Fontanez v. Carolyn W. Colvin Acting Comm'r of Soc. Sec.
| Decision Date | 28 September 2017 |
| Docket Number | 16-CV-01300 (PKC) |
| Parties | BARBARA FONTANEZ, Plaintiff, v. CAROLYN W. COLVIN ACTING COMMISSIONER OF SOCIAL SECURITY, Defendant. |
| Court | U.S. District Court — Eastern District of New York |
Plaintiff Barbara Fontanez ("Plaintiff") brings this action under 42 U.S.C. §§ 405(g) and 1383(c)(3), seeking judicial review of the final determination of the Commissioner of Social Security (the "Commissioner" or "SSA") that Plaintiff is not entitled to Supplemental Security Income ("SSI") disability benefits under Title XVI of the Social Security Act. The parties have cross-moved for judgment on the pleadings pursuant to Federal Rule of Civil Procedure 12(c). (Dkts. 16, 22.) Plaintiff seeks reversal of the Commissioner's decision and remand for further administrative proceedings. The Commissioner, in turn, seeks to have the Court affirm the Commissioner's disability determination.
For the reasons set forth below, the Court GRANTS Plaintiff's motion for judgment on the pleadings and DENIES the Commissioner's motion. The case is remanded for further proceedings consistent with this opinion.
On May 8, 2013, Plaintiff applied for SSI alleging disability due to depression, back injury, allergies, and asthma. (Tr. 220-25, 234.)1 On January 9, 2015, the ALJ, Marilyn Hoppenfeld, held a hearing at which testimony was heard from Plaintiff, a non-examining State agency medical expert, and a vocational expert. (Tr. 31.) The ALJ issued a written decision on September 17, 2015, concluding that Plaintiff was not disabled and therefore not entitled to SSI benefits. (Tr. 5-30.) On January 11, 2016, the ALJ's decision became the Commissioner's final decision when the Appeals Council of the Office of Disability Adjudication and Review denied Plaintiff's request for review in accordance with the terms of the class action settlement agreement in Padro v. Astrue, No. 11-CV-1788 (CBA), 2013 WL 5719076 (E.D.N.Y. Oct. 1, 2013).2 (Tr. 1-3.) Plaintiff timely commenced this action on March 16, 2016, and cross-motions for judgment on the pleading were fully briefed on April 21, 2017. (See Docket No. 16-CV-1300.)
Plaintiff was born on September 10, 1970, and was forty-one on the onset date of her alleged disability, September 8, 2011. (Tr. 24, 220, 230.) She completed up to tenth grade in high school (Tr. 52), and she had worked temporarily, in 2000, as a census-taker for the United States Census Bureau, where she would walk for three and a half hours, stand for thirty minutes, climbfor thirty minutes, write, type or handle small objects for four hours, and reach for four hours, in a day. (Tr. 235-36.) In 2007, for about six months, she worked part-time as a mail clerk. (Tr. 54-55.) Plaintiff has four children and lives with three of them. (Tr. 43.) One of her sons, now fourteen years old, is disabled and suffers from cerebral palsy, seizure, and developmental delay. (Tr. 44.)
In her July 19, 2013 disability report, Plaintiff stated that she was unable to work due to depression, back injury, allergies, and asthma. (Tr. 234.) She reported that she was taking the following medications: Zoloft for depression, ibuprofen and Tylenol for pain, methocarbamol for back and hip pain, albuterol for asthma, calcium, and iron for anemia, and Prevacid for acid reflux. (Tr. 237.) Plaintiff reported she had been in the emergency room once in 2010 and once in July 2013. (Tr. 237.)
In a function report dated August 2, 2013, Plaintiff reported that she was able to dress, bathe, feed herself, and use the toilet without any assistance. (Tr. 243-44.) She did not need any special help or reminders to take care of her personal needs and grooming, but required help remembering to take her medication. (Tr. 244.) She could do chores such as cleaning, laundry, and household repairs, but needed help from family members. (Tr. 245.) Due to back pain, she had difficulty sleeping, could no longer take care of her son with special needs, and could not stand long enough to prepare her own meals. (Tr. 243-44.) Plaintiff did not go out alone because she experienced dizziness and was afraid she would pass out. (Tr. 245.) She was generally able to manage household finances. (Tr. 246.) She reported that her pain, anxiety, and depression made it difficult to spend time and get along with others. (Tr. 247.) She had trouble finishing what shestarted and remembering things. (Tr. 249-50.) Plaintiff described her pain, presumably in her lower back,3 as stabbing and aching, and explained that waking up, walking, standing, and sitting for extended amounts of time triggered the pain. (Tr. 250-51.) Her pain had worsened over time, and the pain could be described as "needlelike," "shooting," and "chronic." (Tr. 251.) Plaintiff reported to taking a number of medications, including Acetaminophen, ibuprofen, Robaxin, and Tramadol, which helped only temporarily. (Tr. 251.) Plaintiff reported experiencing headaches about four to five times a month, which caused nausea, sensitivity to light and sound, and sometimes blurred vision. (Tr. 253.) She reported that she received treatment for headaches once at Jamaica Hospital Medical Center ("JHMC"). (Tr. 252.) She had been diagnosed with depression and anxiety, and such conditions were triggered in crowded areas as well as by stress. (Tr. 253-54.) She described her depression and anxiety to cause shaky hands, palpitation, nervousness, confusion, disorientation, and crying. (Tr. 254.)4
On August 30, 2013, Plaintiff was examined by Dr. Jesus Navarro, an internal medicine specialist, at FedCap Rehabilitation Services ("FedCap"), a New York City Human Resources Administration public assistance program that provides advocacy for claimants seeking federal disability benefits.5 (Tr. 464-500.) Plaintiff reported that she had difficulty walking, standing, climbing stairs, and sometimes grooming, bathing, and dressing due to back pain. (Tr. 472.)Plaintiff also reported that she had had anxiety since the 1990's and depression since 2011. (Tr. 482.) Plaintiff was observed to be groomed and responsive during the interview. (Tr. 475.)
In the evaluation summary, Dr. Navarro noted Plaintiff's back, leg, joint, and muscle pain, stiffness, swelling, and limitation of movement. (Tr. 486.) He noted that Plaintiff did not experience neck pain. (Tr. 484.) Dr. Navarro also conducted a physical examination, where he assessed abnormal musculoskeletal functions in range of motion, strength, and tone. (Tr. 490.) He noted that Plaintiff experienced continuous, moderate levels of pain in her lumbar spine, left hip, and left knee. (Id.) As a result, Dr. Navarro concluded that Plaintiff had physical limitations in standing, walking, pushing, pulling, sitting, reaching, kneeling, squatting, and bending. (Tr. 491.) He also concluded that Plaintiff had emotional and cognitive limitations due to depression, respiratory limitations due to asthma, and other general limitations in her capacity to maintain energy level, sustain attendance, and achieve adequate work pace and productivity due to her medical conditions and use of a cane. (Tr. 492-93.) Dr. Navarro diagnosed Plaintiff with sprains and strains of hip, thigh, knee, leg, and parts of the back, asthma, migraine, and episodic mood disorders. (Tr. 496-98.) He concluded that Plaintiff was "unable to work." (Tr. 498.)
Plaintiff's FedCap case manager and non-attorney representative, Cooper Goodman, completed a third-party function report. (Tr. 273-81.) According to the report, Plaintiff's day consisted mainly of resting and supervising other people who took care of her son with special needs because Plaintiff's medical conditions significantly limited her physical capacity. (Tr. 273.) She was no longer able to dress and bathe herself, nor was she able to use public bathrooms because the toilets were too low. (Tr. 274.) Similarly, Plaintiff could not perform household chores. (Tr. 275-76.) Her physical limitations—inability to walk, stand, prepare food, and perform any form of exertion—perpetuated her mental health problems. (Tr. 274.) Her physical limitations also ledher to withdraw from her hobbies and social life. (Tr. 277-78.) Plaintiff reported having difficulty lifting, squatting, bending, standing, reaching, walking, sitting, kneeling, talking, concentrating, remembering, completing tasks, understanding, following instructions, and getting along with others. (Tr. 278.) Goodman concluded that Plaintiff had no physical or mental residual functional capacity ("RFC") to perform either relevant past work (i.e. poll taker) or other work given her background. (Tr. 281.)
On October 20, 2011, Plaintiff saw Nurse Practitioner Rosanne Martone for migraine headaches at Richmond Hill Family Medicine ("RHFM") of JHMC. (Tr. 335-36.) Plaintiff reported that her pain was moderate, intermittent, and that it had been gradually worsening. (Tr. 335.) Symptoms included dizziness, phonophobia,6 and photophobia,7 but Plaintiff experienced no nausea, vision change or vomiting. (Id.) Martone noted Plaintiff's significant medical history of migraine headaches. (Id.) At her January 18, 2012 follow-up visit at JHMC with Dr. Thambiraja Nandakumar, a neurologist, Plaintiff reported having headaches twice a week, with associated visual disturbances, nausea, and vomiting. (Tr. 338.) Dr. Nandakumar diagnosed Plaintiff with migraine and prescribed Imitrex.8 (Tr. 340.) However, within five weeks of being prescribed the medication—even though the medication had been effective—Plaintiff...
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...without providing any reasons for doing so, the ALJ committed error that requires remand. See Fontanel v. Colvin, No. 16-CV-01300 (PKC), 2017 WL 4334127, at *18 (E.D.N.Y. Sept. 28, 2017); see also Calzada v. Asture, 753 F. Supp. 2d250, 275 (S.D.N.Y. 2010) (ALJ erred by failing to further de......