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Caplan v. Astrue

March 15, 2009


The opinion of the court was delivered by: Dora L. Irizarry, United States District Judge


Plaintiff Bess I. Caplan filed an application for disability insurance benefits ("DIB") under the Social Security Act (the "Act") on April 13, 1999. Plaintiff's application was denied initially and on reconsideration. Plaintiff appeared with her attorney and testified at a hearing held before an Administrative Law Judge ("ALJ") on September 13, 2000. By a decision dated January 25, 2001, the ALJ partially found in plaintiff's favor. The ALJ concluded that plaintiff was disabled within the meaning of the Act as of September 25, 2000, but not prior to that date. The ALJ's decision became the Commissioner's final decision when the Appeals Council denied plaintiff's request for review. Plaintiff filed the instant action seeking judicial review of the denial of benefits for the period December 31, 1997 to September 25, 2000, pursuant to 42 U.S.C. § 405(g). The Commissioner now moves for judgment on the pleadings pursuant to Rule 12(c) of the Federal Rules of Civil Procedure, seeking affirmation of the denial of benefits prior to September 25, 2000, which plaintiff opposes. For the reasons set forth more fully below, the Commissioner's motion is denied and the case is remanded.


A. Non-medical and Testimonial Evidence

Plaintiff appeared with counsel and testified before ALJ Eileen P. Burlison at a hearing held on September 13, 2000. (Admin. R. at 273.) Plaintiff testified that she began working as a secretary in 1982 and that her duties consisted of scheduling, running errands, and taking shorthand. (Admin. R. at 276.) In terms of physical exertion, her position required walking and sitting. (Admin. R. at 294.) She ceased working in July 1997, due to fibromyalgia, irritable bowel syndrome, and panic attacks. (Admin. R. at 282-83.) In her final year of work, her absences totaled approximately four months. (Admin. R. at 283.) Plaintiff received her salary through December 31, 1997. She alleges that she became disabled at that time. (Admin. R. at 273, 276.) She attempted to find work unsuccessfully in 1998. (Admin. R. at 292.)

Plaintiff first saw a therapist for psychiatric problems in the 1970s. (Admin. R. at 284.) Plaintiff indicated that at the time of the hearing, she took a variety of medications, including Prozac, Klonopin, Synthroid, Imodium, and Excedrin. (Admin. R. at 288.) Plaintiff testified that she could sit for fifteen minutes at a time before needing to change positions. (Admin. R. at 292.) She could stand for short periods and could walk four blocks at most. (Admin. R. at 292-93.) Plaintiff naps several times daily. (Admin. R. at 293.) Plaintiff lives with her brother in an apartment and performs household chores. (Admin R. at 278-79.)

B. Medical and Psychiatric Evidence Submitted Prior to the ALJ Hearing

1. Medical Evidence

In January 1997, Plaintiff began treating at Brooklyn Women's Services and Dr. Ana Hansen was her primary care physician. (Admin. R. at 93, 234-36.) Dr. Hansen diagnosed her with hypothyroidism, chronic sinusitis, fibromylagia, irritable bowel syndrome, degenerative joint disease with back pain, and hay fever. (Admin. R. at 207-17.) Dr. Hansen prescribed Synthroid, Prozac, Klonopin, Librax, Vancenase, Duratuss, Naprosyn, and Cytotec. (Id.)

In January 1998, Dr. Kersti Bruining, a neurologist, diagnosed plaintiff with localized elbow pain. (Admin. R. at 178-80.) Plaintiff brought copies of her prior MRI and EMG reports to a follow-up visit. (Admin. R. at 179.) Her nerve conduction and EMG test results were normal; however, her MRI indicated small disc herniations of the cervical spine, and degenerative joint disease with mild left foraminal stenosis. (Id.)

Dr. David Goddard examined plaintiff on April 7, 1998, noting that Plaintiff stated that she was diagnosed with rheumatoid arthritis roughly thirty years ago and had received treatment, including the use of steroids. (Admin. R. at 174.) Plaintiff also indicated that she had a discectomy for her low back pain and received treatment for her right elbow. (Id.) Dr. Goddard described plaintiff's examination as "unremarkable." (Id.) Dr. Goddard's examination revealed evidence of paracervical and lumbar tenderness, bilateral epicondylitis, bilateral anserine bursitis, and generalized mild osteoarthritis. (Id.) Dr. Goddard diagnosed plaintiff with polyarticular osteoarthritis and secondary fibromyalia. (Id.) On April 29, 1998, plaintiff returned to Dr. Goddard, who noted that the bone density measurements of her left and right hips were consistent with early bone mineral loss and recommended that she take a daily calcium supplement and vitamin D. (Admin. R. at 76.) In a subsequent visit, on June 29, 1999, Dr. Goddard diagnosed her with polyarticular osteoarthritis and secondary fibromyalgia. (Admin. R. at 75.) He noted that the "combination of these two conditions results in difficulty with bending, stooping, lifting, and carrying" and determined that plaintiff was unable to work. (Id.) He opined that her "disability is likely to continue indefinitely." (Id.)

Plaintiff visited Dr. Donald Huml, her chiropractor, on July 12, 1999. The report indicates that plaintiff began treating with him approximately five years earlier for lumbar plexion disorder, carpal tunnel syndrome, and headaches. (Admin. R. at 84.) Plaintiff's complaints included headaches, tempero-mandibular joint ("TMJ") pain, other unspecified joint pain, low back pain with paresthesias in both legs, and difficulty breathing when walking and climbing stairs. (Id.) Plaintiff also complained of symptoms consistent with thyroid disease, irritable bowel syndrome, and chronic fatigue. (Admin. R. at 85.) Dr. Huml concluded that plaintiff could lift and carry up to three pounds, stand and walk for less than two hours a day and sit for less than six hours a day. (Admin. R. at 87.)

Plaintiff began seeing Dr. Shefali Patel, another physician at Brooklyn Women's Services, as her primary care physician in February 1999. (Admin. R. at 93-96.) In a report from July 1999, Dr. Patel noted unspecified limitations on lifting and carrying. (Admin. R. at 95.) She noted that plaintiff could stand and walk for up to six hours a day and sit without limitations. (Admin. R. at 95-96.) In October and November 1999, plaintiff underwent a series of diagnostic tests. A pulmonary function test revealed shortness of breath. (Admin. ...

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