Cuevas v. Apfel
| Decision Date | 02 November 1999 |
| Docket Number | Civil No. 98-CV-4819 (JBS). |
| Parties | ANTONIO CUEVAS, Plaintiff, v. KENNETH S. APFEL, COMMISSIONER OF SOCIAL SECURITY, Defendant. |
| Court | U.S. District Court — District of New Jersey |
Alan H. Polonsky, Esquire, Polonsky & Polonsky, Audubon, New Jersey, Attorney for Plaintiff.
Faith S. Hochberg, United States Attorney, By: Anthony J. LaBruna, Assistant United States Attorney, Newark, New Jersey, Attorney for Defendant.
This matter comes before the court pursuant to section 205(g) of the Social Security Act ("Act"), as amended, 42 U.S.C. § 405(g), to review the final decision of the Commissioner of the Social Security Administration ("Commissioner"), denying the plaintiff's claim for Disability Insurance Benefits under Title II and Supplemental Security Income ("SSI") benefits under Title XVI of the Act. For the reasons stated below, this court affirms the Commissioner's final decision.
The plaintiff, Antonio Cuevas, filed an application for Social Security Disability Benefits on September 22, 1995, alleging disability due to a nervous problem, back problems and high blood pressure. (Joint Stipulation of Facts at 1.) His application was denied both initially and on reconsideration. Id. The plaintiff subsequently requested a hearing before an Administrative Law Judge ("ALJ"). Id. On June 24, 1997, the plaintiff, represented by counsel, appeared before the Honorable Alfred K. Tyminski in Voorhees, New Jersey. (R. 15.)
The plaintiff testified at the hearing that he can sit for one hour before he has to stand up. (R. 57.) He stated that he can lift up to twenty pounds once, and ten pounds repeatedly for about five minutes. (R. 57.) He further testified that he has thoughts of suicide and that he does not go any where by himself. (R. 53-56.)
In a written opinion dated August 28, 1997, the ALJ determined that the plaintiff was "not disabled" within the meaning of the Act, and was therefore not entitled to benefits. (R. 22.) In applying the regulation's five-step sequential evaluation analysis, see infra, the ALJ found at step one that the plaintiff had not engaged in substantial gainful activity since June 20, 1995. (R. 16, 21.) At steps two and three, the ALJ found that the plaintiff suffered from degenerative disc disease at L3-L4, L4-L5 and L5-S1, as well as anxiety disorder and dependent personality. (R. 18.) The ALJ found these impairments to be severe, but that they did not equal an impairment listed in Appendix 1 to Subpart P (20 C.F.R. 404.1520(d) and 416.920(d)). (R. 18, 21.) At step four, finding that the plaintiff has the physical residual functional capacity to do medium work,1 and that the plaintiff's mental residual functional capacity was not significantly limited, the ALJ concluded that these impairments did not preclude the plaintiff from returning to his past relevant work as a janitor. (R. 18, 21.) The ALJ's decision that the plaintiff was not disabled became final when the Appeals Council denied the plaintiff' request for review. (Joint Stipulation of Facts at 1.)
On October 22, 1998, the plaintiff timely filed this action in the United States District Court, claiming that the Commissioner's finding that his is "not disabled" was not based upon substantial evidence.
The plaintiff stated in the Disability Report completed in connection with his application that he last worked in June of 1995, when he was employed for twenty years as a janitor at a factory in Puerto Rico. (R. 16.) He claims that he has not engaged in any substantial gainful employment since coming to the United States, approximately twenty months before the hearing. (R. 16.) He claims that his family doctor in Puerto Rico, a Dr. Gonzales, instructed him to discontinue working when he fell from a ladder at the factory in June of 1995. (R. 50-51.) When he came to New Jersey, the plaintiff sought the treatment of Dr. Udom Suvansri on July 1, 1995 for pain in his right leg and lower back. (R. 52.)
The plaintiff was examined by six doctors besides Dr. Gonzales, including Dr. Seth L. Jaffe and Dr. Mark J. Reiner, who are orthopedic specialists, as well as Dr. Stephen J. Zionts and Dr. Willa M. Greenberg. Moreover, the plaintiff visited the Hispanic Counseling and Family Services of New Jersey on at least eleven different occasions, and was examined by Dr. Young B. Lee, a psychiatrist. A summary of the medical findings regarding the plaintiff's physical and mental conditions follow.
Between July 1, 1995 and April 8, 1996, Dr. Suvansri, the plaintiff's treating physician, examined the plaintiff on at least nineteen different occasions for complaints ranging from back and leg pain to anxiety. (R. 160-184.) On the second visit, December 5, 1995, Dr. Suvansri diagnosed the plaintiff as suffering from hypertension and osteoarthritis. (R. 193-196). A CT scan of the lumbar spine was performed on the same day, which gave the impression of lumbar spondylosis resulting in mild spinal stenosis at the L4-L5 and L5-S1 levels. (R. 173).
On January 2, 1996, Dr. Jaffe and Dr. Reiner, orthopedists at Cherry Hill Orthopedic Surgeons, examined the plaintiff at the request of Dr. Suvansri. The doctors observed that the plaintiff could walk normally, that his reflexes were normal and symmetrical, and that the muscle strength in his lower extremities was full. (R. 198.) Doctor Jaffe advised Dr. Suvansri that the CAT scans of the plaintiff's back showed evidence of herniated discs at L4-L5 and L5-S1 but ordered an MRI to be performed on the plaintiff the same day. (R. 198.)
On January 24, 1996, Dr. Stephen J. Zionts completed a consultative physical examination of the plaintiff at the request of the Social Security Administration. (R. 215-16.) In his report, Dr. Zionts noted that it was "almost impossible to obtain an accurate [medical] history." (R. 215). Doctor Zionts found that the plaintiff was in no acute distress, was ambulating without difficulty, and was able to get up on his heels and toes. (R. 215.) Doctor Zionts found that the plaintiff's lumbar range of motion was "slight," while he enjoyed a full range of motion of, inter alia, hips, cervical regions the spine and ankles. (R. 216.) Notably, Dr. Zionts found that the plaintiff's deep tendon flexes to be equal and active and that there was no gross muscle wasting in the lower extremities. (R. 216.) Finally, Dr. Zionts opined that the plaintiff is suffering from degenerative joint disease primarily affecting his lumbosacral spine. (R. 216.)
On January 30, 1996, Drs. Jaffe and Reiner re-examined the plaintiff following receipt of an MRI performed on January 15, 1996. The MRI, conducted in order to confirm the doctors' initial suspicion that the plaintiff's discs were herniated, revealed that the discs were not, in fact, herniated. (R. 217.) Doctor Jaffe advised Dr. Suvansri that the plaintiff suffered from degenerate disc disease at L3-L4, L4-L5, and L5-S1, and that the plaintiff should undergo EMG testing and epidural steroid injections. (R. 217.)
Subsequently, Dr. Suvansri referred the plaintiff to Dr. Willa M. Greenberg for EMG testing. On March 22, 1996, Doctor Greenberg examined the plaintiff, which included an electrodiagnostic study. (R. 219-221.) A physical examination revealed that the plaintiff's "[b]ilateral upper and lower extremities have full strength and range of motion." (R. 219.) Doctor Greenberg found electrodiagnostic evidence suggestive of right L5 radiculopathy as well as right S1 radiculopathy, with no evidence of peripheral neuropathy.2 (R. 220.)
On April 29, 1996, the plaintiff was reevaluated at the office of Cherry Hill Orthopedic Surgeons, where the diagnosis of degenerative disc disease was affirmed. (R. 223.) That examination revealed that straight leg raising and other physical tests were negative, and that the plaintiff's distal, sensory motor vascular and strength exam were normal. (R. 223.)
Meanwhile, the plaintiff continued to see his treating physician, Dr. Suvansri. On April 3, 1996, following examinations conducted by Drs. Jaffe, Reiner and Greenberg, Dr. Suvansri indicated that there had been no significant changes in the plaintiff's condition since the December 5 visit, and that the plaintiff suffered from herniated discs at L4-L5 and L5-S1, and right renal calculus and hypertension. (R. 222.) On May 14, 1996, Dr. Suvansri indicated in a letter that the plaintiff was under his care due to hypertension and disc herniation. (R. 224.) On July 18, 1996, Dr. Suvansri expressed in another letter that the plaintiff was under his care due to severe low back pain due to disc herniation, and opined that the plaintiff was unable to work at the time. (R. 225.) This diagnosis was reaffirmed in another letter on January 31, 1997, as well as office notes dated January 26, 1997. (R. 229, 237.)
The plaintiff was under the care of the Hispanic Counseling and Family Services of New Jersey from November of 1995 to February of 1997. He was treated for generalized affective disorder and depressive disorder3 with a variety of medications including Paxil, Xanax, Klonopin, Atclazine and Risperdal. (R. 185-86, 200-211.)
Doctor Lee conducted an examination of the plaintiff on January 9, 1996, at the request of the Social Security Administration Division of Disability Determinations. (R. 212-13.) Doctor Lee found that the plaintiff's affect was appropriate to his thought process, and his mood was mildly depressed and somewhat anxious, but not to a significant degree. (R. 213.) Notably, Dr. Lee assessed the plaintiff "able to follow directions," that his "interpersonal relationship is moderately impaired," and that the plaintiff's "subjective symptoms are not entirely substantiated by the objective findings." (R. 213.) Doctor Lee diagnosed the plaintiff as suffering from mild anxiety order...
To continue reading
Request your trial