Valderrama v. Comm'r of Soc. Sec.
Valderrama v. Comm'r of Soc. Sec.
Opinion of the Court
Plaintiff Victor Valderrama brings this action under
BACKGROUND
I. PROCEDURAL HISTORY
On April 9, 2014, Plaintiff filed an application for SSI, alleging disability beginning on September 11, 2005. (Administrative Transcript ("Tr."), Dkt. 8, at ECF 22, 44.)
II. THE ALJ DECISION
In evaluating disability claims, the ALJ must adhere to a five-step inquiry. The claimant bears the burden of proof in the first four steps of the inquiry; the Commissioner bears the burden in the final step. Talavera v. Astrue ,
Having determined that Plaintiff satisfied his burden at the first two steps, the ALJ proceeded to the third step, at which the ALJ considers whether any of the claimant's impairments meet or equal one of the impairments listed in the Social Security Act's regulations (the "Listings").
Relying on her RFC finding from step four, the ALJ determined that Plaintiff was unable to perform any of his past relevant work as "a messenger, hot walker (cooling down racehorses after practice), security guard, [or] construction laborer." (Id. at ECF 34.) The ALJ then proceeded to step five. At step five, the ALJ must determine whether the claimant-given his RFC, age, education, and work experience-has the capacity to perform other substantial gainful work in the national economy.
(1) cleaner II, job code 919.687-014, classified as [Specific Vocational Profile ('SVP') ] 1 work at the medium level of exertion, of which there are 40,000 jobs nationally; (2) ironer, job code 590.685-042, classified as SVP 2 work at the light exertional level, of which there are 18,000 jobs; and (3) fusing machine feeder, job code 583.686-014, which is classified as SVP I work at the light level of *145exertion, of which there are 7,000 jobs in the national economy.
(Tr., Dkt. 8, at ECF 35.)
DISCUSSION
Unsuccessful claimants for disability benefits under the Social Security Act may bring an action in federal district court seeking judicial review of the Commissioner's denial of their benefits.
Plaintiff argues that the Commissioner's decision was not supported by substantial evidence and that the ALJ failed to apply the relevant legal standards. (Plaintiff's Motion for Judgment on the Pleadings, Dkt. 16, at ECF 5.) Specifically, Plaintiff argues that the ALJ erred in disregarding the medical reports of Plaintiff's treating psychiatrist, Dr. Donn Weidershine,
In rejecting Dr. Weidershine's medical opinion, the ALJ reasoned as follows:
The only opinion in the record from a treating source is Dr. Weidershine's [July] 2016 letter, which states in conclusory terms that the claimant's limited focus, heightened anxiety, panic attacks, and low frustration tolerance would considerably impair his ability to function in a work setting (Ex. B12F). The Social Security Administration recognizes a 'treating physician' rule of deference to the opinion of the physician who has engaged in the primary treatment of claimant, but only if the opinion is well supported by medically acceptable clinical and laboratory diagnostic techniques and not inconsistent with other substantial evidence in the record. (20 CFR 404.1257(d)(2); SSR 96-2p). However, Dr. Weidershine's letter does not provide any specific limitations and is more in the nature of a vocational opinion on an issue reserved to the Commissioner than a medical opinion. In determining the claimant's mental residual functional capacity, I considered all of Dr. Weidershine's contemporaneous progress notes, including the treating social worker's records and the [New York Psychotherapy and Counseling Center *146("NYPCC") ]4 treatment plan reviews, as well as Dr. Weidershine's statement that the claimant is easily provoked, which I accommodated by limiting the claimant's dealing with the public.
(Tr., Dkt. 8, at ECF 33.)
The Court concludes that the ALJ's rejection of Dr. Weidershine's July 2016 medical opinion was not supported by substantial evidence. Because Dr. Weidershine was Plaintiff's treating physician,
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. Among those factors are: (i) the frequency of examination and the length, nature and extent of the treatment relationship; (ii) the evidence in support of the treating physician's opinion; (iii) the consistency of the opinion with the record as a whole; (iv) whether the opinion is from a specialist; and (v) other factors brought to the [SSA's] attention that tend to support or contradict the opinion. The regulations also specify that the Commissioner will always give good reasons in her notice of determination or decision for the weight she gives claimant's treating source's opinion.
Halloran v. Barnhart ,
The Court concludes that remand is required to allow the ALJ to specifically identify and consider the aforementioned factors as they relate to Dr. Weidershine's medical opinion. To the extent the ALJ is unable to engage in an analysis under the five factors on the record before her, she must affirmatively consult with Dr. Weidershine in order to develop a record that enables her to do so. As courts in this Circuit have held, "the ALJ must make every reasonable effort to help an applicant get medical reports from his medical sources" and "must seek additional evidence or clarification when the report from the claimant's medical source contains a conflict or ambiguity that must be resolved, the report does not contain all the necessary information, or does not appear to be based on medically acceptable clinical and laboratory diagnostic techniques." Calzada v. Astrue ,
To the extent the ALJ found that Dr. Weidershine's opinion that "claimant's limited focus, heightened anxiety, panic attacks, and low frustration tolerance would considerably impair his ability to function in a work setting" was "conclusory," she should have sought more evidence or information from the doctor to clarify the basis of his opinion, rather than summarily *147dismiss it. Furthermore, although the ALJ explained that, in determining Plaintiff's mental RFC (and rejecting Dr. Weidershine's July 2016 letter), she "considered all of Dr. Weidershine's contemporaneous progress notes, including the treating social worker's records and the NYPCC treatment plan reviews, as well as Dr. Weidershine's statement that the claimant is easily provoked," she did not explain how these other records undermined Dr. Weidershine's conclusion in July 2016 that Plaintiff's mental health conditions "would considerably impair his ability to function in a work setting." (Tr., Dkt. 8, at ECF 33.) Such an elaboration was required. See Cichocki v. Astrue ,
The ALJ's consideration of the opinions of other medical professionals in arriving at her conclusion that Dr. Weidershine's opinion was not entitled to deference suffers from the similar defects.
Accordingly, the Court finds that remand is warranted to allow the ALJ, inter alia , to: (1) supplement and further develop the record as necessary (e.g. , to identify the bases of Dr. Weidershine's July 2016 opinion); (2) reconsider Dr. Weidershine's opinion with proper deference owed a treating source and in the context of the entire record; and (3) if appropriate, to explain with specificity the ALJ's consideration of the factors set forth in Halloran ,
CONCLUSION
For the reasons set forth above, the Court grants Plaintiff's motion for judgment on the pleadings and denies the Commissioner's cross-motion. The Commissioner's decision is remanded for further consideration consistent with this Order. The Clerk of Court is respectfully requested to enter judgment and close this case.
SO ORDERED.
"ECF" refers to the pagination generated by the Court's CM/ECF docketing system and not the document's internal pagination.
To determine the claimant's RFC, the ALJ must consider the claimant's "impairment(s), and any related symptoms ... [which] may cause physical and mental limitations that affect what [the claimant] can do in the work setting."
The Court notes that the spelling of Dr. Weidershine's name is inconsistent throughout the parties' briefing as well as within the Administrative Transcript itself. (Compare Tr., at ECF 4 ("Weidershine"), with
NYPCC is the New York Psychotherapy and Counseling Center where Dr. Weidershine worked. (Tr., Dkt 8, at ECF 29.)
Under the "treating physician rule," an ALJ must defer "to the views of the physician who has engaged in the primary treatment of the claimant." Burgess v. Astrue ,
In determining Plaintiff's RFC, the ALJ (1) gave great weight to Dr. Chitoor Govindaraj's July 2014 opinion that Plaintiff had no exertional or other physical limitations at that time; (2) gave some weight to Dr. Chaim Shtock's August 2016 opinion that the claimant had a gait dysfunction and mild to moderate exertional and postural limitations at that time; (3) gave substantial wait to Dr. Ram Ravi's August 2016 opinion that Plaintiff had at most mild exertional limitations; (4) gave some weight to Dr. Brickell Quarles' July 2014 opinion that Plaintiff had mild limitations in concentration and short term memory; and (5) gave some weight to Dr. Lucy Kim's August 2016 opinion that Plaintiff had mild limitations in attention and concentration and no other limitations. (Tr., Dkt. 8, at ECF 32-34.)
Reference
- Full Case Name
- Victor E. VALDERRAMA, Jr. v. COMMISSIONER OF SOCIAL SECURITY
- Cited By
- 6 cases
- Status
- Published