RODRIGUEZ v. COMMISSIONER OF SOCIAL SECURITY
OPINION. Signed by Chief Judge Jose L. Linares on 8/18/17. (sr, )
NOT FOR PUBLICATION
UNITED STATES DISTRICT COURT
DISTRICT OF NEW JERSEY
WILSON HERNANDEZ RODRIGUEZ,
Civil Action No.: 17-440 (JLL)
COMMISSIONER OF SOCIAL SECURITY,
LINARES. Chief District Judge.
This matter comes before the Court by way of Plaintiff Wilson Hernandez Rodriguez’s
appeal for judicial review of a final decision issued on behalf of the Commissioner of the Social
Security Administration (“Commissioner”), which denied his claim for disability insurance
benefits. (ECF No. 1; see also 42 U.S.C.
§ 405(g); L. Civ. R. 9.1). After careful consideration of
the administrative record, submissions made in support of and in opposition to the instant appeal,
the Court decides this matter without oral argument pursuant to Rule 7$ of the Federal Rules of
Civil Procedure. (ECF Nos. 10, 11, 12). For the reasons set forth below, the Court rernands this
matter for further proceedings that are consistent with this Opinion.
On December 6, 2010, Plaintiff filed applications for payment of disability insurance
benefits (“DIB”) and supplemental security income (“SSI”). (R. 128-29, 140-41, 152, 164, 3364$). Plaintiff alleged that he was disabled due to his anxiety and psychotic disorder, which began
“R.” refers to the Administrative Record, which uses continuous pagination and can be found at ECF No. 6.
on September 28, 2010. (R. 128-29, 140-41, 152, 164, 336-48). Plaintiffs applications were
denied, and he requested a hearing, which was conducted before Administrative Law Judge Donna
A. Krappa (“AU”) on February 11,2013. (R. 64-99, 202-07, 220-21). Upon the completion of
said hearing, AU determined that Plaintiff was not disabled and therefore ineligible for payments
of DIB and S$I. (R. 178-89). Thereafter, Plaintiff filed a request to the Appeals Council for
review of AU’s decision. (R. 270-71). The Appeals Council ultimately remanded the case for
AU’s failure to consider Plaintiffs obesity. (R. 195-99).
At remand, AU again determined that Plaintiff was not disabled, reaching said conclusion
at step-five of a five sequential step analysis. (R. 41, 44-56). At step-one, AU found that Plaintiff
had not engaged in substantial gainful activity since September 28, 2010. (R. 46). At step-two,
AU determined that Plaintiffs affective disorders, right heel pain, right knee pain, low back pain,
and obesity were “severe.” (R. 46-47). Notwithstanding said finding, AU found at step-three that
Plaintiffs “severe” impairments did not meet or equal a listed impairment under 20 C.F.R.
416.920(a)(4)(iii), bringing the AU to step-four. (R. 47-49). There, AU found Plaintiff had a
residual functional capacity (“RFC”) “to perform a reduced range of light work as defined in 20
404.1567(b) and 416.967(b).” (R. 49).
In determining Plaintiffs RFC, AU considered most of the record. (R. 50-54). Although
Plaintiff alleged full disability in his right heel, right knee, and lower back, the record indicated
minimal and intermittent treatment for those conditions. (R. 50). Despite a July 2012 medical
imaging study which revealed that Plaintiff had “heels spurs,” Plaintiff still did not receive
treatment for same.
July and October 2012 medical imaging studies indicated no
abnormalities in Plaintiffs back, and January 2013 treatment notes provided that Plaintiff had full
range of motion in his right foot. (Id.). A March 2013 consultative examination with Rahel
Eyassu, M.D., “showed primarily nonnal findings” except that Plaintiff had minimal reduction
in the range of motion in his knees and could not walk on his right heel. (R. 51). AU also
considered her own observations of Plaintiff; specifically that Plaintiff had no difficulty walking
in and out of the hearing room despite alleging leg difficulty. (Id.). As for Plaintiff’s obesity, AU
acknowledged that it could exacerbate Plaintiffs other physical ailments. (Id.). AU concluded
that “the record supports a finding that [Plaintiff] is able to work at the light exertional level.”
As for Plaintiffs mental impairments, AU considered various treatment notes between the
years 2010-2013. (R. 51-54). Contained therein, Plaintiff showed improvement, graduating from
his partial hospitalization program and transferring to outpatient care.
consistently showed a Global Assessment of functioning of 60.2 (Id.). The outpatient care notes
throughout Plaintiffs treatment indicated that, although he did suffer from anxiety and depression,
Plaintiff was, for the most part, alert and oriented; i.e. his thoughts were clear and organized, and
he was overall functional.
Additionally, “the state agency psychiatric consultant
determined that [Plaintiff] had a moderate mental impairment.” (R. 53).
Most pertinent to this appeal, ALl assigned no weight to consultative examiner Paul
fulford, Ph.D., and physician Rakesh Bansil, M.D, who both concluded that Plaintiff was totally
disabled. (R. 53-54). AU did so because Dr. Fulford was a one-time examiner, and his diagnosis
of Plaintiff was inconsistent with the entirety of the record, which showed Plaintiff was improving
over time. (R. 53). As for Dr. Bansil, although he provided two separate and consistent diagnoses
of Plaintiff; he failed to provide explanation for those diagnoses. (Id.). Indeed, Dr. Bansil’s
A Global Assessment of Functioning of 60 indicates symptoms of mental impairment between mild and moderate
according to the fourth edition of the Diagnostic and Statistical Man ual of Mental Disorders. See Isaac Colvin,
2014 WL 1942555, at *8 n.l0 (M.D. Pa. May 14, 2014).
conclusions were in check-box fonn “issued in connection with a state program using unknown
criteria to assess whether [Plaintiff] was disabled.” (R. 53-54).
Ultimately, AU concluded that Plaintiff was
totally disabled and could perform light
exertional work. (R. 51, 53). Notwithstanding said finding. Plaintiffs RFC made him unable to
perform his past relevant work, where he worked as a short order cook, a barber, a brick layer, a
warehouse worker, and in floor maintenance. (R. 54). Moving on to step-five, with the help of a
vocational expert, AU concluded that given Plaintiffs RFC, “there are jobs that exist in significant
numbers in the national economy that [Plaintiff] can perforrn[.]” (R. 55). As such, AU concluded
that Plaintiff was ineligible for payment of DIB and SSI. (R. 56).
Plaintiff again requested rehearing, which the Appeals Council denied, making AU’s
determination that Plaintiff was not disabled the final decision of the Commissioner. (R. 1-7). On
January 21, 2017, Plaintiff filed this appeal. (ECF No. 1). For the reasons set forth below, this
matter is remanded for further proceedings consistent with this Opinion.
STANDARD OF REVIEW
This Court must affirm an ALYs decision if it is supported by substantial evidence. See 42
§ 405(g), 13$3(c)(3). Substantial evidence is “more than a mere scintilla. It means such
relevant evidence as a reasonable mind might accept as adequate to support a conclusion.”
Richardson v. Ferales, 402 U.S. 389, 401 (1971) (quoting Consol. Edison Co.
NLRB, 305 U.S.
197, 229 (193$)). To deteniiine whether an AU’s decision is supported by substantial evidence,
this Court must review the evidence in its totality. Daring v. Heckler, 727 F.2d 64, 70 (3d Cir.
1984). However, this Court may not “weigh the evidence or substitute its conclusions for those of
Williams v. Sullivan, 970 f.2d 117$, 1182 (3d Cir. 1992) (citation omitted).
Consequently, this Court may not set an AUJ’s decision aside, “even if[it] would have decided the
factual inquiry differently.”
Hartranft v. Apfel, 181 F.3d 358, 360 (3d Cir. 1999) (citations
Plaintiff argues that AU erred when she provided no weight to the diagnoses of Dr. Fulford
and Dr. Bansil because both “findings and opinions are entirely consistent with the medical
evidence in record.” (ECF No. 10 at 37). According to Plaintiff, as a result of this error, AU did
not conduct a full analysis to determine RFC. (Id. at 38-41). Defendant argues that substantial
evidence supports ALl’s decision to assign no weight to the findings of both Dr. Fulford and Dr.
Bansil. (ECF No. 11 at 16-17). Defendant avers that this is because Dr. Fulford was a one-time
examiner, whose diagnosis was contrary to the entirety of the record, and Dr. Bansil failed to
provide any reason for same, which were in connection with a state program using unknown
criteria. (Id. at 18, 20-21).
Under the Social Security Act, the Social Security Administration is authorized to pay
Social Security Insurance to “disabled” persons. 42 U.S.C.
§ 13 82(a). A person is “disabled” if
“he is unable 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.”
1382c(a)(3)(A). A person is unable to engage in substantial gainful activity when 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, edcLcation, and work experience, engage in any other kind of
substantial gainful work which exists in the national economy.
Regulations promulgated under the Social Security Act establish a five-step process for
determining whether a claimant is disabled.
§ 416.920(a)(1). At step one, an
administrative law judge assesses whether the claimant is currently performing substantial gainful
activity. 20 C.F.R.
§ 416.920(a)(4)(i). If so, the claimant is not disabled and, thus, the process
ends. Id. If not, the administrative law judge proceeds to step two and determines whether the
claimant has a “severe” physical or mental impairment or combination of impairments. 20 C.F.R.
§ 41 6.920(a)(4)(ii). Absent such impairment, the claimant is not disabled. Id. Conversely, if the
claimant has such impairment, an administrative law judge proceeds to step three. Id. At step
three, an administrative law judge evaluates whether the claimant’s severe impairment either meets
or equals a listed impairment.
If so, the claimant is
disabled. Id. Otherwise, an administrative law judge moves on to step four, which involves three
(1) the ALl must make specific findings of fact as to the claimant’s
[RFC]; (2) the ALl must make findings of the physical and mental
demands of the claimant’s past relevant work; and (3) the AU must
compare the [RFC] to the past relevant work to determine whether
claimant has the level of capability needed to perform the past
Burnett v. Comrn’r ofSoc. Sec. Admin., 220 f.3d 112, 120 (3d Cir. 2000) (citations omitted).
When determining Rf C, “[a]n AU may reject a treating physician’s opinion outright only
on the basis of contradictory medical evidence, but may afford a treating physician’s opinion more
or less weight depending upon the extent to which supporting explanations are provided.” Hoyman
Colvin, 606 Fed.Appx. 678, 679-80 (3d Cir. 2015) (quoting Flummer v. Apfel, 186 F.3d 422,
429 (3d Cir. 1999)). Unsupported diagnoses are not entitled to great weight. Jones v. Sullivan,
954 F.2d 125, 129 (3d Cir. 1991). Moreover, an administrative law judge must provide the reason
for providing more or less weight to the evidence. See Fragnoti v. Massanari, 247 f.3d 34, 42 (3d
The claimant is not disabled if his RFC allows him to perform his past relevant work. 20
§ 416.920(a)(4)(iv). However, if the claimant’s RFC prevents him
from doing so, an
administrative law judge proceeds to the fiflh and final step of the process. Id. The final step
requires the administrative law judge to “show [that] there are other jobs existing in significant
numbers in the national economy which the claimant can perform, consistent with her medical
impairments, age, education, past work experience, and [Rf C].” Fhtmmer, 186 F.3d at 428. In
doing so, “[t]he ALl must analyze the cumulative effect of all the claimant’s impairments in
detenTlining whether she is capable of perfonning work and is not disabled.” Id. (citation omitted).
Notably, an administrative law judge typically seeks the assistance of a vocational expert at this
final step. Id. (citation omitted).
The claimant bears the burden of proof for steps one, two, and four. Sykes v. Apfel, 228
F.3d 259, 263 (3d Cir. 2000). Neither side bears the burden of proof for step three “[b]ecause step
three involves a conclusive presumption based on the listings
Id. at 263 n.2 (citing Bowen
v. Yuckert, 482 U.S. 137, 146-47 n.5 (1987)). An administrative law judge bears the burden of
proof for the final step. See Id. at 263.
Both parties have narrowed the issue to whether or not AU erred at step-four of the analysis
when she determined Plaintiff’s RFC. (ECF No. 10 at 33; ECF No. 11 at 16). specifically, the
question is whether AU erred when she assigned no weight to Dr. Fulford and Dr. Bansil’s
diagnoses of Plaintiff
This Court declines to assess whether substantial evidence supports
assigning no weight to Dr. Fulford’s diagnosis because AU erred, as a matter of law, when she
assigned no weight to Dr. Bansil’s diagnoses. The Third Circuit directive is clear that “[a]n ALl
may reject a treating physician’s opinion outright only on the basis of contradictory medical
evidence, but may afford a treating physician’s opinion more or less weight depending upon the
extent to which supporting explanations are provided.”
Hoyinan, 606 F ed.Appx. at 679-80
(quoting Plttmmcr, 186 F.3d at 429) (emphasis added). Here, AL
in determining the weight to
afford to Dr. Bansil’s diagnoses, reasoned that the doctor’s diagnoses were without explanation
and were in connection with a state program with unknown criteria. (R. 53-53). In other words,
because supporting explanations were lacking in Dr. Bansil’s diagnoses, AU outright rejected all
of its probative value. ALl’s reasoning may have been sufficient to provide less weight to Dr.
Bansil’s diagnoses, but was insufficient, as a matter of law, to assign it no weight. Hoyman, 606
F. App’x at 679-80.
Accordingly, ALl erred when she assigned no weight to Dr. Bansil’s
diagnoses for lack of explanation. As such, this matter shall be remanded for further proceedings
consistent with this Opinion.
For the aforementioned reasons, the Court remands this matter for further proceedings that
are consistent with the instructions contained herein. An appropriate Order accompanies this
DATED: AugustJ20 17
Judge, United States District Court
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