La Cruz v. Colvin
| Decision Date | 02 July 2014 |
| Docket Number | 12-cv-3660 (SAS) |
| Parties | STEPHANIE YVONNE DE LA CRUZ, Plaintiff, v. CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant. |
| Court | U.S. District Court — Southern District of New York |
I. INTRODUCTION
Stephanie Yvonne De La Cruz brings this action, pursuant to the Social Security Act (the "Act"),1 seeking judicial review of a final decision by the Commissioner of Social Security (the "Commissioner") denying her claim for Supplemental Security Income ("SSI") disability benefits. Both parties have moved for judgment on the pleadings. For the reasons set forth below, the Commissioner's motion is granted, the decision denying benefits is affirmed, and plaintiff's motion is denied.
II. BACKGROUND
De La Cruz filed an application for SSI disability benefits on June 12, 2008, which was denied on August 22, 2008.2 The application alleged that she has been disabled since February 7, 2008, due to depression, dizziness, chest pain, back pain, and acid reflux.3 De La Cruz requested a hearing before an Administrative Law Judge ("ALJ"), and ALJ Rosanne M. Dummer presided over a video hearing on November 18, 2009.4 De La Cruz, who was represented by counsel, and David A. Festa, a vocational expert, testified at the hearing. After the hearing, the record was held open for De La Cruz to submit further documentation, which was added to the record. She also underwent additional psychological evaluation at the request of the New York State Office of Temporary and Disability Assistance. The ALJ referred the medical evidence of record for further review by a medical expert before issuing a decision on July 16, 2010, finding that De La Cruz is not "under a disability" as defined in the Act.5 The ALJ's decisionbecame the final decision of the Commissioner on April 24, 2012, when the Appeals Council denied De La Cruz's request for review of the ALJ's decision.6 On March 2, 2013, plaintiff filed the instant action. The period at issue is from June 12, 2008, the date De La Cruz filed her SSI application, through July 16, 2010, when the ALJ issued her decision.7
The administrative record consists of non-medical evidence, medical evidence, and hearing testimony.
De La Cruz is a childless twenty-six-year-old single woman who speaks both English and Spanish.8 She was born on August 3, 1987, and was twenty years old at the onset of her alleged disability.9 Prior to her alleged disability, De La Cruz had attended one year of college and had worked in variouscustomer and food services jobs,10 but her work never rose to the level of substantial gainful activity ("SGA").11 At the ALJ hearing, De La Cruz gave the following testimony. She was last employed in the first quarter of 2008 in a donut shop.12 She left this job due to depression and problems concentrating, focusing, remembering, and interacting with others; she also reported back pain.13 De La Cruz recalled being hospitalized as a child for mental problems and stated that she saw doctors at Jacobi Hospital in 2007, who referred her to a psychiatrist and therapist, after her condition worsened around the time of her mother's death in a fire.14 She saw Nurse Practitioner Tirza Santilli once a month, who prescribed and managed her medications. She also saw a therapist weekly, though she had onlybeen seeing her current therapist for about "a month or two" because her previous one resigned.15
She lives with her father, whom she described as a drug addict and schizophrenic.16 She drank occasionally and had smoked marijuana - the last time a month before the hearing.17 She did very little during the day, staying inside most of the time, and experienced frequent crying spells.18 She cooked daily, washed her own laundry, and saw her boyfriend once or twice per week. She was able to use public transportation by herself, could walk ten blocks at a time, and had no problem standing or using her hands. She felt she was not ready to return to work and would have trouble getting a regular job.
a. Consulting Physicians
i. Dr. Sharon Revan (August 14, 2008)
The Division of Disability Determination referred De La Cruz to Dr. Sharon Revan, who performed a physical examination of plaintiff on August 14,2008.19 Dr. Revan diagnosed back pain, as well as acid reflux, headaches, and dizziness.20 The doctor opined that De La Cruz had mild limitations in climbing stairs due to fatigue, and mild limitations in activities of daily living "depending [on] her psychological state."21 The doctor noted that plaintiff had no limitation with respect to personal grooming, or in her speech, vision, or hearing. She also found no limitation in plaintiff's fine or gross motor activity using her upper extremities, and no limitation in sitting, standing, or walking distances.22
Dr. Revan found that plaintiff had a normal gait and stance. She could walk on heels and toes, squat fully, rise from a chair, and get on and off the examination table without difficulty. She had full range of motion in her cervical and lumbar spine as well as in her shoulders, elbows, forearms, wrists, hips, knees, and ankles, with full strength throughout. De La Cruz also had intact hand and finger dexterity, with full grip strength, and her joints were stable and non-tender. Straight leg raising was negative bilaterally, and her lumbar x-rays were alsonegative.23 De La Cruz reported to Dr. Revan that she had "upper back pain for the past two or three years, [which becomes] worse with crying or when she is depressed and is better with a massage."24 She also told Dr. Revan that she tired after climbing three to four flights of stairs, but had no difficulty walking, sitting, standing, or lying down. She stated that she was able to cook, clean, do laundry, and shop.25
ii. FEGS (September 2008)
De La Cruz also underwent a "biopsychosocial evaluation" at the Federation Employment and Guidance Service ("FEGS") in connection with an application for public assistance.26 During the physical examination, she reported suffering from back pain, for which she took ibuprofen.27 Plaintiff also reported that she walked to the appointment, and that she could travel independently on public transportation. She stated that she was able to perform activities of daily living - including washing dishes and clothes, sweeping, mopping, vacuuming,making a bed, cooking meals, shopping for groceries, bathing, and grooming herself - but that she spends her day at home in bed watching television.28
The physical examination was unremarkable except for findings of an "abnormal spine" and "mild mid-thoracic tenderness."29 Despite these findings, Dr. Oksana Luke assessed plaintiff's level of mid-back pain during the appointment as one, on a scale from zero to ten, and opined that De La Cruz could stand for four to five hours in an eight-hour day; bend for one to three hours per day; and lift, carry, and push less than ten pounds between ten and fifteen times per hour.30
From August 2008 to October 2009, De La Cruz was treated by Nurse Practitioner Tirza Santilli at the Clay Avenue Health Center in the Bronx, who monitored plaintiff's psychological condition and managed her medication.31Santilli diagnosed De La Cruz with "Major Depressive Disorder, recurrent" at their first meeting on August 18, 2008, though plaintiff rejected medication at that time.32 Treatment notes indicate that De La Cruz was feeling "depressed [and] irritable" and experiencing "crying spells, poor sleep, hopelessness, and occasional passive [suicidal] [ideation]," though she reportedly also had adequate impulse control and spontaneous, relevant, and goal-directed thoughts whose content was unremarkable.33 At their next meeting on September 17, 2008, Santilli described plaintiff's presentation of symptoms as "[somewhat] contradictory."34 On examination, plaintiff's mood was irritable and her affect constricted, and she exhibited tense behavior, an uncooperative attitude, and poor reasoning. She had clear, challenging speech with an "angry undertone," and was also described as "oddly related."35 However, she was well-groomed, with unremarkable psychomotor behavior and fair impulse control, judgment, and insight.36 She also had logical, concrete thought processes with unremarkable content, no signs ofpsychosis or mania, and no suicidal or homicidal ideation. Her memory was intact, and her intellect was described as average. The diagnosis was "Recur[rent] Depr[ession] Psych - Severe" and "Personality Disorder [not otherwise specified]," and she was prescribed Lexapro and Ambien.37
In October 2008, De La Cruz reported to Santilli of "minimal improvement" in her symptoms, though she admitted that she had not taken her medication.38 In November, she claimed to be in compliance with her medication as prescribed and reported improved sleep and mood, though she continued to feel depressed, lonely, and irritable, and was experiencing side effects of occasional daytime sedation and nausea.39 In December, she again reported improved sleep and mood, but without medication side effects, and stated that she had started going to church, was getting along with her family, and continued to consider going back to school. Santilli observed that her mood was "euthymic" and her affect was no longer constricted. Santilli discontinued the Ambien prescription.40
At her next appointment on February 23, 2009, De La Cruz's mood was "depressed," and she reported having low motivation.41 She stopped going to church, had not reapplied for school, and was having problems with her father and boyfriend. Her speech and affect were otherwise "appropriate," and her attitude cooperative.42 In May, plaintiff stated that she...
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