Guzman v. Astrue, 09 Civ. 3928 (PKC)

• Decision Date: 03 February 2011
• Docket Number: 09 Civ. 3928 (PKC)
• Parties: JULIAN DEJESUS GUZMAN Plaintiff, v. MICHAEL J. ASTRUE, COMMISSIONER OF SOCIAL SECURITY, Defendant.
• Court: U.S. District Court — Southern District of New York

JULIAN DEJESUS GUZMAN Plaintiff,
v.
MICHAEL J. ASTRUE,
COMMISSIONER OF SOCIAL SECURITY, Defendant.

09 Civ. 3928 (PKC)

UNITED STATES DISTRICT COURT SOUTHERN DISTRICT OF NEW YORK

Filed: February 4, 2011
February 3, 2011

MEMORANDUM AND ORDER

P. KEVIN CASTEL, District Judge:

Plaintiff Julian Guzman seeks judicial review of a final decision by the Commissioner of Social Security (the "Commissioner") denying his application for a Period of Disability and Disability Insurance Benefits under Title II and Title XVI of the Social Security Act, 42 U.S.C. § 401 et seq. Plaintiff asserts that the decision of the Administrative Law Judge ("ALJ") was "erroneous, not supported by substantial evidence on the record, and/or contrary to the law." (Compl. ¶ 9.) Specifically, he alleges that (1) the ALJ failed to apply the treating physician rule properly and (2) the ALJ wrongly assessed Mr. Guzman's credibility. (Pl.'s Mem. 2) Defendant and plaintiff have each moved for judgment on the pleadings pursuant to Rule 12(c), Fed. R. Civ. P. For the reasons explained below, the order denying disability benefits is reversed and the case is remanded to the Commissioner for further proceedings. Defendant's motion is denied.

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I. PROCEDURAL HISTORY

On September 26, 2006, plaintiff applied to the Social Security Administration ("SSA") for disability insurance benefits due to a heart condition, high blood pressure, and high cholesterol. (R. 107)¹ The Alleged Onset Date is September 12, 2006 and the Date Last Insured for his Title II claim is December 31, 2010. (R. 104) On January 22, 2007, the SSA determined that plaintiff's conditions were not severe enough to prevent him from working and denied his application. (R. 56) The SSA notified plaintiff that his claim was disapproved and informed him of his right to request a hearing. (R. 57-59)

Plaintiff then requested a de novo hearing before an Administrative Law Judge ("ALJ"), which was held on April 2, 2008. (R. 19) Plaintiff appeared at the hearing and was represented by counsel. (R. 21)

In a written decision issued April 23, 2008, ALJ Leonard Olarsch denied plaintiff's claim for benefits. (R. 9-15) After applying the five-step sequential test for determining whether an individual is disabled, ALJ Olarsch concluded that plaintiff is not disabled under sections 216(i) and 223(d) of the Social Security Act. (R. 15) He reviewed plaintiff's claims stemming from his heart condition and determined that plaintiff has a severe impairment-coronary artery disease, but still has the residual functional capacity ("RFC") to perform the full range of light work defined in 20 CFR 404.1567(b). (R. 11) He noted that "[plaintiff's] medically determinable impairment could reasonably be expected to produce the alleged symptoms; however, the [plaintiff's]

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statements considering the intensity, persistence and limiting effects of these symptoms are not credible to the extent they are inconsistent with the RFC assessment . . . ." (R. 12)

On June 21, 2008, plaintiff requested review of the ALJ's decision. (R. 5) The SSA Appeals Council denied plaintiff's request to review the ALJ's decision, and ALJ Olarsch's decision became the final decision of the Commissioner on March 13, 2009. (R. 1) This case was then ripe for judicial review.

On March 30, 2009, plaintiff, proceeding pro se, filed a timely action with this Court seeking review of the Commissioner's final decision.² (Compl. ¶ 1) A notice of appearance was filed on behalf of plaintiff on September 13, 2010. (Docket #12) Both parties moved for a judgment on the pleadings pursuant to Rule 12(c), Fed. R. Civ. P.

II. EVIDENCE BEFORE THE ALJ

At the hearing before ALJ Olarsch, plaintiff testified about his age, height, weight, background, education, family, work history, daily activities, and physical and psychiatric condition. (R. 21-55) ALJ Olarsch also heard the testimony of a board certified cardiologist and medical expert, Dr. Gerald Galst, regarding plaintiff's physical condition. (R. 41-54) ALJ Olarsch reviewed documentary evidence, including plaintiff's medical records from North Central Bronx Hospital ("NCBH"), a report from Dr. E.B. Balinberg, an internal medicine specialist who performed a consultative physical examination on the plaintiff, and letters from two treating physicians—Dr. David Kaufman, a cardiologist, and Dr. Lori Ciuffo, a primary care physician. (R. 25, 155-96)

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A. Non-Medical Evidence

Plaintiff was born in February 1959, and was between forty-seven and forty-nine years old during the period at issue. (R. 22, 88) He is five feet eight inches tall and weighs 170 pounds. (R. 22) He lives on the third floor of a walk-up apartment building with his girlfriend and two children, ages 12 and 19. (R. 26-27) He drives a car, can use public transportation, sits without difficulty, and is able to walk to the grocery store around the corner to purchase a few grocery items. (R. 22, 28, 35) He attends church weekly and is involved in church activities. (R. 31-32)

He has an eighth-grade education and worked as a roofer for about fourteen years. (R. 94-103, 112) He stopped working in September 2006, due to his cardiac condition. (R. 108) After a hospitalization at NCBH, he briefly returned to work but stopped working after he experienced "very hard palpitations" in his chest. (R. 23) As a roofer, he "carried materials and roofing products from the ground to the roof and on occasion, lifted materials weighing 100 lbs or more. (R. 109)

B. Medical Evidence

ALJ Olarsch reviewed plaintiff's medical records from NCBH, where the plaintiff received ongoing medical treatment. (R. 155-78) These included the records of Drs. Bodhanovic, Ramasamy, Ciuffo, and Christensen. ALJ Olarsch also reviewed letters written by Drs. Kaufman and Ciuffo and an examination conducted by Dr. Balinberg, a consultative examining internal medicine physician. (R. 179-95) Lastly, he considered the testimony of Dr. Gerald Galst, a board certified cardiology expert who heard plaintiff's testimony and reviewed all the medical evidence in the record. (R. 41-42)

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1. Treating Physicians' Records

Plaintiff was hospitalized at NCBH from September 5, 2006 to September 6, 2006 for atypical chest pain. (R. 170-78) He presented to the hospital with complaints of sharp, intense, left-sided chest pain. (R. 174) He reported that the pain lasted approximately fifteen minutes before it subsided without any treatment. (R. 174) Upon examination by Dr. Zoran Bodhanovic on September 5, 2006, his blood pressure was 114/73 and he had normal heart sounds. (R. 174) His peripheral pulses were palpable bilaterally and he had no edema. (R. 174) An electrocardiogram ("EKG") revealed normal sinus rhythm without any ST-T changes. (R. 174) His chest x-ray was normal and his vital signs were stable. (R. 174-75)

An echocardiogram was performed on September 6, 2006 and showed (1) normal left ventricular size, wall motion and systolic function, with a 60 percent estimated left ventricular ejection fraction; (2) normal right ventricular size and systolic function; (3) moderate to severe left atrium dilatation, and mild right atrium dilation; (3) a thickened and calcified mitral valve with markedly reduced mobility, and significant subvalvular calcification; (5) mild mitral regurgitation; (6) mild tricuspid regurgitation and (7) no pulmonary hypertension. (R. 170) This test was described by Dr. Elizabeth Natal as "essentially WNL [within normal limits]." (R. 165)

Dr. Bodhanovic summarized plaintiff's hospitalization as "uneventful" and without chest pains during his inpatient treatment. (R. 174) A myocardial infarction was ruled out based on three negative troponin levels. (R. 174) The discharge plan was for the plaintiff to undergo a cardiac stress test and follow-up with his primary care physician. (R. 174)

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Plaintiff was readmitted to NCBH from September 13, 2006 through September 22, 2006 for chest pain. (R. 156, 159-69) The chest pain began while performing heavy lifting at work. (R. 159) A stress test was performed on September 15, 2006 and revealed apical ischemia. (R. 159, 168). Plaintiff was described as asymptomatic throughout the test, which required plaintiff to walk for nine minutes on a treadmill. (R. 168-69) The test was terminated because plaintiff reached maximal performance and then reported dizziness, shortness of breath, and fatigue. (R. 168-69) During the test, plaintiff's heart rate reached eighty percent of his predicted maximal heart rate. (R. 169) The test was considered negative for exercise induced ischemic symptoms, ischemic ST-segment changes, and significant arrhythmias. (R. 169) Dr. Ramasamy concluded that plaintiff's "physical working capacity is fair for a man of his age." (R. 169)

Plaintiff underwent a cardiac catheterization on September 19, 2006, which showed minimal disease of the right coronary artery and the obtuse marginal branch. (R. 159) During the catheterization, plaintiff had an episode of atrial fibrillation, but returned to normal sinus rhythm after receiving a dose of Ibutilide. (R. 159, 164) Coumadin, an anticoagulation medication, was prescribed after the plaintiff's episode of atrial fibrillation and in light of his dilated right atrium. (R. 159) His primary diagnosis was coronary artery disease. (R. 159) It was documented that plaintiff was started on Lipitor, a cholesterol medication, but self-discontinued it because he could not refill the prescription. (R. 165, 174) On September 17, 2006, plaintiff's total cholesterol was 110 mg/dl. (R. 166) Dr. Vimala Ramasamy, an attending physician, noted that plaintiff's EKG and physical examination were normal. (R. 159)

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Following plaintiff's discharge from NCBH, the patient continued outpatient treatment with Dr. Lori Ciuffo, a primary care physician. (R. 158) On September 25, 2006, Dr. Ciuffo evaluated his anti-coagulation levels, (R. 158) His blood pressure was 112/70 and his heart rate was 64 beats per...