Tibeatha M. v. Comm'r of Soc. Sec.

Decision Date31 March 2021
Docket Number19-CV-730Sr
PartiesTIBEATHA M., Plaintiff, v. COMMISSIONER OF SOCIAL SECURITY, Defendant.
CourtU.S. District Court — Western District of New York
DECISION AND ORDER

As set forth In the Standing Order of the Court regarding Social Security Cases subject to the May 21, 2018 Memorandum of Understanding, the parties have consented to the assignment of this case to the undersigned to conduct all proceedings in this case, including the entry of final judgment, as set forth in 42 U.S.C. § 405(g). Dkt. #19.

BACKGROUND

Plaintiff applied for disability insurance benefits with the Social Security Administration ("SSA"), on June 2, 2016, alleging disability beginning October 21, 2015, at the age of 44, due to back injury, headaches, depression and neck pain. Dkt. #6, p.264.

On July 19, 2018, plaintiff appeared with counsel and testified, along with an impartial vocational expert ("VE"), Edward Pagella, at an administrative hearing before Administrative Law Judge ("ALJ"), Asad M. Ba-Yunus. Dkt. #6, pp.220-263. Plaintiff testified that she was a high school graduate and had worked for an insurance company providing customer service for approximately 25 years before she was injured in a motor vehicle accident on October 21, 2015. Dkt. #6, pp.232-237. She testified that since the accident, she is unable to lift more than 5-10 pounds or sit, stand or walk for more than 15 minutes at a time. Dkt. #6, pp. 239 & 243-246. She walks on a treadmill 10-15 minutes at a time or walks in a nearby park with a friend, stopping on a bench for 10-15 minutes after walking for 10-15 minutes. Dkt. #6, p.246. She is depressed, angry and experiences anxiety. Dkt. #6, p.255. She can drive short distances, but experiences numbness or tingling down her leg and back pain if she drives more than 15 minutes Dkt. #6, pp.231-232. She testified that the Oxycodone she takes for pain makes her drowsy and nauseous and triggers migraine headaches 3-4 times per week, which she relieves with a cold compress and staying quiet in a dark place. Dkt. #6, pp.247-248 & 254. Plaintiff's daughter prepares meals for her and her son transfers laundry from the washer to the dryer and then removes the laundry from the dryer for plaintiff to fold. Dkt. #6, pp.248-249. She mostly uses paper plates to avoid washing dishes. Dkt. #6, p.250. She generally wears slip-on shoes because she needs assistance to tie her sneakers. Dkt. #6, p.250. She has difficulty reaching overhead to curl her hair or behind her back to fasten a bra. Dkt. #6, p.256.

The VE classified plaintiff's past work as a customer service representative, which is a semi-skilled, light exertion position. Dkt. #6, p.258. When asked to assume an individual with plaintiff's age, education and past work experience who could perform light work, except that she could only frequently crouch and crawland only occasionally stoop, kneel, climb ramps or stairs, climb ladders, ropes or scaffolds, the VE testified that plaintiff could perform her past work. Dkt. #6, p.259. If plaintiff was limited to sedentary work with frequent balancing, occasional reaching overhead bilaterally and no kneeling, crouching, crawling or climbing and no hazards, including unprotected heights and dangerous machinery, the VE testified that plaintiff could work as a receptionist, which is a semi-skilled, sedentary position, or as an order clerk or packer, each of which were unskilled, sedentary positions. Dkt. #6, pp.259-260. If plaintiff was unable to bend at least occasionally throughout the workday, the VE testified that plaintiff would be unable to engage in substantial gainful activity. Dkt. #6, p.261.

The ALJ rendered a decision that plaintiff was not disabled on October 3, 2018. Dkt. #6, pp.204-215. The Appeals Council denied review on May 13, 2019. Dkt. #6, p.5. Plaintiff commenced this action seeking review of the Commissioner's final decision on June 5, 2019. Dkt. #1.

DISCUSSION AND ANALYSIS

"In reviewing a final decision of the SSA, this Court is limited to determining whether the SSA's conclusions were supported by substantial evidence in the record and were based on a correct legal standard." Talavera v. Astrue, 697 F.3d 145, 151 (2d Cir. 2012). Substantial evidence is defined as "such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Moran v. Astrue, 569 F.3d 496, 501 (2d Cir. 2009). If the evidence is susceptible to more than onerational interpretation, the Commissioner's determination must be upheld. McIntyre v. Colvin, 758 F.3d 146, 149 (2d Cir. 2014). "Where an administrative decision rests on adequate findings sustained by evidence having rational probative force, the court should not substitute its judgment for that of the Commissioner." Yancey v. Apfel, 145 F.3d 106, 111 (2d Cir. 1998).

To be disabled under the Social Security Act ("Act"), a claimant must establish an inability to do 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 twelve months. 20 C.F.R. § 404.1505(a). The Commissioner must follow a five-step sequential evaluation to determine whether a claimant is disabled within the meaning of the Act. 20 C.F.R. § 404.1520(a). At step one, the claimant must demonstrate that he is not engaging in substantial gainful activity. 20 C.F.R. § 404.1520(b). At step two, the claimant must demonstrate that he has a severe impairment or combination of impairments that limits the claimant's ability to perform physical or mental work-related activities. 20 C.F.R. § 404.1520(c). If the impairment meets or medically equals the criteria of a disabling impairment as set forth in Appendix 1 of Subpart P of Regulation No. 4 (the "Listings"), and satisfies the durational requirement, the claimant is entitled to disability benefits. 20 C.F.R. § 404.1520(d). If the impairment does not meet the criteria of a disabling impairment, the Commissioner considers whether the claimant has sufficient Residual Functional Capacity ("RFC"). for the claimant to return to past relevant work. 20 C.F.R. § 404.1520(e)-(f). If the claimant is unable to return to pastrelevant work, the burden of proof shifts to the Commissioner to demonstrate that the claimant could perform other jobs which exist in significant numbers in the national economy, based on claimant's age, education and work experience. 20 C.F.R. § 404.1520(g).

In the instant case, the ALJ made the following findings with regard to the five-step sequential evaluation: (1) plaintiff had not engaged in substantial gainful activity since the alleged onset date of October 21, 2015; (2) plaintiff's compression fracture, radiculopathy and chronic migraines constitute severe impairments; (3) plaintiff's impairments did not meet or equal any listed impairment; (4) plaintiff retained the RFC to perform sedentary work with the following limitations: frequent balancing, occasional overhead bilateral reaching, stooping and climbing ramps and stairs, and no kneeling, crouching, crawling, climbing ladders, ropes, scaffolds or hazards, including unprotected heights and dangerous machinery; and (5) plaintiff was not capable of performing her past work, but was capable of working as a receptionist, which was a semi-skilled sedentary position, or as an order clerk or packer, each of which were unskilled sedentary positions, and was not, therefore, disabled within the meaning of the SSA. Dkt. #6, pp.207-214.

Mental RFC

Plaintiff argues that the ALJ failed to address her depression and adjustment disorder despite substantial evidence that they were severe impairments, and failed to account for the functional limitations imposed by such mental impairments in the RFC. Dkt. #12-1, pp.16-19.

The Commissioner responds that the ALJ acknowledged some mental health problems associated with an affective disorder, but appropriately relied upon the opinion of Dr. Ipplito and Dr. Tzetzo that plaintiff's mental health symptoms caused no more than mild limitations and were non-severe. Dkt. #17-1, pp.15-16.

An alleged impairment is deemed severe only if it significantly limits an individual's physical or mental ability to do basic work activities; slight abnormalities that have no more than a minimal effect on the ability to do basic work activities are considered not severe. SSR 96-3P, 1996 WL 374181, at *1 (July 2, 1996). The mere presence of a disease or impairment, or evidence that a person has been diagnosed or treated for a disease or impairment, is insufficient, by itself, to render a condition severe. Lau v. Comm'r of Soc. Sec., 339 F. Supp.3d 421 (S.D.N.Y. 2018). For mental impairments, an ALJ assesses severity by rating the degree of functional limitation resulting from a medically determinable impairment in four functional areas: (1) understanding, remembering or applying information; (2) interacting with others; (3) concentrating, persisting or maintaining pace; and (4) adapting or managing oneself. 20 C.F.R. § 44.1520a(c)(3). Each functional area is rated on a five-point scale of none, mild, moderate, marked and extreme. 20 C.F.R. § 404.1520a(c)(4). A rating of none or mild generally results in a determination that the impairment is not severe. 20 C.F.R. § 404.1520a(d)(1).

Upon examination by Dr. Ippolito on August 30, 2016, plaintiff reported that she had been suffering from a sad and depressed mood, low self-esteem, and hadbeen more distant and withdrawn from others since her accident. Dkt. #6, pp.573-574. She also reported feeling stress and irritability related to chronic pain, financial problems and an inability to work or perform various physical activities, as well as short-term memory deficits and difficulty concentrating. Dkt. #6, p.574. Dr. Ippolitio observed that plaintiff's posture was tense due to pain and discomfort and that her attention and concentration was mildly impaired due...

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