy. 42 U.S.C.
1382c(a)(3)(B). A person is disabled for these purposes only if his physical or
mental impairments are “of such severity that he is not only unable to do his previous work, but
cannot, considering his age, education, and work experience, engage in any other kind of
substantial gainful work which exists in the national economy..
Decisions regarding disability will be made individually and will be “based on evidence
adduced at a hearing.” Sykes v. Apfel, 22$ f.3d 259, 262 (3d Cir. 2000) (citing Heckler v.
Campbell, 461 U.S. 458, 467 (1983)). Congress has established the type of evidence necessary to
prove the existence of a disabling impairment by defining a physical or mental impairment as “an
impairment that results from anatomical, physiological, or psychological abnormalities which are
demonstrable by medically acceptable clinical and laboratory diagnostic techniques.” 42 U.S.C.
Sequential Evaluation Process
The Social Security Administration follows a five-step, sequential evaluation to determine
whether a plaintiff is disabled within the meaning of the statute. 20 C.F.R. §5S 404.1520, 4 16.920.
First, the AU must determine whether the plaintiff is currently engaged in gainful activity. Sykes,
22$ F.3d at 262. Second, if he is not, the AU determines whether the Plaintiff has an impairment
that limits his ability to work. Id. Third, if he has such an impairment, the AU considers the
medical evidence to determine whether the impairment is listed in 20 C.F.R. Part 404, Subpart P,
Appendix 1 (the “Listings”).
If it is, this results in a presumption of disability. Id.
impairment is not in the Listings, the AU must determine how much residual functional capacity
(“RFC”) the applicant retains in spite of his impairment. Id. at 263. Fourth, the AU must consider
whether the plaintiffs RFC is enough to perform his past relevant work. Id. Fifth, if his RFC is
not enough, the AU must determine whether there is other work in the national economy the
plaintiff can perform. Id.
The evaluation continues through each step unless it is determined at any point the plaintiff
is or is not disabled. 20 C.F.R.
§ 404.1520(a)(4), 416.920(a)(4). The plaintiff bears the burden
of proof at steps one, two, and four, upon which the burden shifts to the Commissioner at step five.
Sykes, 22$ F.3d at 263. Neither party bears the burden at step three. Id. at 263 n.2.
Summary of the AU’s Findings
At step one, the AU found Plaintiff met the insured status requirements of the SSA and
had not engaged in substantial gainful work activity since the application date. Tr. at 31. At steps
two and three, the AU found Plaintiffs impairments of depression, schizoaffective disorder, Type
II diabetes mellitus, and obesity were “severe,” but not severe enough to meet, either individually
or in combination, any of the impairments listed in 20 C.F.R.
404, Subpart P, Appendix 1. Id.
The AU concluded Plaintiff had the residual functional capacity (“Rf C”) to perform the
exertional demands of light work as defined in 20 C.F.R.
416.967(b), except he was limited to
simple, routine, and repetitive tasks in a work environment free of fast-paced production
requirements, involving only simple work-related decisions, with few workplace changes, and
with only occasional contact with the public, co-workers, or supervisors. Id. at 33. To make this
conclusion, the AU considered all of Plaintiffs symptoms and their consistency with the evidence.
Specifically, the AU
considered Plaintiffs testimony of his personal, medical, and
professional history. Id. at 34. As for mental impairments, the AU took into consideration
Plaintiffs brief hospitalization in 2011, the psychological consultative examination with Dr. Paul
Fulford, and records from the Community Psychiatric Institute. See Id. at 34-35. The AU noted
“[t]he record contains little by way of any physical impairments,” but took into consideration the
reports by internal consultative examiners Dr. Rambhai Patel and Dr. Rahel Eyassu, and reports
by Dr. Vincente Lim and Dr. Frank Ostella. See Id. 35-36. The AU concluded that Plaintiffs
diabetes and documented obesity warranted a limitation to light work, but that Plaintiffs mental
impairments were not as severe as he described. Id. at 36.
At step four, the AU found Plaintiff was incapable of performing past relevant work as a
worker in an assembly line, maintenance, upholstery, or bakery. Id. at 37. At step five, the AU
found there were jobs in significant numbers in the national economy that Plaintiff could perform.
Id. The AU identified these jobs as: silver wrapper and night cleaner. Id.
Plaintiff makes the following arguments in support of his contention that the AU’s
decision should be remanded: (1) the AU failed to consider and explain his reasons for discounting
all of the evidence relating to Plaintiffs spinal impairments, and (2) the AU should not have found
Plaintiff capable of light work. The Court will address each argument in turn.
Plaintiffs Spinal Impairments
Plaintiff alleges that at step two, the AU “fails to discuss documented lumbar spine
impairments,” and that this error influenced the RFC analysis. ECF No. 10 at 26-27. Plaintiff
states that he underwent MRI testing of his lumbar spine in February 2013, and in May 2014 he
was diagnosed with low back pain, lumbar herniated discs, and diabetes. Id. However, the reports
Plaintiff cites to support his claim of severe spinal impairments appear to have been made part of
the record by the Appeals Council after the AU issued his decision in April 2014. See Id. at 6,
3$. The AU. therefore, would not have had the opportunity to consider this medical evidence. To
the extent the record is unclear as to whether the AU did have the records Plaintiff relies upon
before him, the Court cannot provide meaningful review of the AU’s consideration of this
evidence. On remand, the AU should clarify which records he considered in his decision, whether
the documents Plaintiff references were before him, and if so to what extent, if any, they impact
The AU’s RFC Analysis was Supported by Substantial Evidence
Plaintiff argues the AU did not discuss his reasons for discounting all of the pertinent
evidence in making his RFC determination, and appears to argue the AU should have adopted the
opinion of Dr. Ostella, that Plaintiff was unable to meet the quality standards for productivity on
a sustained basis and would be unemployable. ECF No. 10 at 31.
“In evaluating medical reports, the AU is free to choose the medical opinion of one doctor
over that of another.” Diaz v. Comm ‘r ofSoc. $ec,, 577 F.3d 500, 505 (3d Cir. 2009) (citing Cotter
v. Harris, 642 F.2d 700, 705 (3d Cir. 1981)). “When a conflict in the evidence exists, the AU
may choose whom to credit but cannot reject evidence for no reason or for the wrong reason. The
AU must consider all the evidence and give some reason for discounting the evidence she rejects.”
Plummet v. Apfel, 186 F.3d 422, 429 (3d Cir. 1999) (internal citation omitted).
substantial evidence standard of review, the issue is whether sufficient evidence reasonably
supports the AU’s analysis, not whether the evidence could support a different finding. See Logan
v. Co/yin, No. 14-4571, 2015 WL 5722391, at *7 (D.N.J. Sept. 29, 2015) (finding “[t]he role of
the District Court in reviewing an AU’s denial of disability benefits is not to reweigh the evidence
presented, but instead to determine whether the AU made a decision supported by substantial
evidence”). Plaintiff here appears only to argue the AU should have interpreted the medical
The Court finds the AU’s assessment was supported by substantial evidence. Here, the
AU explained that Dr. Ostella indicated he had only met Plaintiff on one occasion prior to
completing the evaluation and “no mental status examination [was] included.” Id. at 36. The AU
noted Dr. Ostella indicated Plaintiff had an adequate response to medication management, the
“limitations opined” by Dr. Ostella were “inconsistent with other evidence of record and with
[Plaintiffs] own testimony,” and that because the date of the evaluation was in November 2012,
it “does little to help establish functioning at or near the alleged onset date.”2 Id. Moreover, the
With respect to the alleged onset date, the Court notes the AU first explains Plaintiff alleged
disability as of June 15, 2008. Tr. at 29. Later on in the decision, the AU refers to August 2012
as the “alleged onset date.” Id. at 35. However, Plaintiff has waived any argument based on this
issue because it was not raised on appeal. See folger v. Comm ofSoc. Sec., 16-1487-JLL 2017
AU stated that the severity of Plaintiffs alleged mental impairments is contradicted by the fact
that he lives independently, and evaluations repeatedly showed him to be capable of adequate
social behavior. Id. at 36-37. The AU further provided limitations for Plaintiffs impairments in
concentration. Id. Accordingly, the Court finds the AU’s Rf C evaluation to be supported by
for the foregoing reasons, the Court will affirm in part and vacate in part the AU’s decision
and remands this case for further administrative proceedings consistent with this Opinion. An
appropriate order accompanies this Opinion.
CLAIRE C. CECCHI, U.S.D.J.
U.S. Dist. LEXIS 12253, *47 (D.N.J. Jan. 30, 2017) (citing Knepp v. Apfel, 204 F.3d 7$, $4 (3d
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