United States District Court, D. Vermont
OPINION AND ORDER (DOCS. 10, 11)
John M. Conroy United States Magistrate Judge
Plaintiff Vicki Lou Johnson brings this action pursuant to 42 U.S.C. § 405(g) of the Social Security Act, requesting review and remand of the second decision of the Commissioner of Social Security (Commissioner) denying her applications for Disability Insurance Benefits (DIB) and Social Security Income (SSI). Pending before the Court are Johnson’s motion to reverse the Commissioner’s decision (Doc. 10), and the Commissioner’s motion to affirm the same (Doc. 11). For the reasons stated below, the Court GRANTS Johnson’s motion, in part; DENIES the Commissioner’s motion; and REMANDS for yet another decision.
Johnson was 51 years old on her alleged disability onset date of June 30, 2010. She has a high school education and has taken specialized training courses in office management. Her work history consists of working as an at-home daycare provider, an office manager for an automotive repair company, and a registration representative at an emergency department. She last worked in November 2008. She is divorced and has three adult children. As of November 2014, she was living in Jericho with her daughter and one of her sons when he was not working overseas. (AR 2349.)
In July 2011, Johnson protectively filed applications for SSI and DIB. Therein, she alleges that she has been disabled since June 30, 2010 due to neck and back pain, asthma, irritable bowel syndrome, a bleeding disorder, inoperable bleeding hemorrhoids, clinical depression, tremors in her right hand, left ankle pain, high blood pressure, and headaches. Johnson testified at her first administrative hearing in January 2013 that she frequently drops things due to hand tremors; she has difficulty sitting and standing for long periods; she has pain in her left ankle, left knee, lower back, neck, and shoulders after standing for more than five minutes; and she has debilitating headaches a couple times a week. (AR 42-43, 48, 51-52.) Two years later, at her second administrative hearing in January 2015, Johnson again testified that she has approximately two migraines each week. (AR 1532.) She further testified that she has difficulty remembering things (AR 1533-34), and her neck pain has worsened, occurring on a daily basis and often requiring her to take pain medication or a muscle relaxant before getting out of bed in the morning (AR 1535).
On a typical day in January 2013, Johnson did minor household chores for short periods of time and with the help of her daughter, checked email, sewed for 10-15 minutes at a time, went to doctor appointments, and spent time sitting partially reclined with a heating pad on the back of her neck. (AR 44-50.) She exercised for 30 minutes on a treadmill three days a week, resting for a couple of hours afterwards. (AR 48.) In January 2015, Johnson testified that she continued to exercise for up to 30 minutes at a time at least two to three times each week but felt exhausted and in pain when she was done and usually had to rest for the remainder of the day. (AR 1534-35.) She further testified that she was limited in her ability to engage in personal care activities, including getting dressed, washing her hair, and preparing meals. (AR 1536-37, 1539.) She stated that her hand shook “all the time, ” leaving her unable to hold anything and no longer able to do any quilting activities. (AR 1538.)
On January 24, 2013, after holding an administrative hearing on Johnson’s claim, Administrative Law Judge (ALJ) Thomas Merrill issued a decision finding that Johnson was not disabled under the Social Security Act from her alleged onset date of June 30, 2010 through the date of the decision. (AR 19-30.) After the Appeals Council denied her request for review, Johnson sought judicial review of the ALJ’s decision. On May 21, 2014, this Court issued an Opinion and Order (hereafter referred to as “the remand order”) finding that the ALJ failed to follow the treating physician rule with respect to Dr. Edward Terrien’s opinions and erred in his consideration of Johnson’s migraine headaches and assessment of Johnson’s credibility. (AR 1572-87.) Given these findings, the Court remanded the matter to the ALJ for further proceedings and a new decision.
On January 28, 2015, ALJ Merrill held a second administrative hearing on the claim. (AR 1529-42.) Thereafter, the ALJ issued a decision again finding that Johnson was not disabled from her alleged disability onset date through March 31, 2015, the date of the decision. (AR 1494-1509.) The Appeals Council again denied Johnson’s request for review, prompting her to file the Complaint in this matter on May 19, 2015. (Doc. 3.)
The Commissioner uses a five-step sequential process to evaluate disability claims. See Butts v. Barnhart, 388 F.3d 377, 380-81 (2d Cir. 2004). The first step requires the ALJ to determine whether the claimant is presently engaging in “substantial gainful activity.” 20 C.F.R. §§ 404.1520(b), 416.920(b). If the claimant is not so engaged, step two requires the ALJ to determine whether the claimant has a “severe impairment.” 20 C.F.R. §§ 404.1520(c), 416.920(c). If the ALJ finds that the claimant has a severe impairment, the third step requires the ALJ to make a determination as to whether that impairment “meets or equals” an impairment listed in 20 C.F.R. Part 404, Subpart P, Appendix 1 (“the Listings”). 20 C.F.R. §§ 404.1520(d), 416.920(d). The claimant is presumptively disabled if his or her impairment meets or equals a listed impairment. Ferraris v. Heckler, 728 F.2d 582, 584 (2d Cir. 1984).
If the claimant is not presumptively disabled, the ALJ is required to determine the claimant’s residual functional capacity (“RFC”), which means the most the claimant can still do despite his or her mental and physical limitations based on all the relevant medical and other evidence in the record. 20 C.F.R. §§ 404.1520(e), 404.1545(a)(1), 416.920(e), 416.945(a)(1). The fourth step requires the ALJ to consider whether the claimant’s RFC precludes the performance of his or her past relevant work. 20 C.F.R. §§ 404.1520(f), 416.920(f). Finally, at the fifth step, the ALJ determines whether the claimant can do “any other work.” 20 C.F.R. §§ 404.1520(g), 416.920(g). The claimant bears the burden of proving his or her case at steps one through four, Butts, 388 F.3d at 383; and at step five, there is a “limited burden shift to the Commissioner” to “show that there is work in the national economy that the claimant can do, ” Poupore v. Astrue, 566 F.3d 303, 306 (2d Cir. 2009) (clarifying that the burden shift to the Commissioner at step five is limited, and the Commissioner “need not provide additional evidence of the claimant’s [RFC]”).
Employing this sequential analysis in his most recent decision, ALJ Merrill first determined that Johnson had not engaged in substantial gainful activity since her alleged disability onset date of June 30, 2010. (AR 1497.) At step two, the ALJ found that Johnson had the following severe impairments: “spondylosis of the cervical and lumbar spine, migraines, and hemorrhoids.” (Id.) Conversely, the ALJ found that Johnson’s “[o]ther complaints and diagnoses”-including hypertension, hyperlipidemia, osteopenia, asthma and allergies, ankle impairment, left knee and hip pain, and affective disorder-were nonsevere. (AR 1497-99.) At step three, the ALJ determined that none of Johnson’s impairments, alone or in combination, met or medically equaled a listed impairment. (AR 1499-1500.) Next, the ALJ determined that Johnson had the RFC to perform “light work, ” as defined in 20 C.F.R. §§ 404.1567(b) and 416.967(b), “except she cannot do rapid repetitive work with her right hand.” (AR 1500.) Given this RFC, and considering testimony from the vocational expert,  the ALJ found that Johnson was capable of performing her past relevant work as a hospital patient representative, an office manager, and a dog breeder. (AR 1509.) The ALJ concluded that Johnson had not been under a disability from the alleged onset date of June 30, 2010, through the date of the decision. (Id.)
Standard of Review
The Social Security Act defines the term “disability” as the “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 12 months.” 42 U.S.C. § 423(d)(1)(A). A person will be found disabled only if it is determined that his “impairments are of such severity that he is not only unable to do his previous work[, ] but cannot, considering his age, education, ...