Renaud v. Colvin

Decision Date01 July 2015
Docket NumberC.A. No. 14–483–M.
Citation111 F.Supp.3d 155
Parties Brian RENAUD, Plaintiff v. Carolyn W. COLVIN, Acting Commissioner of Social Security, Defendant.
CourtU.S. District Court — District of Rhode Island

Donna M. Nesselbush, Marasco & Nesselbush, L.L.P., Providence, RI, for Plaintiff.

Mary Rogers, U.S. Attorney's Office, Providence, RI, for Defendant.

MEMORANDUM AND ORDER

JOHN J. McCONNELL, JR., District Judge.

This matter is before the Court on Mr. Renaud's Motion for Reversal (ECF No. 6) of the decision of an Administrative Law Judge (ALJ) affirming the denial of supplemental security income (SSI) benefits to him on his claim of total disability. The Commissioner has filed a Motion to Affirm. (ECF No. 7). For the reasons stated below, the Court remands the case for reconsideration by the ALJ.

I.Procedural History

Brian K. Renaud filed an application for supplemental security income (SSI) on June 19, 2012. (Tr. 48). He alleged a disability, due to a number of impairments, beginning June 6, 2012. Id. Mr. Renaud's original claim cited only physical impairments, but on reconsideration he added anxiety disorder as well as sleep apnea

.

(Tr. 48, 72). His claim was initially denied, denied on reconsideration, and denied after an evidentiary hearing held by ALJ Hugh S. Atkins on July 18, 2013. Mr. Renaud testified at that hearing, as did vocational experts Stephen Kaplan and Paul Murgo. On August 1, 2013, the ALJ granted the Commissioner's Motion to Affirm and denied Mr. Renaud's Motion for Reversal, finding that he was not under a disability during the relevant time period because he had the residual functional capacity (RFC) to perform his former work as a customer service representative. (Tr. 21). Most significant to this decision, the ALJ also found that Mr. Renaud did not suffer from a severe anxiety impairment. (Tr. 15).

II.Background

Mr. Renaud at the time of the hearing was a 48–year–old man living with a disabled partner. (Tr. 35, 36). Armed with a GED, Mr. Renaud had worked consistently, most recently employed for two years by a temporary agency that deployed him to a call-in center for CVS Caremark, where he spoke to customers and investigated and verified insurance information. (Tr. 31, 32). Before that, he had worked as a maintenance worker at a nursing home, as the parts manager of a repair shop, in a warehouse, in retail for eight years, and as a "rides supervisor" at Rocky Point Amusement Park. (Tr. 33, 34, 180). His earnings record dated back to 1980, and was sufficient to permit him to remain insured through December 31, 2017. (Tr. 13).

III.Central Issue

Mr. Renaud premised his claim for disability on myriad conditions, specifically: coronary heart disease

, which had required triple bypass surgery in 2012 as well as the subsequent placing of stents (Tr. 530), sleep apnea, diabetes mellitus with neuropathy, and anxiety manifested by frequent panic attacks of significant duration. The ALJ agreed that the heart disease, the sleep apnea, and the diabetes were all severe impairments, "because they cause more than a minimal limitation on the claimant's ability to perform basic work activities ... [,] are demonstrated by medically acceptable clinical and laboratory diagnostic techniques, and have lasted or are expected to last at least 12 months." (Tr. 15).1

The core of this Motion to Reverse is Mr. Renaud's complaint that the ALJ failed to find his anxiety disorder severe.2

For the reasons outlined below, this Court agrees that the ALJ's finding was not supported by substantial evidence, that the ALJ failed to justify the little weight given to opinions of both treating and consultative experts, and that the ALJ did not sufficiently explain his failure to credit completely Mr. Renaud's description of the limitations his anxiety disorder placed upon him. These reasons, along with the substantial evidence that his anxiety disorder presents limitations both to his daily living and to his working ability, require reconsideration. The Step 4 RFC finding is integrally linked to the type and extent of the severe impairments found and thus cannot stand if the Step 2 determination is not sustained.3

IVEvidence of Anxiety

A mental state impairment requires assessment of the condition against four broad functional areas: (a) activities of daily living; (b) social functioning, (c) concentration, persistence or pace; and (d) episodes of decompensation. 20 C.F.R. § 404.1520a(c)(3). There was no evidence in this case of decompensation. The evidence of anxiety disorder, manifested in panic attacks,4 came from three sources: Mr. Renaud's treating physicians (including their treatment notes), the state agency consultants, and Mr. Renaud's testimony at the hearing.

Treating Physicians

Jeffrey Borkan, M.D. was Mr. Renaud's treating physician, having been his primary care physician since 2005. (Tr. 176, 501). He offered the opinion that Mr. Renaud had a severe panic and anxiety disorder that significantly limited his ability to engage in substantial gainful activity. (Tr. 514, 886, 512). Dr. Borkan appears to have first begun prescribing medication for Mr. Renaud's anxiety in early July 2012, with a 30–day trial of Buspar

. (Tr. 299). By November, 2012, Mr. Renaud had been switched to Prozac. (Tr. 204, 220). Even though the Prozac had increased from 20 mg daily to 40 mg (Tr. 506, 513), Dr. Borkan concluded in January 2013 that Mr. Renaud's "[d]aily panic attacks will make work difficult to impossible." (Tr. 512–13). While there was some improvement in February 2013 (Tr. 516, 880), by April 2013, Mr. Renaud was again reporting daily panic attacks (sometimes twice daily), lasting for about an hour each time. (Tr. 968). By July 2013, Dr. Borkan had added Paxil to the Prozac Mr. Renaud was already taking, as well as Klonopin at night, because the anxiety had outstripped the ability of Prozac to control it. (Tr. 228, 995).

A second treating physician, Priya Kholi, M.D., reported on June 11, 2013, that Mr. Renaud's "significant depression/anxiety," combined with the other impairments found severe by the ALJ, precluded him from working full time. She noted that significant fatigue of "moderate severity" resulted from anxiety. (Tr. 792). She had treated him for more than a year by that time. (Tr. 789).

A third professional, psychologist Cara Fuchs, was treating Mr. Renaud for anxiety5 in both individual and group sessions from November 2012 at least into June 2013. (Tr. 605, 868, 980, 988). She was specifically helping him to leave his house alone, and from time to time she reported some progress. For example, her notes of 2/11/13 indicate he was able to go to the supermarket on one occasion by himself. (Tr. 516). On the other hand, the "nearly" daily panic attacks reported in November by Dr. Surti had increased to "daily" reported by Dr. Borkan five months later. (Tr. 633).

Consulting Physicians6

Dr. Ghulam Mustafa Surti performed a psychiatric consultative examination in November 2012. (Tr. 505–09). It showed that while Mr. Renaud's memory and concentration tested normal in a one-on-one setting, he had an "anxious effect and a nervous mood." (Tr. 507). Dr. Surti reviewed Mr. Renaud's past medical history, including his past psychiatric history, and assigned a GAF score of 45–50.7 Dr. Surti diagnosed him as suffering from "severe panic attacks, caused by a panic disorder without agoraphobia

." Mr. Renaud's nearly-daily attacks, as early as November 2012, contributed to his opinion that "[b]ased on his present level of symptoms at functioning, [Mr. Renaud] is unable to hold a job." (Tr. 507).8

State agency psychologist Stacey Fiore, Psy.D. reviewed the entire file as a consulting expert on November 19, 2012. She found a severe anxiety disorder, with severe panic attacks, resulting in moderate limitations both in maintaining social functioning and the ability to maintain a workday. (Tr. 60). Those limitations rendered him unable to tolerate social demands beyond minimal ones. (Tr. 63–64). She further concluded Mr. Renaud was "moderately" limited in his ability to interact with the general public, could tolerate only simple changes in routine, and could make or carry out only simple plans. Id.

Medical Records

The record is replete with references to Memorial Hospital visits, most often to emergency rooms, sometimes by ambulance, when Mr. Renaud complained of chest pain that was attributed to anxiety because it was not of cardiac origin.9 E.g., trip to ER on 5/20/12 and 6/26/12, admissions on 5/23/12, 6/17/12, 7/29/12, 9/5/12, 9/30/12, 10/17/12, 3/22/13 (Tr. 236, 245, 265, 266, 563, 572, 576, 597). Consulting physician Surti explained that while the panic attacks were occurring several times per week as of November 2012 (nearly daily according to his notes), every week or two there would be one of such intensity that Mr. Renaud would think it might be a heart attack and go to the ER. (Tr. 505).

Mr. Renaud's Testimony

Mr. Renaud testified that the health problems that led to the disability application began coincident in time with his triple bypass surgery in 2011. At the time he was working at an insurance call center, talking with insureds through a headset, and working in a room with six other employees. (Tr, 45). While he returned to work after the operation, the surgery was followed within a year by anxiety attacks, an emergency visit to the hospital, and the placement of a cardiac stent

. (Tr. 32). The anxiety attacks that followed on the heels of the stents were feared by him to be heart attacks, sending him to the hospital. (Tr. 36). Ultimately, the anxiety attacks became more frequent, and precluded him from working altogether. (Tr. 37). Without medication, the attacks were as frequent as 2–3 times per day; with medication, and some therapy strategies, they reduced to 3–4 times per week. Id. The call center job no longer existed, he testified, but he would not be able to perform it any longer because of his anxiety. (Tr. 32, 34–35).10

Mr. Renaud...

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