Santiago v. Commissioner of Social Security
Filing
17
DECISION AND ORDER granting 13 Motion for Judgment on the Pleadings. For the foregoing reasons, Plaintiff's Motion for Judgment on the Pleadings (Docket No. 13) is GRANTED, and this case is remanded for further administrative proceedings consistent with this Decision and Order. The Clerk is directed to enter final judgment in favor of the Plaintiff and then close the file. (Signed by Magistrate Judge Gary R. Jones on 1/27/25) (yv)
UNITED STATES DISTRICT COURT
SOUTHERN DISTRICT OF NEW YORK
----------------------------------------------------EMILSE S.,
Plaintiff,
DECISION AND ORDER
1:24-CV-03732-GRJ
v.
COMMISSIONER OF SOCIAL SECURITY,
Defendant.
----------------------------------------------------GARY R. JONES, United States Magistrate Judge:
In February of 2020, Plaintiff Emilse S. 1 applied for Disability
Insurance Benefits under the Social Security Act. The Commissioner of
Social Security denied the application. Plaintiff, represented by Ny
Disability, LLC, Daniel Berger, Esq., of counsel, commenced this action
seeking judicial review of the Commissioner’s denial of benefits under 42
U.S.C. §§ 405 (g) and 1383 (c)(3). The parties consented to the jurisdiction
of a United States Magistrate Judge. (Docket No. 9).
This case was referred to the undersigned on October 8, 2024.
Presently pending is Plaintiff’s Motion for Judgment on the Pleadings
pursuant to Rule 12 (c) of the Federal Rules of Civil Procedure. (Docket
Plaintiff’s name has been partially redacted in compliance with Federal Rule of Civil
Procedure 5.2 (c)(2)(B) and the recommendation of the Committee on Court
Administration and Case Management of the Judicial Conference of the United States.
1
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No. 13). For the following reasons, Plaintiff’s motion is due to be granted,
and this case is remanded for further administrative proceedings.
I. BACKGROUND
A.
Administrative Proceedings
Plaintiff applied for benefits on February 27, 2020, alleging disability
beginning April 27, 2019. (T at 10, 66). 2 Plaintiff’s application was denied
initially and on reconsideration. She requested a hearing before an
Administrative Law Judge (“ALJ”).
A hearing was held on May 8, 2023, before ALJ Angela Banks. (T at
29-56). Plaintiff appeared with an attorney and testified. (T at 37-50). The
ALJ also received testimony from a vocational expert. (T at 51-54).
B.
ALJ’s Decision
On August 2, 2023, the ALJ issued a decision denying the application
for benefits. (T at 7-23). The ALJ found that Plaintiff had not engaged in
substantial gainful activity since April 27, 2019 (the alleged onset date) and
meets the insured status requirements of the Social Security Act through
December 31, 2024 (the date last insured). (T at 12).
The ALJ concluded that Plaintiff’s schizophrenia spectrum disorder,
2
Citations to “T” refer to the administrative record transcript at Docket No. 10.
2
bipolar disorder, and anxiety disorder were severe impairments as defined
under the Act. (T at 12).
However, the ALJ found that Plaintiff did not have an impairment or
combination of impairments that met or medically equals one of the listed
impairments in 20 CFR Part 403, Subpart P, Appendix 1. (T at 13).
At step four of the sequential analysis the ALJ determined that
Plaintiff retained the residual functional capacity (“RFC”) to perform a full
range of work at all exertional levels, with the following non-exertional
limitations: she can tolerate no more than occasional exposure to
respiratory irritants, as that term is defined by the Selected Characteristics
of Occupations in the Dictionary of Occupational Titles (“DOT”); she can
understand, remember, and carry out simple instructions; use judgment to
make simple work-related decisions; occasionally interact with supervisors,
coworkers, and the public; and occasionally deal with changes in a routine
work setting. (T at 15).
The ALJ concluded that Plaintiff could not perform her past relevant
work as a commercial cleaner. (T at 17).
However, considering Plaintiff’s age (46 on the alleged onset date),
education (limited), work experience, and RFC, the ALJ determined that
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there were jobs that exist in significant numbers in the national economy
that Plaintiff can perform. (T at 17-18).
As such, the ALJ found that Plaintiff had not been under a disability,
as defined under the Social Security Act, and was not entitled to benefits
for the period between April 27, 2019 (the alleged onset date) and August
2, 2023 (the date of the ALJ’s decision). (T at 18-19).
On April 5, 2024, the Appeals Council denied Plaintiff’s request for
review, making the ALJ’s decision the Commissioner’s final decision. (T at
1-6).
C.
Procedural History
Plaintiff commenced this action, by and through her counsel, by filing
a Complaint on May 15, 2024. (Docket No. 1). On October 28, 2024,
Plaintiff filed a motion for judgment on the pleadings, supported by a
memorandum of law. (Docket Nos. 13, 14). The Commissioner interposed
a brief in opposition to the motion and in support of a request for judgment
on the pleadings on December 31, 2024. (Docket No. 15). On January 24,
2024, Plaintiff submitted a reply memorandum of law in further support of
her motion. (Docket No. 16).
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II. APPLICABLE LAW
A.
Standard of Review
“It is not the function of a reviewing court to decide de novo whether a
claimant was disabled.” Melville v. Apfel, 198 F.3d 45, 52 (2d Cir. 1999).
The court’s review is limited to “determin[ing] whether there is substantial
evidence supporting the Commissioner's decision and whether the
Commissioner applied the correct legal standard.” Poupore v. Astrue, 566
F.3d 303, 305 (2d Cir. 2009) (per curiam).
The reviewing court defers to the Commissioner's factual findings,
which are considered conclusive if supported by substantial evidence. See
42 U.S.C. § 405(g). “Substantial evidence” is “more than a mere scintilla”
and “means such relevant evidence as a reasonable mind might accept as
adequate to support a conclusion.” Lamay v. Commissioner of Soc. Sec.,
562 F.3d 503, 507 (2d Cir. 2009) (internal quotations omitted) (quoting
Richardson v. Perales, 402 U.S. 389, 401 (1971)).
“In determining whether the agency's findings are supported by
substantial evidence, the reviewing court is required to examine the entire
record, including contradictory evidence and evidence from which
conflicting inferences can be drawn.” Talavera v. Astrue, 697 F.3d 145,
151 (2d Cir. 2012) (internal quotations omitted).
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“When there are gaps in the administrative record or the ALJ has
applied an improper legal standard,” or when the ALJ’s rationale is unclear,
remand “for further development of the evidence” or for an explanation of
the ALJ’s reasoning is warranted. Pratts v. Chater, 94 F.3d 34, 39 (2d Cir.
1996).
B.
Five-Step Sequential Evaluation Process
Under the Social Security Act, a claimant is disabled if he or she
lacks the ability “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).
A claimant’s eligibility for disability benefits is evaluated pursuant to a
five-step sequential analysis:
1. The Commissioner considers whether the claimant is
currently engaged in substantial gainful activity.
2. If not, the Commissioner considers whether the claimant has
a “severe impairment” which limits his or her mental or physical
ability to do basic work activities.
3. If the claimant has a “severe impairment,” the Commissioner
must ask whether, based solely on medical evidence, claimant
has an impairment listed in Appendix 1 of the regulations. If the
claimant has one of these enumerated impairments, the
Commissioner will automatically consider him disabled, without
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considering vocational factors such as age, education, and
work experience.
4. If the impairment is not “listed” in the regulations, the
Commissioner then asks whether, despite the claimant's severe
impairment, he or she has residual functional capacity to
perform his or her past work.
5. If the claimant is unable to perform his or her past work, the
Commissioner then determines whether there is other work
which the claimant could perform.
See Rolon v. Commissioner of Soc. Sec., 994 F. Supp. 2d 496, 503
(S.D.N.Y. 2014); see also 20 C.F.R. §§ 404.1520(a)(4)(i)–(v),
416.920(a)(4)(i)–(v).
The claimant bears the burden of proof as to the first four steps; the
burden shifts to the Commissioner at step five. See Green-Younger v.
Barnhart, 335 F.3d 99, 106 (2d Cir. 2003). At step five, the Commissioner
determines whether the claimant can perform work that exists in significant
numbers in the national economy. See Butts v. Barnhart, 416 F.3d 101,
103 (2d Cir. 2005); 20 C.F.R. § 404.1560(c)(2).
III. DISCUSSION
Social Security proceedings are non-adversarial and the ALJ is
obliged “to investigate the facts and develop the arguments both for and
against granting benefits.” Sims v. Apfel, 530 U.S. 103, 111, 147 L. Ed. 2d
80, 120 S. Ct. 2080 (2000) (citation omitted). This obligation applies even if,
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as is the case here, the claimant is represented by counsel. See, e.g.,
Rosa v. Callahan, 168 F.3d 72, 79 (2d Cir. 1999)(citing Perez v. Chater, 77
F.3d 41, 47 (2d Cir. 1996)).
The ALJ’s duty to develop the record has been described as a
“bedrock principle of Social Security law.” Batista v. Barnhart, 326
F.Supp.2d 345, 353 (E.D.N.Y.2004)(citing Brown v. Apfel, 174 F.3d 59 (2d
Cir.1999)).
Further, “an ALJ has a heightened duty to develop the record when a
claimant asserts a mental impairment.” Gabrielsen v. Colvin, No. 12-CV5694 KMK PED, 2015 WL 4597548, at *4-5 (S.D.N.Y. July 30,
2015)(collecting cases). “This ‘heightened duty’ derives from the fact that a
claimant’s mental illness may greatly impede an evaluator’s assessment of
a claimant’s ability to function in the workplace, thus necessitating a more
thorough review.” Piscope v. Colvin, 201 F. Supp. 3d 456, 462-63
(S.D.N.Y. 2016).
In the present case, Dr. Siddhartha Nadkarni, Plaintiff’s treating
neurologist, provided a letter dated September 9, 2021, in which he
diagnosed bipolar 1 disorder and stated that Plaintiff was “medically
disabled and unable to work.” (T at 411).
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The ALJ noted (correctly) that Dr. Nadkarni’s conclusory statement
that Plaintiff was “medically disabled and unable to work” is not entitled to
any persuasive power. (T at 17). See 20 C.F.R. § 404.1520b(c) (statement
on an issue reserved to the Commissioner, such as a statement that a
claimant is or is not disabled, is evidence that “is inherently neither valuable
nor persuasive to the issue of whether [a claimant is] disabled.”)
The ALJ further found that Dr. Nadkarni’s objective treatment records
did not “support debility from a psych or medical perspective.” (T at 17).
The record also contains a letter from Dr. Leonardo Vando, a
psychiatrist, who reported that Plaintiff had been treating with his office for
more than six years, was diagnosed with psychotic depression and anxiety
state unspecified, and was treated with prescription medication. (T at 412).
Dr. Vando did not provide an assessment of Plaintiff’s ability to meet the
mental demands of basic work activity.
For the following reasons the Court finds that the ALJ erred by
determining Plaintiff’s RFC without requesting a functional assessment
from Dr. Nadkarni and/or Dr. Vando.
The Second Circuit has long recognized the value of treating source
opinions when reviewing claims involving mental impairments. See Flynn
v. Comm'r of SSA, 729 F. App'x 119, 122 (2d Cir. 2018)(“The treatment
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provider’s perspective would seem all the more important in cases involving
mental health, which are not susceptible to clear records such as [x-rays] or
MRIs. Rather, they depend almost exclusively on less discretely
measurable factors, like what the patient says in consultations.”).
Although the “treating physician rule” no longer applies, this principle
persists, as the opportunity to observe and treat the claimant constitutes
important “support” for a medical opinion under the new regulations. See,
e.g., Raymond M. v. Comm'r of Soc. Sec., No. 5:19-CV-1313 (ATB), 2021
U.S. Dist. LEXIS 32884, at *28 (N.D.N.Y. Feb. 22, 2021).
“As the amended regulations note, ‘[a] medical source may have a
better understanding of your impairment(s) if he or she examines you than
if the medical source only reviews evidence in your folder.’” Id. (quoting 20
C.F.R. §§ 404.1520c(c)(3)(v), 416.920c(c)(3)(v))); see also Cuevas v.
Comm'r of Soc. Sec., No. 20-CV-0502 (AJN) (KHP), 2021 U.S. Dist. LEXIS
19212, at *25-26 (S.D.N.Y. Jan. 29, 2021)(“A survey of … cases … show[s]
that while the treating physician’s rule was modified, the essence of the rule
remains the same, and the factors to be considered in weighing the various
medical opinions in a given claimant’s medical history are substantially
similar.”)(collecting cases).
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“Even though ALJs are no longer directed to afford controlling weight
to treating source opinions—no matter how well supported and consistent
with the record they may be—the regulations still recognize the
‘foundational nature’ of the observations of treating sources, and
‘consistency with those observations is a factor in determining the value of
any [treating source’s] opinion.’” Shawn H. v. Comm'r of Soc. Sec., No.
2:19-CV-113, 2020 WL 3969879, at *6 (D. Vt. July 14, 2020)(quoting
Barrett v. Berryhill, 906 F.3d 340, 343 (5th Cir. 2018)).
Here, the ALJ’s determination that Plaintiff retained the RFC to meet
the mental demands of a reduced range of work was based on her
conclusion that the treatment record “show[ed] essentially normal findings
on mental status exam ….” (T at 16).
As the Commissioner concedes (Docket No. 15, at p. 17-18),
however, the record documents significant symptomology, particularly
during periods of increased stress. These symptoms included panic
attacks (T at 290-294, 296-299, 379-383, 390-391, 481-482, 492, 574-576),
self-harm (T at 43, 44, 46, 290-294, 372, 373, 392-393), hallucinations (T at
290-294, 368, 379-383, 393-394), and poor insight and judgment. (T at 89,
393-394, 481-482, 492, 500, 507-509, 515-517, 523-525, 533-535).
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Although the record demonstrates periods of improvement and
relative stability in Plaintiff’s mental functioning, the ALJ overrated the
relevance of Plaintiff’s ability to occasionally maintain appropriate
attendance and affect during brief, relatively infrequent encounters with
supportive medical professionals.
The Commissioner’s regulations recognize that a claimant’s “ability to
complete tasks in settings that are highly structured, or that are less
demanding or more supportive than typical work settings does not
necessarily demonstrate [her] ability to complete tasks in the context of
regular employment during a normal workday or work week.” 20 C.F.R.
Subpt. P, App. 1 § 12.00 (C) (6) (b); see also Primo v. Berryhill, 17 Civ.
6875, 2019 U.S. Dist. LEXIS 27074, at *31 (S.D.N.Y. Feb. 19, 2019)(noting
that ALJs must recognize that “the effects of a mental health issue may be
different in a work setting than in a non-work setting”); Flynn v. Comm’r of
Soc. Sec. Admin., 729 Fed. Appx. 119, 121 (2d Cir. 2018)(decision to
discount opinion based on treatment notes indicating claimant was “wellgroomed and with calm affect” was “an assessment ... beyond the scope of
the ALJ’s authority”).
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Indeed, the primary question presented is whether, and to what
extent, would Plaintiff’s symptoms be exacerbated if she was exposed to
the demands of competitive, remunerative work on a consistent basis.
Although Dr. Nadkarni’s September 2021 letter is not entitled to any
persuasive power on its own, a treating neurologist’s statement that he
believed Plaintiff could not meet the mental demands of basic work activity,
combined with the significant symptomology documented in the record,
particularly during periods of stress, triggered the ALJ’s duty to re-contact
Dr. Nadkarni and request a functional assessment and explanation for his
belief that Plaintiff could not maintain employment.
Likewise, although Dr. Vando’s treatment notes are in the record,
there is no evidence that the ALJ contacted Dr. Vando to obtain a
functional assessment, notwithstanding Dr. Vando’s statement that they
should “feel free to contact us if you need additional information.” (T at
412).
“It is not sufficient for the ALJ simply to secure raw data from the
treating physician. What is valuable about the perspective of the treating
physician—what distinguishes him from the examining physician and from
the ALJ—is his opportunity to develop an informed opinion as to the …
status of a patient.” Robins v. Astrue, No. CV-10-3281 FB, 2011 WL
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2446371, at *4 (E.D.N.Y. June 15, 2011)(quoting Peed v. Sullivan, 778 F.
Supp. 1241, 1246 (E.D.N.Y.1991)(emphasis original); see also Skartados
v. Comm'r of Soc. Sec., No. 20-CV-3909 (PKC), 2022 WL 409701, at *4
(E.D.N.Y. Feb. 10, 2022)(noting that “an ALJ must attempt to obtain
medical opinions—not just medical records—from a claimant’s treating
physicians”)(citing Prieto v. Comm'r of Soc. Sec., No. 20-CV-3941 (RWL),
2021 WL 3475625, at *10–11 (S.D.N.Y. Aug. 6, 2021) (collecting cases)).
The duty to develop the record, which includes re-contacting treating
physicians when needed to afford the claimant a full and fair hearing based
on an adequately developed record, applies to claims governed by the new
medical opinion regulations. See, e.g., Snoke v. Comm'r of Soc. Sec., No.
22-CV-3708 (AMD), 2024 WL 1072184, at *9 (E.D.N.Y. Mar. 12, 2024);
Fintz v. Kijakazi, No. 22-CV-00337(KAM), 2023 WL 2974132, at *7
(E.D.N.Y. Apr. 15, 2023); Cheryl W. v. Kijakazi, No. 3:22-CV-1476 (VAB),
2024 WL 1012923, at *5 (D. Conn. Mar. 8, 2024); Daniela B. v. Kijakazi,
675 F. Supp. 3d 305, 316 (E.D.N.Y. 2023); see also Ramos v. Comm'r of
Soc. Sec., No. 20-CV-9436 (OTW), 2023 WL 3380660, at *2 (S.D.N.Y. May
11, 2023).
While the Court recognizes that some support for the ALJ’s decision
is found in the opinion of Dr. W. Amory Carr, who performed a consultative
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psychiatric evaluation via videoconference in May of 2020, Dr. Carr
diagnosed unspecified depressive disorder and unspecified anxiety
disorder and opined that Plaintiff had no limitation in her ability to
understand, remember, or apply simple or complex directions; use reason
and judgment to make work-related decisions; sustain concentration and
perform at consistent pace; sustain an ordinary routine and regular
attendance at work; maintain personal hygiene and appropriate attire; and
be aware of normal hazards and take appropriate precautions. (T at 29293).
Although the Second Circuit has long cautioned that “ALJs should not
rely heavily on the findings of consultative physicians after a single
examination,” Selian v. Astrue, 708 F.3d 409, 419 (2d Cir. 2013)(citing Cruz
v. Sullivan, 912 F.2d 8, 13 (2d Cir. 1990)) “[t]his concern is even more
pronounced in the context of mental illness where … a one-time snapshot
of a claimant's status may not be indicative of her longitudinal mental
health.” Estrella v. Berryhill, 925 F.3d 90, 98 (2d Cir. 2019).
Moreover, Dr. Carr’s assessment appears to be at odds with several
aspects of his examination, including Plaintiff’s report that she was
terminated from employment due to excessive absences, as well as her
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inability to perform serial 7s, impaired memory skills, below average
cognitive functioning, and “fair” insight and judgment. (T at 290, 292).
Lastly, Dr. Carr himself believed Plaintiff had moderate impairment in
her ability to interact with others, regulate her emotions, control behavior,
and maintain well-being. (T at 292-93). Thus, the question is not whether
Plaintiff’s ability to meet the mental demands of basic work activity is
limited, but rather to what extent she is so impaired. It was error for the
ALJ to assess the extent of Plaintiff’s limitations without seeking a
functional assessment from a treating provider.
Accordingly, for the reasons discussed above, the Court finds that the
ALJ erred by determining that Plaintiff’s undisputed mental limitations did
not preclude her from maintaining competitive, remunerative employment
without further development of the record. A remand is required. 3
B.
Remand
“Sentence four of Section 405 (g) provides district courts with the
authority to affirm, reverse, or modify a decision of the Commissioner ‘with
or without remanding the case for a rehearing.’” Butts v. Barnhart, 388 F.3d
377, 385 (2d Cir. 2002) (quoting 42 U.S.C. § 405 (g)). Remand for further
Plaintiff also challenges the ALJ’s assessment of her ability to maintain attention and
attendance and the ALJ’s step five analysis. These issues will necessarily need to be
revisited on remand after further development of the record as directed above.
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administrative proceedings is the appropriate remedy “[w]here there are
gaps in the administrative record or the ALJ has applied an improper legal
standard.” Rosa v. Callahan, 168 F.3d 72, 82-83 (2d Cir. 1999); see also
Rhone v. Colvin, No. 13-CV-5766 (CM)(RLE), 2014 U.S. Dist. LEXIS
180514, at *28 (S.D.N.Y. Nov. 6, 2014).
For the reasons outlined above, the Court concludes that a remand is
necessary for further development of the record.
IV. CONCLUSION
For the foregoing reasons, Plaintiff’s Motion for Judgment on the
Pleadings (Docket No. 13) is GRANTED, and this case is remanded for
further administrative proceedings consistent with this Decision and Order.
The Clerk is directed to enter final judgment in favor of the Plaintiff and then
close the file.
s/ Gary R. Jones
Dated: January 27, 2025
GARY R. JONES
United States Magistrate Judge
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