Stackhouse v. Astrue
Filing
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-CLERK TO FOLLOW UP- ORDER granting plaintiff's 9 Motion for Judgment on the Pleadings; denying the Commissioner's 10 Motion for Judgment on the Pleadings. The Commissioner's decision that plaintiff was not disabled is reversed , and the matter is remanded for further proceedings. Upon remand, the Commissioner is instructed to request RFC reports and updated treatment records from all of plaintiff's treating sources with regard to her non-exertional (psychiatric) limitations, to order consultative examinations and obtain additional records as appropriate, and to redetermine plaintiff's disability status upon a full and complete record. Signed by Hon. David G. Larimer on 10/3/14. (EMA)
UNITED STATES DISTRICT COURT
WESTERN DISTRICT OF NEW YORK
_______________________________________________
LATOYA T. STACKHOUSE,
Plaintiff,
DECISION AND ORDER
12-CV-6474L
v.
CAROLYN W. COLVIN, Acting Commissioner
Of Social Security, 1
Defendant.
________________________________________________
Plaintiff appeals from a denial of supplemental security income and disability insurance
benefits by the Commissioner of Social Security (“the Commissioner”). The action is one brought
pursuant to 42 U.S.C. § 405(g) to review the final determination of the Commissioner.
On February 8 and February 13, 2009, plaintiff filed applications for disability insurance
and supplemental security income benefits under Title II of the Social Security Act, alleging a
disability onset date of May 6, 2002. Her applications were initially denied. (Administrative
Transcript (“T.”) at 11). Plaintiff requested a hearing, which was held on August 2, 2010 via
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Plaintiff’s complaint names former Commissioner of Social Security Michael J. Astrue as the defendant.
Carolyn W. Colvin, the current Acting Commissioner, automatically is substituted as the defendant pursuant to FED. R.
CIV. P. 25(d)(1).
videoconference before Administrative Law Judge (“ALJ”) Barry Peffley. (T. 27-62). Following
the hearing, the ALJ issued a decision on September 23, 2010, that plaintiff was not disabled under
the Social Security Act. Id. That decision became the final decision of the Commissioner when the
Appeals Council denied review on July 13, 2012 (T. 1-3).
Plaintiff has moved (Dkt. #9) for judgment on the pleadings pursuant to Fed. R. Civ. Proc.
12(c), requesting remand of the matter for additional development of the record. The Commissioner
has cross moved (Dkt. #10) pursuant to Fed. R. Civ. Proc. 12(c) for judgment on the pleadings
affirming the decision-appealed-from. For the reasons that follow, the Commissioner’s motion is
denied, plaintiff’s motion is granted, and the matter is remanded for further proceedings.
DISCUSSION
I.
Standard of Review
To determine whether a claimant is disabled within the meaning of the Social Security Act,
the ALJ proceeds through a five-step sequential evaluation. See Bowen v. City of New York, 476
U.S. 467, 470-71 (1986). At step one, the ALJ must determine whether the claimant is engaged in
substantial gainful work activity. See 20 CFR §404.1520(b). If so, the claimant is not disabled. If
not, the ALJ proceeds to step two, and determines whether the claimant has an impairment, or
combination of impairments, that is “severe,” e.g., that imposes significant restrictions on the
claimant's ability to perform basic work activities. 20 CFR §404.1520(c). If not, the analysis
concludes with a finding of “not disabled.” If so, the ALJ continues to step three.
At step three, the ALJ examines whether the claimant’s impairment meets or equals the
criteria of a listed impairment in Appendix 1 of Subpart P of Regulation No. 4. If the claimant’s
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impairment meets or medically equals the criteria of a listing and meets the durational requirement
(20 CFR §404.1509), the claimant is disabled. If not, analysis proceeds to step four, and the ALJ
determines the claimant's residual functional capacity (“RFC”), which is the ability to perform
physical or metal work activities on a sustained basis notwithstanding limitations for the claimant's
collective impairments. See 20 CFR §404.1520(e), (f). Then, the ALJ determines whether the
claimant’s RFC permits him to perform the requirements of his past relevant work. If so, the
claimant is not disabled. If not, analysis proceeds to the fifth and final step, wherein the burden
shifts to the Commissioner to show that the claimant is not disabled, by presenting evidence
demonstrating that the claimant “retains a residual functional capacity to perform alternative
substantial gainful work which exists in the national economy” in light of his age, education, and
work experience. See Rosa v. Callahan, 168 F.3d 72, 77 (2d Cir.1999), quoting Bapp v. Bowen,
802 F.2d 601, 604 (2d Cir.1986). See 20 CFR §404.1560(c).
The Commissioner’s decision that plaintiff is not disabled must be affirmed if it is supported
by substantial evidence, and if the ALJ applied the correct legal standards. See 42 U.S.C. § 405(g);
Machadio v. Apfel, 276 F.3d 103, 108 (2d Cir.2002); Rivera v. Sullivan, 923 F.2d 964, 967 (2d
Cir.1991). Substantial evidence is defined as “more than a mere scintilla. It means such relevant
evidence as a reasonable mind might accept as adequate to support a conclusion.” Richardson v.
Perales, 402 U.S. 389, 401 (1971), quoting Consolidated Edison Co. v. N.L.R.B., 305 U.S. 197, 229
(1938). “The Court carefully considers the whole record, examining evidence from both sides
‘because an analysis of the substantiality of the evidence must also include that which detracts from
its weight.’” Tejada v. Apfel, 167 F.3d 770, 774 (2d Cir. 1998) quoting Quinones v. Chater, 117
F.3d 29, 33 (2d Cir.1997). Still, “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). “Where the
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Commissioner’s decision rests on adequate findings supported by evidence having rational
probative force, [this Court] will not substitute our judgment for that of the Commissioner.” Veino v.
Barnhart, 312 F.3d 578, 586 (2d Cir.2002).
II.
Issues on Appeal
ALJ Peffley’s decision stated the findings supporting his decision in great detail, and
followed the required five-step analysis carefully and accurately. However, upon review, I find that
the record upon which his decision was based is incomplete and inadequate, and as such, the matter
must be remanded for the purpose of gathering additional medical records and reports.
“Because a hearing on disability benefits is a non-adversarial proceeding, the ALJ generally
has an affirmative obligation to develop the administrative record.” Perez v. Chater, 77 F.3d 41, 47
(2d Cir. 1996). See also Burger v. Astrue, 2008 U.S. App. LEXIS 13638 at *4 (2d Cir. 2008).
The record in this case is decidedly sparse. Initially, there is no “acceptable medical source”
with whom plaintiff treated for any of her allegedly disabling psychological and psychiatric
conditions. To the extent that plaintiff did have a longstanding treatment relationship with licensed
social worker Barbara Shapiro (“Shapiro”), an “other source” that the ALJ apparently considered,
the record contains no psychiatric RFC questionnaire from Shapiro assessing plaintiff’s nonexertional limitations. While the ALJ described Shapiro’s records as expressing Shapiro’s apparent
optimism that plaintiff might someday return to work, it is manifest from the face of those records
that Shapiro was merely parroting plaintiff’s own aspirations and future goals for her treatment, and
not rendering an objective professional assessment of plaintiff’s contemporaneous mental
functioning or ability. See e.g., T. 539 (“[w]e discussed what her career goals might be and she said
she wants to be an accountant”).
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The record contains only one psychiatric RFC questionnaire from any of the individuals
who treated plaintiff. That questionnaire, completed by licensed social worker Vincent Bosso
(“Bosso”), with whom plaintiff began treating biweekly on December 11, 2008, opined that plaintiff
was incapable of working with or in proximity to others, responding to changes or stress, or
maintaining a routine consistent with the demands of full-time employment. (T. 580-584).
Acknowledging Bosso’s July 12, 2010 report, the ALJ nonetheless opted to reject Bosso’s
opinion, largely because it conflicted with the opinion of Dr. R. Altmansberger, a consulting
psychiatrist who had evaluated some of plaintiff’s medical records on May 18, 2009 in connection
with a state disability benefits application (T. 491-493), and concluded that plaintiff had no more
than moderate limitations in any functional category, and was therefore not disabled. Id.
However, as plaintiff points out, Dr. Altmansberger did not have the benefit of reviewing
plaintiff’s complete records from Catholic Family Medical Center, which contain not only medical
records and opinions relative to her diagnosis of bipolar disorder (the only diagnoses Dr.
Altmansberger identified), but also post-traumatic stress disorder, panic attacks, a learning disorder,
personality disorder and agoraphobia. Given the incompleteness of the record before him, Dr.
Altmansberger cited only three treatment notes, dated between January 2009 and May 2009, in
support of his conclusion that plaintiff has no marked psychiatric limitations. In fact, so great was
the dearth of medical records that Dr. Altmansberger observed that plaintiff had no “documented
[longitudinal history] of chronic mental illness,” and was reduced to basing his conclusions on
trivial, anecdotal observations from treatment notes, such as the fact that plaintiff was “artistic and
made note cards,” and was reported to have been “neatly dressed” and “smiled several times”
during one particular session. (T. 493).
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Dr. Altmansberger’s opinion was the only one which the ALJ afforded “great weight,” and
it was used as the primary basis for the ALJ’s RFC finding, as well as his justification for rejecting
the lone RFC assessment by a treating source (albeit an “other source” not automatically entitled to
deference).
Because Dr. Altmansberger’s opinion was itself based upon an incomplete and
insufficient record, the ALJ’s decision cannot be said to rest upon substantial evidence. At the very
least, the ALJ “should have sought a conclusive determination from a medical consultant” who was
able to evaluate the plaintiff’s entire medical record, given the absence of other evidence in the
record by treating or examining sources specific to plaintiff’s non-exertional limitations. Falcon v.
Apfel, 88 F. Supp. 2d 87, 90 (W.D.N.Y. 2000). See generally 20 C.F.R. §404.1519a(b)(4) (an ALJ
must order a consultative examination when a “conflict, inconsistency, ambiguity or insufficiency in
the evidence must be resolved”). Failure to obtain a valid consultative examination when necessary
is reversible error. Falcon, 88 F. Supp. 2d 87 at 90.
Based on the foregoing, I believe the ALJ failed to adequately develop the record, and that
the matter must be remanded for further proceedings.
CONCLUSION
For these reasons, plaintiff’s motion for judgment on the pleadings (Dkt. #9) is granted, and
the Commissioner’s cross-motion (Dkt. #10) is denied.
The Commissioner’s decision that plaintiff, Latoya Stackhouse, was not disabled is
reversed, and the matter is remanded for further proceedings. Upon remand, the Commissioner is
instructed to request RFC reports and updated treatment records from all of plaintiff’s treating
sources with regard to her non-exertional (psychiatric) limitations, to order consultative
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examinations and obtain additional records as appropriate, and to redetermine plaintiff’s disability
status upon a full and complete record.
IT IS SO ORDERED.
_______________________________________
DAVID G. LARIMER
United States District Judge
Dated: Rochester, New York
October 3, 2014.
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