Jackson v. Astrue

Filing 12

DECISION AND ORDER granting judgment on the pleadings in favor of plaintiff and remanding this matter to the Social Security Administration for the calculation of benefits. Signed by Hon. Michael A. Telesca on 1/17/12. (JMC)

UNITED STATES DISTRICT COURT
WESTERN DISTRICT OF NEW YORK
___________________________________________________
GREGORY JACKSON,
Plaintiff,

09-CV-6497T
DECISION
and ORDER

v.
MICHAEL J. ASTRUE, Commissioner
of Social Security

Defendant.
___________________________________________________

INTRODUCTION
Plaintiff Gregory Jackson (“Plaintiff”) brings this action
pursuant to 42 U.S.C. § 405(g) of the Social Security Act (“the
Act”) seeking review of a final decision of the Commissioner of
Social

Security

(“Commissioner”),

denying

his

application

for

Supplemental Security Income (“SSI”).
The Commissioner moves for judgment on the pleadings pursuant
to Federal Rule of Civil Procedure 12(c) (“Rule 12(c)”) on the
grounds that the Administrative Law Judge’s (“ALJ”) decision was
supported

by

substantial

evidence.

Plaintiff

opposes

the

Commissioner’s motion and cross-moves for judgment on the pleadings
pursuant to Rule 12(c), on grounds that the Commissioner’s decision
was erroneous and not supported by substantial evidence in the
record.

For

the

Commissioner’s

reasons

motion

set

for

forth

judgment

below,
on

I

the

hereby

deny

pleadings,

the

grant

Plaintiff’s motion for judgment on the pleadings, and remand this
1

case to the Social Security Administration for calculation and
payment of benefits.
BACKGROUND
On March 5, 2003, Plaintiff protectively filed an application
for SSI alleging disability beginning January 5, 2001. On May 23,
2003, Plaintiff’s application was denied. Subsequently, Plaintiff
filed

a

timely

Approximately

request

four

years

for

a

later,

hearing
on

June

on

July

26,

2007,

22,

2003.

Plaintiff

appeared at a video hearing before ALJ Jan K. Michalski. In a
decision dated July, 26, 2007, the ALJ determined that Plaintiff
had severe impairments, but he retained the residual functional
capacity (“RFC”) to perform light work with certain limitations.
Two years later, on July 29, 2009, the ALJ’s decision became the
Commissioner’s final decision after the Appeals Council denied
Plaintiff’s request for review. Upon the denial by the Appeals
Council, Plaintiff timely filed the instant action.
DISCUSSION
42 U.S.C. § 405(g) grants jurisdiction to district courts to
hear claims based on the denial of Social Security benefits.
Additionally, the section directs that when considering such a
claim, the Court must accept the findings of fact made by the
Commissioner,

provided

that

such

findings

are

supported

by

substantial evidence in the record. Substantial evidence is defined
as, “such relevant evidence as a reasonable mind might accept as
2

adequate to support a conclusion.” Consolidated Edison Co. v. NLRB,
305 U.S. 197, 217 (1938). Section 405(g) thus limits the Court’s
scope of review to determining whether or not the Commissioner’s
findings were supported by substantial evidence. See Mongeur v.
Heckler

722

F.2d

1033,

1038

(2d

Cir.

1983)

(finding

that

a

reviewing Court does not try a benefits case de novo). The Court is
also authorized to review the legal standards employed by the
Commissioner in evaluating plaintiff’s claim.
The Court must “scrutinize the record in its entirety to
determine the reasonableness of the decision reached.” Lynn v.
Schweiker,

565

F.

Supp.

265,

267

(S.D.

Tex.

1983)

(citation

omitted). The Commissioner asserts that his decision was reasonable
and is supported by substantial evidence in the record, and moves
for judgment on the pleadings pursuant to Rule 12(c). Judgment on
the pleadings may be granted under Rule 12(c) where the material
facts are undisputed and where judgment on the merits is possible
merely by considering the contents of the pleadings. Sellers v.
M.C. Floor Crafters, Inc., 842 F.2d 639 (2d Cir. 1988). If, after
a review of the pleadings, the Court is convinced that Plaintiff
has not plead a plausible claim for relief, judgment on the
pleadings may be appropriate. See Bell Atlantic v. Twombly, 550
U.S. 544 (2007).

3

The ALJ’s decision denying Plaintiff’s application for disability
benefits is not supported by substantial evidence and is based on
errors of law.
In her decision, the ALJ found that Plaintiff was not disabled
within the meaning of the Social Security Act (“the Act”). The ALJ
adhered

to

the

Social

Security

Administration’s

five-step

sequential analysis in determining disability benefits. See 20
C.F.R. § 404.1520. At step one, the ALJ considers whether the
claimant is currently engaged in substantial gainful activity. If
the claimant is not engaged in substantial gainful activity at
Step Two, the ALJ considers whether the claimant has a severe
impairment

which

significantly

limits

his

physical

or

mental

ability to do basic work activities. If the claimant suffers from
an impairment that is listed in Appendix 1 of Subpart P of the
Social

Security

analysis,

the

Regulations,
claimant

will

pursuant
be

to

Step

considered

Three

disabled

of

the

without

considering other factors. If the claimant does not have a listed
impairment, the ALJ will move to Step Four of the analysis and
determine whether or not the claimant, despite his impairments,
retains the residual functional capacity to perform his past work.
Finally, if the claimant is unable to perform any past work, at
Step Five of the analysis, the ALJ will determine whether the
claimant can perform other work in the local or national economy.
Here,

at

Step

One

of

the

analysis,

the

ALJ

found

that

Plaintiff had not engaged in substantial gainful activity since the

4

alleged disability onset date of January 5, 2001. (Transcript of
Administrative Proceedings at 18 (“Tr.”). At Steps Two and Three,
the ALJ concluded that Plaintiff’s impairments, which include
disorders of the back (discogenic and degenerative), affective
disorders,

depression,

and

drug

addiction/alcohol

abuse,

were

“severe” within the meaning of the Regulations. However, the ALJ
concluded that Plaintiff’s impairments did not meet or equal,
either singly or in combination, any of the impairments listed in
Appendix 1, Subpart P. (Tr. at 18).
Under Steps Four and Five of the sequential analysis, the ALJ
concluded that Plaintiff has the residual functional capacity
(“RFC”) to perform light work within the meaning of the regulations
with

the

following

limitations:

he

can

do

no

climbing

of

ropes/ladders/scaffolds and must have limited contact with the
general public. (Tr. at 20). At Step Four, the ALJ found that even
without the drug addiction/alcohol abuse, Plaintiff is unable to
perform any of his past relevant work. (Tr. at 22). At Step Five,
considering the claimant’s age, education, work experience, and
RFC, and absent drug addiction/alcohol abuse, the ALJ concluded
that there are jobs that exist in significant numbers in the
national economy that the Plaintiff can perform. Specifically, the
ALJ found that Plaintiff could work at light, low stress, routine
jobs. (Tr. at 22).

5

The Treating Physician’s Rule
A thorough examination of the record demonstrates that William
S. Beckett, M.D., and Berthollet Bavibidila, M.D., two of the
Plaintiff’s treating physicians, rendered opinions which should
have been given controlling weight under the treating physician
rule.

Pertinent

evaluations

from

each

physician’s

course

of

treatment with the Plaintiff are discussed below.
Dr. Beckett
Plaintiff has an extensive well-documented treatment history
with Dr. Beckett. Between August 2001 and January 2005, Plaintiff
was examined by Dr. Beckett approximately twenty times. Plaintiff
first presented to Dr. Beckett on August 7, 2001. At this initial
examination,

Dr.

Beckett

documented

an

extensive

history

of

Plaintiff’s condition, noting the existence of a back problem with
origins from his work performing manual labor at the Town of Gates
Highway Department. (Tr. at 206). After conducting a physical
examination, Dr. Beckett opined that Plaintiff had persistent low
back pain and pain in his calf concluding that Plaintiff was
temporarily permanently disabled. (Id.).
After conducting a physical examination on October 23, 2001,
Dr.

Beckett

opined

that

Plaintiff

had

symptomatic

lumbar

degenerative disc disease and thromboembolism1 in the left femoral
1

Thromboembolism is an embolism from a “clot in the
cardiovascular systems formed during life from constituents of
blood.” Thomas L. Stedman, Stedman’s Medical Dictionary, 1984-85
6

artery.

(Tr.

treatment

at

for

201).

the

On,

November

degenerative

disc

28,

2001,

disease

while

and

seeking

blood

clot,

Dr. Beckett opined that Plaintiff had reached “maximum medical
improvement” and had a “moderate 50% permanent partial disability
of the spine due to work-related degenerative disc disease.” (Tr.
at 199-200). Dr. Beckett encouraged him to seek job training so
that he could work within his restriction. (Id.).
After seeing Plaintiff on December 12, 2001 and March 12,
2002, Plaintiff presented to Dr. Beckett on June 3, 2002. After
physical

examination,

Dr.

Beckett

opined

that

Plaintiff

had

degenerative disc disease of the lumbar spine, a left ankle sprain,
intermittent pain and locking in his left elbow, and pain in his
calf. On July 8, 2002, Dr. Beckett noted that Plaintiff had been
following his treatment program and was in stable condition.
Plaintiff was given a work slip to return to work for a trial run
without

limitations.

(Tr.

at

194).

On

July

19,

2002,

after

attempting to return to unrestricted work, Plaintiff returned to
Dr. Beckett exhibiting a recurrence of his work-related back
injury. (Tr. at 193). Dr. Beckett concluded that it would not be
“safe for him” to return to work in that current position. (Id.).
According to Dr. Beckett, Plaintiff was still partially disabled.
(Id.).

(28th ed. 2006).
7

Dr. Beckett examined Plaintiff on August 5, 2002, and found
that Plaintiff had an exacerbation of degenerative disc disease of
the spine related to his work injury and that Plaintiff was still
temporarily

disabled.

(Tr.

at

192).

On

September

19,

2002,

Plaintiff presented to Dr. Beckett and was given a permanent work
restriction

due

to

Plaintiff’s

maximum

medical

improvement

regarding the degenerative disc disease of the spine. (Tr. at 190).
Plaintiff had a moderate marked 50% permanent partial disability of
the lumbar spine, with a 15 pound lifting restriction. (Id.). His
work restrictions were as follows: He must be able to stand or walk
at

will

and

without

uninterrupted

sitting,

no

long

distance

walking, limited bending, squatting and stooping; no crawling,
climbing heights, or kneeling, lifting restriction of no more than
15 pounds, and pushing and pulling restrictions of no more than 50
pounds. At this point, Plaintiff also had a mild 7.5% permanent
partial disability of the right ankle, and a mild 10% permanent
partial disability of the left elbow. (Tr. at 191).
On November 18, 2002, Plaintiff was evaluated by Dr. Beckett
for

his

degenerative

disc

disease

of

the

lumbar

spine,

thromboembolism of the left femoral artery, ankle sprain, and elbow
pain. (Tr. at 188). However, Dr. Beckett noted that Plaintiff “is
now presenting with new symptoms of depression, which I believe are
due to chronic pain and loss of function.” (Id.). Plaintiff was

8

referred to a social worker for his “reactive depression due to
pain and loss of function.” (Id.).
On April 21, 2003, Plaintiff was seen by Dr. Beckett who made
two new observations. First, Plaintiff had a new diagnosis of
diabetes. Second, Dr. Beckett stated “[m]ost important now is
treatment of [Plaintiff’s] depression, which is in part related to
his

work-related

injury,

but

for

which

he

has

a

previous

history.”(Tr. at 186). He referred Plaintiff to Park Ridge Hospital
Mental Health for psychological and psychiatric treatment. (Id.) On
June 11, 2003, during a follow-up examination, Dr. Beckett noted
that Plaintiffs reactive depression had become more severe and was
very active. (Tr. at 395).
Plaintiff was seen by Dr. Beckett on January 13, 2004 (Tr. at
398) and again on May 18, 2004 (Tr. at 344), when he noted
Plaintiff’s five day hospitalization in a psychiatric unit for his
active, severe depression. (Id.). Dr. Beckett opined that although
he was still permanently partially disabled from his work related
injuries, Plaintiff’s most limiting factor was now his reactive
depression. (Id. at 345).
Dr. Beckett saw Plaintiff on August 6, 2004 (Tr. at 342) and
on December 20, 2004 and concluded that Plaintiff was temporarily
partially disabled due to his reactive depression from chronic pain
and

loss

of

Dr.

Beckett

function.
met

with

(Tr.

at

Plaintiff

9

339).
and

On

January

opined

that

31,

2005,

Plaintiff’s

disability status had not changed and that he remains totally
disabled in large part, due to his depression. (Tr. at 347).
Plaintiff was seen by Dr. Beckett on June 7, 2007, for a
social security evaluation. (Tr. at 316). Dr. Beckett stated that
he needed additional information from certain sources to complete
his evaluation. (Id.). On June 19, 2007, Dr. Beckett completed an
RFC evaluation. (Tr. at 400). On July 13, 2007, after reviewing all
of the information available to him, Dr. Beckett concluded that
Plaintiff has been totally disabled since January 19, 2004 and that
“neither alcohol nor drug use has significantly caused any portion
of [Plaintiff’s] disability during these periods.” (Tr. at 405).
Dr. Bavibidila
Dr. Bavibidila was Plaintiff’s primary care physician and was
responsible for referring Plaintiff to Dr. Beckett. (Tr. at 178).
On February 14, 2001, Plaintiff was seen by Dr. Bavibidila for
cardiomyopathy and hypertension. (Tr. at 184). Dr. Bavibidila noted
that the “[c]ardiomyopathy, multifactorial, most likely related to
alcohol abuse and uncontrolled hypertension” and that “[p]atient
has stopped smoking and drinking alcohol.” (Id.).

Dr. Bavibidila

met with Plaintiff on May 9, 2001 and on June 6, 2001 and noted
that Plaintiff was an “ex-heavy smoker,” “ex-heavy alcohol user,”
and “[e]x-cocaine user.” (Tr. at 180).

Due to work-related low

back pain, on July 3, 2001, Dr. Bavibidila opined that Plaintiff
was totally disabled until further evaluation. (Tr. at 178).

10

Plaintiff was seen by Dr. Bavibidila for a pneumonia-related
examination on March 22, 2002 (Tr. at 174), Plaintiff was seen
later by Dr. Bavibidila on July 16, 2002. During this evaluation,
Dr. Bavibidila noted pain and numbness in Plaintiff’s feet, workrelated

low

back

pain,

hypertension,

and

cardiomyopathy.

Dr. Bavibidila recorded that Dr. Beckett was closely following up
with

Plaintiff.

Bavibidila

on

(Tr.

at

November

172).

16,

Plaintiff

2002

who

next

noted

met

that

with

Dr.

Plaintiff’s

hypertension was uncontrolled due to a week long non-compliance
with medication. On March 5, 2003, Dr. Bavibidila confirmed that
plaintiff

had

hypertension,

obstructive

sleep

apnea,

morbid

obesity, and pain in his feet.
After approximately a year long gap in the record between
treatments, Plaintiff was seen by Dr. Bavibidila on April 4, 2004
at which time he updated Plaintiff’s medical history to include
hypertension, obesity, depression, osteoarthritis, work related
back pain, history of thromboembolism, renal failure, and a history
of depression. (Tr. at 358).
The record reflects that Plaintiff continued to meet with
Dr. Bavibidila throughout 2004, 2005, and 2006. During this period,
Dr. Bavibidila noted, among other medical issues, a hypercoagulable
state involving both arteries (Tr. at 328), the need for vascular
surgery to correct peripheral vascular disease (Tr. at 377), left
eye blurred vision (Tr. at 377), vein occlusion in the left eye

11

(Tr. at 386), and a history of depression (Tr. at 390). On November
11, 2006, Dr. Bavibidila stated that Plaintiff should apply for
social security benefits. (Tr. at 325).
Application of the treating physician rule
Having reviewed the record relevant to Plaintiff’s medical
history with Dr. Beckett and Dr. Bavibidila, this Court concludes
that the ALJ misapplied the treating physician rule in failing to
give their opinions controlling weight.
The treating physician rule requires that a medical opinion
given

by

a

claimant’s

treating

physician

should

be

“given

controlling weight if it is well supported by medical findings and
not inconsistent with other substantial record evidence.” Shaw v.
Chater,

221

F.3d

126,

134

(2d

Cir.

2000);

see

20

C.F.R.

§ 416.927(d). If the ALJ decides not to give controlling weight to
a treating physician’s opinion, he must provide “good reasons” for
discounting

the

opinion.

Schaal

v.

Apfel,

134

F.3d

496,

505

(2d Cir. 1998). Should the ALJ decide to discount the treating
physician’s opinion, he must examine the following factors to
determine how much weight to afford to the opinion: (1) the length
of the treatment relationship and the frequency of examination;
(2)

the

nature

and

extent

of

the

treatment

relationship;

(3) whether the treating physician presents relevant evidence to
support an opinion, particularly medical signs and laboratory
findings;

(4)

whether

the

treating

12

physician's

opinion

is

consistent with the record as a whole; (5) whether the treating
physician is a specialist in the area relating to his opinion; and
(6) other factors which tend to support or contradict the opinion.
Shaw,

221

F.3d

at

134;

see

20

C.F.R.

§§

404.1527(d)(2),

416.927(d)(2). Next, “[a]fter considering the factors, the ALJ must
‘comprehensively set forth [his] reasons for the weight assigned to
a treating physician's opinion.” Burgess v. Astrue, 537 F.3d 117,
129 (2d Cir. 2008).
The ALJ discounted both Dr. Beckett’s and Dr. Bavibidila’s
opinions on the basis that “there [was] no evidence showing that
the claimant [had] [overcame] his chronic/alcohol addiction.” (Tr.
at 22). The ALJ’s “good reason” for discounting Dr. Beckett’s
opinion is not supported by the medical evidence in the record and
both physician’s opinions should have been accorded controlling
weight.

Dr.

Beckett’s

treatment

history

is

well

documented

covering the period August 2001 to January 2005 during which he
examined

Plaintiff

20

times.

Plaintiff

also

met

with

Dr. Bavibidila (his primary care physician) starting February 14,
2001 to November 11, 2006
The record contains ample objective medical evidence from both
treating

physicians,

Dr.

Beckett

and

Dr.

Bavibidila,

that

Plaintiff’s disability is occasioned by his extensive, serious
medical problems and that his alcohol consumption and prior drug
use played no part in determining his disability. See (Tr. at 180)
13

(Plaintiff was described as an “ex-heavy drinker” or “ex-drug
user.”); (“neither alcohol nor drug use has significantly caused
any portion of [Plaintiff’s] disability during these periods.”).
(Tr. at 405).
In deciding to discount the treating physicians’ opinions, the
ALJ does not cite to any supportive medical evidence in determining
that Plaintiff’s alcohol or drug abuse are a material factor
contributing to his disability.

See

20 C.F.R. § 404.1527(d)(2).

Nor does the ALJ does cite to any document from the record, or any
medical opinion concluding that the Plaintiff has a chronic drug or
alcohol

abuse

problem

contributing

to

his

disability.

See

Goldthrite v. Astrue, 535 F. Supp. 2d 329, 334 (W.D.N.Y. 2008).
In the absence of a medical opinion to support the ALJ’s
decision, “the ALJ cannot arbitrarily substitute his own judgment
for competent medical opinion...[W]hile an [ALJ] is free to resolve
issues of credibility as to lay testimony or to choose between
properly submitted medical opinions, he is not free to set his own
expertise against that of a physician who [submitted an opinion to
or] testified before him. Balsamo v. Chater, 142 F.3d 75, 81 (2d
Cir. 1998) (quoting McBrayer v. Secretary of Health and Human
Servs., 712 F.2d 795, 799 (2d Cir. 1983).
Moreover, the ALJ gave no “good reason” for discounting
Dr. Beckett’s and Dr. Bavibidila‘s opinions, and failed to discuss
the required factors for determining what weight to give the
14

opinion. (Tr. at 22); see Shaw, 221 F.3d at 134.

The ALJ placed

undue weight on Plaintiff’s prior alcohol use and failed to give
proper weight to the extensive medical history of continuous
treatment to a combination of serious medical problems by treating
physicians, Dr. Beckett and Dr. Bavibidila.

In so doing, she

committed error warranting reversal since her decision denying a
finding of disability was not supported by substantial evidence.
The Plaintiff has met his burden of proving that alcoholism or
drug use was not a contributing factor material to determining his
disability within the meaning of the Act.

See Brueggermann v.

Barnhart, 348 F.3d 689 (8th Cir. 2003).
Based on a review of the entire record, this Court finds that
the

ALJ

erred

in

failing

to

give

controlling

weight

to

Dr. Beckett’s and Dr. Bavibidila’s opinions.
The ALJ incorrectly evaluated the Plaintiff’s credibility.
This Court finds that the ALJ did not properly evaluate the
testimony of Plaintiff and the medical evidence in finding that
Plaintiff is not disabled under the act.
Once an ALJ determines that an applicant suffered from a
medically determinable impairment that could reasonably be expected
to produce a claimant’s pain and other symptoms, he is required to
evaluate the intensity of these symptoms by the following factors:
(i) daily activities; (ii) the location, duration, frequency, and

15

intensity

of

the

claimant’s

pain

and

other

symptoms;

(iii) precipitating and aggravating factors; (iv) the type, dosage,
effectiveness,

and

side

effects

of

any

medications

taken

to

alleviate this pain or these symptoms; (v) other treatment used for
relief of these symptoms; (vi) any other measures used to relieve
the

pain

or

symptoms;

(vii)

other

factors

regarding

your

restrictions or limitations due to pain or symptoms. 20 C.F.R.
§ 404.1529(c)(3); SSR 96-07P.
“The ALJ has discretion to evaluate the credibility of a
claimant and to arrive at an independent judgment, in light of
medical findings and other evidence, regarding the true extent of
the pain alleged by the claimant.” Marcus v. Califano, 615 F.2d 23,
27 (2d Cir. 1979). If the ALJ finds the Plaintiff’s testimony not
credible,

the

ALJ

must

give

specific

reasons

for

the

weight

accorded to Plaintiff’s testimony. Bennett v. Astrue, 07-CV-0780
NAM, 2010 WL 3909530, *9 (N.D.N.Y. 2010). Here, at Step Two of the
sequential evaluation, the ALJ determined that Plaintiff suffered
from severe impairments, including both degenerative and discogenic
disorders of the back, affective disorders, depression, and drug
addiction/alcohol abuse. (Tr. at 18). However, the ALJ failed to
analyze the requisite factors for evaluating the intensity of the
symptoms related to these impairments.
It is worthy to note that at the outset of Plaintiff’s
testimony, the ALJ clearly indicated a predisposition evidenced in
16

her questioning that the Plaintiff’s disability was caused by his
drug and alcohol abuse. Immediately after Plaintiff was sworn in,
the ALJ asked:
Q:
A:

When is the last time that you had a, a drug screen
Mr. Jackson?
I think when I was working for the Town in Gaines
(sic)
...

Q:

Okay. . . . When is the last time, Mr. Jackson,
that you had any nonprescribed substances?
...

A:

Oh, drugs, it’s been it’s been ... for the last 3
years or so.
...
Okay. And what about alcohol?

Q:
A:

You know, I had, I had, I had a beer at the, when
we had my son’s 25th birthday - I had a couple of
beers.
...

Q:

And you don’t abuse drugs?

A:

No.

That’s been years ago.

(Tr. at 448-450).
The

ALJ

concluded

that

although

Plaintiff’s

treating

physician, Dr. Beckett indicated in a July 13, 2007 statement that
the claimant is totally disabled and has been so since January 19,
2004; and that neither alcohol nor drug use has significantly

17

caused any portion of the claimant’s disability. . . . “The
Administrative Law Judge gives little weight to this opinion
because there is no evidence showing that the claimant has overcome
his chronic/alcohol addiction.”

(Tr. at 22.)

The ALJ did not discuss any other reasons for her credibility
determination that Plaintiff’s addiction to drugs contributed to
his disability.
The

record

is

replete

with

establishing Plaintiff’s disability.

objective

medical

evidence

On November 6, 2006, when

the patient was seen by Dr. Bavibidila, his medical condition was
as follows:
-

-

-

He presented a complex medical history including
recurrent arterial thrombosis involving both femoral
arteries and also involving his left brachial artery,
status post umbilectomy.
History of chronic low back pain, status post acute renal
failure
with
acute
myopathy
requiring
emergency
hemodialysis.
History of non-ischemic cardiomyopathy.
History of obstructive sleep apnea who was complaining of
feeling poorly.
He is also blind in his left eye and complains of
fatigue, cannot walk upstairs, and wants to apply for
Social Security benefits.

The ALJ failed to consider any of the medications that Plaintiff
was prescribed during the relevant period, for both his psychiatric
and physical impairments. See (Tr. at 344)(listing four medications

18

for psychiatric needs and five medications for Plaintiff’s physical
needs).

His medications are (Tr. at 390):

-

Felodipine
Lisinopril
Clonidine
Metoprolol
HCTZ
Hydralazine
Coumadin
Pietal
Prozac

The

Plaintiff

was

seen

by

Dr.

Melvin

Zax,

PhD.

for

a

consultative psychiatric examination on May 8, 2003. He concluded,
“it is hard to be terribly optimistic about his prognosis, but I
would say that it is fair to poor.”
In

conclusion,

the

ALJ

made

(Tr. at 224.)
a

generalized

unsupported

statement for her credibility findings and, in doing so, failed to
take into account the substantial medical evidence in the record
support Plaintiff’s disability.
The records also document his seeking eye treatment with
Dr. James Reynolds, O.D., June through December 2006, who noted
occlusion with reduced visual acuity in the left eye.
271.)

(Tr. at 267,

Essentially, Jackson had blood clots and was prescribed

Coumadin.
In sum, the record reveals that the plaintiff was diagnosed
and treated for multiple severe medical problems which are well
19

documented in the record by doctors’ reports.

(Tr. at 149-2007.)

He was treated for hypertensive cardiovascular disease, congestive
heart failure, adult onset diabetes mellitus, acute renal failure
caused by intervenous dye, back pain caused by spine abnormalities,
disc bulging L4-5.

He sustained retinal vein occlusion with loss

of vision to the left eye.
found him to be “disabled.”

(Tr. at 267.)

His treating doctor

(Tr. at 325-26, 338-39.)

Plaintiff was diagnosed with serious back problems, a blood
deficiency which causes thrombosis (blood clots) which required
surgery in the past for their removal. He also has hypertensive
cardiovascular disease, and congestive heart failure.

A diagnosed

protein C+S deficiency is indicative that he is subject to blood
clots which require treatment by appropriate medication (Coumadin)
and followed by continual doctor care.
The

combination

supported

by

the

of

these

record,

medical

and

the

impairments,

opinions

of

which

his

are

treating

physicians provides substantial evidence to support a finding of
disability.
weight

to

It was error for the ALJ not to give controlling
the

opinions

of

Plaintiff’s

treating

physicians.

(Tr. 22.)
The ALJ placed improper emphasis on plaintiff’s prior drug and
alcohol use and justifies this finding based on her conclusion that
plaintiff was not credible.

In doing so, the ALJ did not give

proper weight to the extensive medical history of Plaintiff by his
20

treating

physicians.

disabling

and

the

Clearly,
Plaintiff

Plaintiff’s

would

be

limitations

considered

are

disabled

independent of any past drug or alcohol use which is not a
contributing
disability.

factor

material

to

the

determination

of

his

See 20 C.F.R. § 404.1535ii).
CONCLUSION

This Court finds that the Commissioner’s decision to deny SSI
benefits was not supported by substantial evidence in the record.
The record contains substantial evidence of a disability such that
further evidentiary proceedings would serve no purpose. I therefore
grant judgment on the pleadings in favor of Plaintiff and remand
this

matter

to

the

Social

Security

Administration

for

calculation of benefits.
ALL OF THE ABOVE IS SO ORDERED.
S/Michael A. Telesca
______________________________
MICHAEL A. TELESCA
United States District Judge
Dated:

Rochester, New York
January 17, 2012

21

the