Gualano v. Comm'r of Soc. Sec.

• Decision Date: 05 December 2019
• Docket Number: 18-CV-701MWP
• Citation: 415 F.Supp.3d 353
• Parties: Rachael Marie GUALANO, Plaintiff, v. COMMISSIONER OF SOCIAL SECURITY, Defendant.
• Court: U.S. District Court — Western District of New York

415 F.Supp.3d 353

Rachael Marie GUALANO, Plaintiff,

v.COMMISSIONER OF SOCIAL SECURITY, Defendant.

18-CV-701MWP

United States District Court, W.D. New York.

Signed December 5, 2019

Justin David Jones, Kenneth R. Hiller, Law Offices of Kenneth Hiller, PPLC, Amherst, NY, for Plaintiff.

Anne M. Zeigler, Francis D. Tankard, Office of the General Counsel Social Security Administration, Kansas City, MO, Elizabeth Rothstein, Social Security Administration Office of General Counsel, New York, NY, for Defendant.

DECISION & ORDER

MARIAN W. PAYSON, United States Magistrate Judge

PRELIMINARY STATEMENT

Plaintiff Rachael Marie Gualano ("Gualano") brings this action pursuant to Section 205(g) of the Social Security Act, 42 U.S.C. § 405(g), seeking judicial review of a final decision of the Commissioner of Social Security (the "Commissioner") denying her application for Supplemental Security Income Benefits ("SSI"). Pursuant to the Standing Order of the United States District Court for the Western District of New York regarding Social Security cases dated June 1, 2018, this case has been reassigned to, and the parties have consented to the disposition of this case by, the undersigned. (Docket # 16).

Currently before the Court are the parties' motions for judgment on the pleadings pursuant to Rule 12(c) of the Federal Rules of Civil Procedure. (Docket ## 9, 14). For the reasons set forth below, I hereby vacate the decision of the Commissioner and remand this claim for further administrative proceedings consistent with this decision.

DISCUSSION

I. Standard of Review

This Court's scope of review is limited to whether the Commissioner's determination is supported by substantial evidence in the record and whether the Commissioner applied the correct legal standards. See Butts v. Barnhart , 388 F.3d 377, 384 (2d Cir. 2004) ("[i]n reviewing a final decision of the Commissioner, a district court must determine whether the correct legal standards were applied and whether substantial evidence supports the decision"), reh'g granted in part and denied in part , 416 F.3d 101 (2d Cir. 2005) ; see also Schaal v. Apfel , 134 F.3d 496, 501 (2d Cir. 1998) ("it is not our function to determine de novo whether plaintiff is disabled[;] ... [r]ather, we must determine whether the Commissioner's conclusions are supported by substantial evidence in the record as a whole or are based on an erroneous legal standard") (internal citation and quotation omitted). Pursuant to 42 U.S.C. § 405(g), a district court reviewing the Commissioner's determination to deny disability benefits is directed to accept the Commissioner's findings of fact unless they are not supported by "substantial evidence." See 42 U.S.C. § 405(g) ("[t]he findings of the Commissioner ... as to any fact, if supported by substantial evidence, shall be conclusive"). Substantial evidence is defined as "more than a mere scintilla. It means such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Richardson v. Perales , 402 U.S. 389, 401, 91 S.Ct. 1420, 28 L.Ed.2d 842 (1971) (internal quotation omitted).

To determine whether substantial evidence exists in the record, the court must consider the record as a whole, examining the evidence submitted by both sides, "because an analysis of the substantiality of the evidence must also include that which detracts from its weight." Williams ex rel. Williams v. Bowen , 859 F.2d 255, 258 (2d Cir. 1988). To the extent they are supported by substantial evidence, the Commissioner's findings of fact must be sustained "even where substantial evidence may support the claimant's position and despite the fact that the [c]ourt, had it heard the evidence de novo , might have found otherwise." Matejka v. Barnhart , 386 F. Supp. 2d 198, 204 (W.D.N.Y. 2005) (citing Rutherford v. Schweiker , 685 F.2d 60, 62 (2d Cir. 1982), cert. denied , 459 U.S. 1212, 103 S.Ct. 1207, 75 L.Ed.2d 447 (1983) ).

A person is disabled for the purposes of SSI and disability benefits if he or she is unable "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) & 1382c(a)(3)(A). When assessing whether a claimant is disabled, the ALJ must employ a five-step sequential analysis. See Berry v. Schweiker , 675 F.2d 464, 467 (2d Cir. 1982) (per curiam ). The five steps are:

(1) whether the claimant is currently engaged in substantial gainful activity;

(2) if not, whether the claimant has any "severe impairment" that "significantly limits [the claimant's] physical or mental ability to do basic work activities";

(3) if so, whether any of the claimant's severe impairments meets or equals one of the impairments listed in Appendix 1 of Subpart P of Part 404 of the relevant regulations;

(4) if not, whether despite the claimant's severe impairments, the claimant retains the residual functional capacity [ ("RFC") ] to perform his or her past work; and

(5) if not, whether the claimant retains the [RFC] to perform any other work that exists in significant numbers in the national economy.

20 C.F.R. §§ 404.1520(a)(4)(i)-(v) & 416.920(a)(4)(i)-(v) ; Berry v. Schweiker , 675 F.2d at 467. "The claimant bears the burden of proving his or her case at steps one through four[;] ... [a]t step five the burden shifts to the Commissioner to ‘show there is other gainful work in the national economy [which] the claimant could perform.’ " Butts v. Barnhart , 388 F.3d at 383 (quoting Balsamo v. Chater , 142 F.3d 75, 80 (2d Cir. 1998) ).

II. Gualano's Contentions

Gualano contends that the ALJ's determination that she is not disabled is not supported by substantial evidence and is the product of legal error. (Docket ## 9-1, 15). In his decision, the ALJ determined that Gualano retained the RFC to perform light work involving simple, routine tasks requiring only simple work-related decisions and occasional contact with supervisors and coworkers, but was unable to perform positions requiring tandem work, contact with the public, assembly lines or conveyor belts. (Tr. 20). Gualano challenges this determination on the grounds that the ALJ failed to properly apply the treating physician rule to the opinion rendered by her licensed mental health therapist Cortney Bota ("Bota"), which was cosigned by her treating psychiatrist, Viktor Yatsynovich ("Yatsynovich"), MD. (Docket ## 9-1 at 12-22; 15 at 1-4). According to Gualano, the ALJ treated the opinion as one from an unacceptable medical source rather than from a treating psychiatrist. (Id. ). Further, Gualano maintains that the ALJ failed to consider the requisite factors in determining to give the opinion "little weight" and failed to provide good reasons for discounting the opinion. (Id. ). Gualano also contends that the ALJ's RFC assessment is not supported by any of the medical opinions contained in the record. (Docket ## 9-1 at 23-28; 15 at 5-6). Finally, Gualano challenges the ALJ's RFC determination on the grounds that he failed to evaluate an opinion submitted by her primary care physician Sami A. Raphael ("Raphael"), MD. (Docket ## 9-1 at 28-29; 15 at 6-7).

III. Analysis

An individual's RFC is his or her "maximum remaining ability to do sustained work activities in an ordinary work setting on a regular and continuing basis." Melville v. Apfel, 198 F.3d 45, 52 (2d Cir.1999) (quoting SSR 96–8p, 1996 WL 374184, *2 (July 2, 1996) ). When making an RFC assessment, the ALJ should consider "a claimant's physical abilities, mental abilities, symptomology, including pain and other limitations which could interfere with work activities on a regular and continuing basis." Pardee v. Astrue , 631 F. Supp. 2d 200, 221 (N.D.N.Y. 2009) (citing 20 C.F.R. § 404.1545(a) ). "To determine RFC, the ALJ must consider all the relevant evidence, including medical opinions and facts, physical and mental abilities, non-severe impairments, and [p]laintiff's subjective evidence of symptoms." Stanton v. Astrue , 2009 WL 1940539, *9 (N.D.N.Y. 2009) (citing 20 C.F.R. §§ 404.1545(b) - (e) ), aff'd , 370 F. App'x 231 (2d Cir. 2010).

An ALJ should consider "all medical opinions received regarding the claimant." See Spielberg v. Barnhart , 367 F. Supp. 2d 276, 281 (E.D.N.Y. 2005) (citing 20 C.F.R. § 404.1527(d)¹ ). Generally, a treating physician's opinion is entitled to "controlling weight" when it is "well-supported by medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with the other substantial evidence in [the] case record." 20 C.F.R. § 404.1527(c)(2) ; see also Estrella v. Berryhill , 925 F.3d 90, 95 (2d Cir. 2019) ("[t]he opinion of a claimant's treating physician as to the nature and severity of an impairment is given controlling weight so long as it is well-supported by medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with the other substantial evidence in the case record") (internal quotations and brackets omitted). Thus, "[t]he opinion of a treating physician is generally given greater weight than that of a consulting physician[ ] because the treating physician has observed the patient over a longer period of time and is able to give a more detailed picture of the claimant's medical history." Salisbury v. Astrue , 2008 WL 5110992, *4 (W.D.N.Y. 2008).

"An ALJ who refuses to accord controlling weight to the medical opinion of a treating physician must consider various ‘factors’ to determine how much weight to give to the opinion." Halloran v. Barnhart , 362 F.3d 28, 32 (2d Cir. 2004). The ALJ must explicitly consider the " Burgess factors":

(1) the frequency of examination and length, nature, and extent of the treatment relationship,

(2) the amount of medical evidence supporting the opinion,

(3) the consistency of the opinion with the record as a whole,

(4) whether

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