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Diaz v. Astrue

August 17, 2010


The opinion of the court was delivered by: Hon. Harold Baer, Jr., District Judge.*fn1


Sonia Morales Diaz ("Plaintiff" or "Diaz") brings this action pursuant to the Social Security Act (the "Act"), 42 U.S.C. § 405(g), seeking judicial review of a final decision by the Commissioner of Social Security (the "Commissioner") denying her claim for disability insurance benefits ("DIB") and Social Security Income ("SSI"). Plaintiff contends that the Administrative Law Judge ("ALJ") failed to afford proper weight to the treating physician's opinion or perform a function-by-function assessment of her post-injury abilities. Presently before the Court are the parties' cross-motions for judgment on the pleadings, pursuant to Fed.R.Civ.P. 12(c). For the reasons below, the Commissioner's motion is DENIED, Plaintiff's motion is GRANTED and the case is REMANDED for rehearing.

I. Background

A. Procedural History

On June 17, 2003, Diaz filed an application for DIB and SSI, alleging that back injuries she sustained in a car accident rendered her unable to work. The Social Security Administration ("SSA") denied her application on September 2, 2003. Diaz reapplied for benefits and was denied again on March 11, 2004. Diaz timely requested a hearing before an ALJ.

On August 22, 2005, ALJ Henry Snavely held a hearing at which Diaz, who was represented by counsel, testified. On February 8, 2006, ALJ Snavely opined that Diaz was not disabled because she retained the residual functional capacity ("RFC")*fn2 to perform a range of sedentary to light work. Diaz requested review, and the Appeals Council, by an order dated September 2, 2006, vacated the ALJ decision and remanded for further proceedings on the grounds that the ALJ failed to adequately consider the medical testimony from Dr. Ty A. Trudeau, Diaz's chiropracter. The Appeals Council directed the ALJ to "state the weight given to [Dr. Trudeau's] report and the reasons for the weight assigned," and "[g]ive further consideration to the claimant's maximum residual functional capacity and provide appropriate rationale with specific references to evidence of record in support of the assessed limitations." See Transcript ("Tr.") 282.

On remand, ALJ Paul A. Heyman, newly assigned to Diaz's case, held a hearing on November 16, 2006. Diaz, again represented by counsel, testified. On October 12, 2007, ALJ Heyman found that Diaz was not disabled during the period of June 2003 to October 2007. This decision became final on May 11, 2009, when the Appeals Council declined Diaz's request for review. Diaz then appealed to this Court.*fn3

B. The Administrative Record

1. Relevant Non-Medical Evidence

a. Diaz's Testimony

Diaz was born on April 27, 1955 in the Bronx, New York. On June 2, 2003, Diaz, while employed as a case manager with the Center for Drug Free Living in Orlando, Florida, was involved in a car accident, which injured her back such that she has not returned to work. On November 11, 2004, while her application for benefits was on review, Diaz was involved in a second car accident, which "exacerbated" her back pain. Tr. 376. After the second accident, Diaz returned to New York.

Diaz testified at the hearing that she suffered from "lower back" pain that radiated to her legs. Tr. 374. She also experienced neck pain that often led to headaches and blurred vision.

Diaz stated that her current treatment regime of medication and physical therapy had not reduced her pain. In the fifteen-year period before her first car accident, Diaz held jobs as a "case manager, advocate, bilingual counselor, WIC representative, alcohol treatment program assistant and stenographer." Tr. 14. Diaz described her case manager work as a desk job, but noted that "[t]here was also a lot of driving [because she] had to take the clients to their appointments or home visits." Tr. 373. Diaz testified that her back pain precluded her from returning to this work or similar employment. She stated that she "can't even sit by the computer. It's difficult . to sit. The pain just hits in [the] back . ." Tr. 374. The ALJ noted that Diaz "appeared to be in significant discomfort during the hearing." Tr. 14.

Diaz also testified that the car accident reduced her ability to take care of herself. She stated that she lives with her son and his family in a second floor apartment, and while there is no elevator in the building, she does limited walking. Diaz explained that her daughter-in-law did the household vacuuming, sweeping, cooking and shopping. Diaz also noted that she needed her daughter-in-law's assistance to tie her shoes, and found it difficult to put on her pants by herself. When asked to describe her daily routine, Diaz responded, "I lay down. I elevate my legs and I go to my physical therapy. That's about it." Tr. 383. Diaz broke down in tears while testifying and explained, "It's just frustrating. I have never -- I have never used drugs, have never drank. I've always took care of myself, took care of my family, and now I'm -- I'm useless." Tr. 385.

b. Chiropractor's Report*fn4

In a March 4, 2004 report, Dr. Ty A. Trudeau, a chiropractor from Orlando Neck & Back Center who treated Diaz between November 17, 2003 and January 16, 2004, opined that he did "not feel at this time it would be practical for [Diaz] to return to her work . . . ." Tr. 169. Dr. Trudeau reported that Diaz came into his office complaining of back pain after having gone through unsuccessful physical therapy. Dr. Trudeau ordered a series of lumbar decompression therapy sessions. Ultimately, the sessions were unsuccessful, and Dr. Trudeau diagnosed Diaz with a "permanent impairment to the lumbar spine." Tr. 169. While Dr. Trudeau did not perform a functional capacity evaluation, he opined that Diaz "has been restricted from sitting for more than 20 minutes, standing for more than 20 minutes, and any repetitive bending or twisting. She has been restricted from lifting over 15 pounds." Tr. 169. He requested that Diaz undergo a functional capacity evaluation to quantify her limitations.

c. Other Non-Medical Evidence in the Record

The record also includes letters from Diaz's niece, friend and sister testifying to her limitations. According to Diaz's niece, Maritza Baez, Diaz could no longer use the walking trail in her community, travel on a long car ride to the beach, or sit through a 90 minute movie without "having to leave and go to her room to lay down on her heat pack and use medication because of chronic back pain." Tr. 295. Diaz's friend, Ileana Solla, described how Diaz could not go for walks or stay standing for long periods of time, and was "always complaining that her back hurts . . . ." Tr. 294. Finally, Diaz's sister, Amelia Morales, explained that Diaz was "unable to work or do the simplest daily things." Tr. 297.

2. Relevant Medical Evidence

The medical evidence in the record includes reports from treating and nontreating sources, as those terms are defined in the ...

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