Reynard v. Colvin

          OPINION AND ORDER

          William K. Sessions III District Court Judge.

         Plaintiff Andrew Reynard appeals the decision of an Administrative Law Judge (ALJ) denying his September 27, 2011 applications for Title II social security disability insurance benefits and Title XVI supplemental security income (SSI) benefits. Mr. Reynard alleges that he became unable to work on June 9, 2011. Administrative Record (hereafter “AR”) 296. In particular, Mr. Reynard stated on his initial application that he has difficulties sitting and walking for any extended period of time and that he has difficulties resting. AR 253. With respect to his mental state, Mr. Reynard stated that he has childhood onset of Post-Traumatic Stress Disorder (PTSD), that his PTSD affects his ability to get along with others, and that he does not socialize much because he has difficulties trusting other people. AR 259-260. He also stated that he has a limited attention span and that he forgets spoken instructions easily. AR 258. On his reconsideration application, filed after Mr. Reynard's girlfriend attempted suicide, the plaintiff alleged increased anxiety and depression stemming from trauma triggers. AR 274. In support of his application, Mr. Reynard submitted abundant evidence of his physical and emotional conditions and of their effects on his ability to work.^[1] His application was initially denied on February 7, 2012 and denied on reconsideration on April 18, 2012. Mr. Reynard requested a hearing before an ALJ, who denied Mr. Reynard's application on May 28, 2013. The Social Security Appeals Council denied Mr. Reynard's subsequent request for review, and Mr. Reynard appealed to this Court on November 21, 2014. ECF No. 3. Because the records from the Plaintiff's health care providers persuasively demonstrate the Plaintiff's disability, the Court now reverses the ALJ's decision and remands solely for the calculation of benefits.

         BACKGROUND

         Mr. Reynard is a 48-year old male who has been diagnosed with Post-Traumatic Stress Disorder (PTSD), depression, anxiety, severe obstructive sleep apnea, morbid obesity, chronic obstructive pulmonary disease (COPD) and degenerative disc disease and compression fractures in the lower back. The plaintiff's physical impairments have caused him to have chronic lower back pain and reduced mobility, and his psychological impairments have produced a range of maladaptive symptoms affecting plaintiff's social functioning and energy level.

         Nevertheless, the ALJ found that the plaintiff was not disabled under the definition of that term in the Social Security Act (“Act”). In reaching that conclusion, the ALJ applied a five-step sequential evaluation process established by the Social Security Administration for determining whether an individual is disabled. 20 C.F.R. §§404.1520; 416.920. The Second Circuit has “tracked this methodology … as follows:

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 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. The Commissioner bears the burden of proof on this last step, while the claimant has the burden on the first four steps.”

Shaw v. Chater, 221 F.3d 126, 132 (2d Cir. 2000).

         Applying this approach, the ALJ first found that the plaintiff was not engaged in substantial gainful activity. Next, the ALJ found that the plaintiff had a medically determinable impairment that is severe or a combination of such impairments, such that the impairment limits the plaintiff's ability to perform basic work activities. Specifically, the ALJ found that the plaintiff had the following severe impairments: degenerative disc disease, obstructive sleep apnea, obesity, COPD, an affective disorder and an anxiety-related disorder. AR 19.

         At the third step, the ALJ evaluated whether the plaintiff's impairment or combination of impairments is of a severity to meet or medically equal the criteria of an impairment listed in 20 C.F.R. Part 404, Subpart P, Appendix 1. The ALJ concluded that the plaintiff's impairments in this case did not rise to the level of a listed impairment. With regard to his physical impairments, the ALJ found that the plaintiff's degenerative disc disease, which caused his lower back pain, did not meet or equal the criteria of listing 1.04 because “there is no evidence of nerve root compression characterized by neuro-anatomic distribution of pain, limitation of motion of the spine, motor loss accompanied by sensory or reflex loss, and positive straight-leg raising, or spinal arachnoiditis, or lumbar spinal stenosis resulting in pseudoclaudication.” AR 19. The ALJ did not consider the effects of obesity specifically on the plaintiff's disturbance of the musculoskeletal system, although he did consider it in relation to the plaintiff's overall combination of impairments. The ALJ concluded that the addition of obesity to the sum of his other impairments would not result in a finding of disability under step three because the plaintiff “remains fully weight bearing and does not have abnormal neurological functioning.” AR 19.

         With regard to the plaintiff's obstructive sleep apnea and COPD, the ALJ found that the plaintiff's condition did not rise to the level of those disorders listed under listings 3.09 and 12.02. He also found the plaintiff's conditions did not meet or equal the criteria of listing 3.02. Section 3 of the appendix relates to respiratory disorders, including COPD, with 3.02 providing criteria for chronic respiratory disorders due to any cause (with a non-relevant exception) and 3.09 providing criteria related to chronic pulmonary hypertension. Whether the severity of the impairment rises to the level of a disability is determined by specific test results related to (in relevant part) pulmonary artery pressure, forced expiratory volume or forced vital capacity. Section 3.00(P)(2) provides that sleeping disorders will be evaluated under the listings of the affected body systems, and 12.02 provides criteria relevant to neurocognitive disorders. The ALJ's conclusions regarding the limited impact of plaintiff's sleep apnea on his cognitive functioning and mood disturbance cross-references his evaluation of the evidence pertinent to plaintiff's other psychological disorders.

         With respect to the plaintiff's psychological impairments, the ALJ determined that the plaintiff's anxiety and depression did not meet or equal the criteria in listings 12.04 or 12.06. The ALJ failed to consider whether plaintiff's PTSD diagnoses meets or equals the criteria in listing 12.12. However, his analysis of the factors to be considered in listings 12.04 and 12.06 would also be applicable to the 12.12 analysis. Listings 12.04, 12.06 and 12.12 provide three categories of criteria (A, B, and C) and require that a claimant exhibit either sufficient Category A and B criteria or Category A and C criteria. Category A criteria relate to the symptoms of the disorder itself, while Category B criteria relate to a claimant's functioning and Category C criteria relate to whether the impairment is serious and persistent, requiring a claimant to rely on an ongoing basis upon medical treatment, therapy, psychosocial supports or a highly structured setting to diminish the symptoms or signs of the mental disorder. The ALJ found that plaintiff did not have marked limitations in at least two of the Category B criteria: in the ALJ's view, he only had mild restrictions in activities of daily living and in social functioning, moderate difficulties with regard to concentration, persistence and pace and had experienced no episodes of decompensation. AR 20. The ALJ then found that Category C criteria for 12.04 were not met because “there is no evidence in the record of repeated episodes of decompensation, a current history of one or more years' inability to function outside a highly supportive living arrangement, or a residual disease process that has resulted in such marginal adjustment that even a minimal increase in mental demands or change in environment would be predicted to cause the individual to decompensate.” AR 20. The criteria were not met for 12.06 because “there is no evidence in the record of a complete inability to function independently outside the area of the claimant's home.” Id.

         The ALJ did not specifically reference any of the medical evidence in reaching these conclusions in a summary manner, and relied solely on reports of the plaintiff's daily habits. AR 20. Instead, he cross-referenced his residual functional capacity assessment in explaining his determination of the degree to which Category B criteria were present. AR 21. In particular, at this stage of the analysis, the ALJ gave little weight to the evaluation of the plaintiff's therapist, Gretchen Lewis, because it was inconsistent with the evidence of the plaintiff's daily habits. AR 24. The ALJ did not analyze the consistency between Gretchen Lewis' evaluation and the records from social worker Krystal Cota's prior treatment of the plaintiff or the reports of psychiatric symptoms on his primary care physician's records. Id. Instead, the ALJ took note of the opposite conclusion in a one-time evaluation conducted by Dr. Theodore Williams. The lack of reliance on this medical evidence therefore guided the ALJ's conclusion that Mr. Reynard was not disabled under step 3 of his analysis.

         After concluding that the plaintiff's impairments did not meet or equal any of the impairments listed in 20 C.F.R. Part 404, Subpart P, Appendix 1, the ALJ went on to conclude that the plaintiff had residual functional capacity to perform light work; that he could perform frequent climbing of stairs, ramps, ladders, ropes and scaffolds, as well as balance, stoop, kneel, crouch and call; that he could follow 1-3 step instructions; and that he could sustain concentration, persistence and pace over 2-hour blocks within a typical workday and workweek. AR 21. Once again, with respect to the plaintiff's mental disorders, the ALJ based his assessment on evidence of Mr. Reynard's daily habits and a single evaluation conducted by Dr. Williams, and gave little weight to the available evidence from Mr. Reynard's treatment providers. With regard to his physical impairments, the ALJ gave little weight to the evaluation conducted by Mr. Coleman, an occupational therapist to whom Mr. Reynard's primary care physician, Dr. Lippman, had referred the plaintiff. He also found that the plaintiff's reports of his own physical capacity and pain limitations were not credible because they were “not entirely supported or consistent with the evidence of record.” AR 22. This assessment of the plaintiff's residual functional capacity led him to conclude, based on the testimony of a vocational expert, that the plaintiff could perform past relevant work as it was actually performed, and that, in the alternative, there are other jobs existing in the ...