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Sanyal Valcourt v. Michael J. Astrue

March 31, 2011


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


Plaintiff Sanyal Valcourt appeals a decision of the Commissioner of Social Security (the "Commissioner") that she is not disabled under the Social Security Act (the "Act") and therefore not entitled to disability benefits. Pursuant to Fed. R. Civ. P. 12(c), the parties cross-moved for judgment on the pleadings. For the reasons set forth below: (1) Plaintiff's motion is granted and the case is remanded to the Commissioner, pursuant to the fourth sentence of 42 U.S.C. § 405(g), for further proceedings in which the ALJ is to properly weigh the opinions of Plaintiff's treating physicians and consultative examiners, and further develop the record as needed; and (2) the Commissioner's motion is denied.


I.Procedural History

Plaintiff filed an application for Disability Insurance Benefits ("DIB") pursuant to 42 U.S.C. § 301 et seq., on December 30, 2004, alleging a continuous disability due to herniated discs in her cervical and lumbar spine with nerve root impingement, degenerative disc disease, chronic bilateral shoulder pain and impingement, chronic arthritis in the knees and status-post failed left hip surgeries. (Administrative Record "A.R." 83B.) The application was denied upon initial review, and on May 16, 2005, Plaintiff filed a request for an administrative hearing. (Id. at 66.) On March 28, 2007, Administrative Law Judge ("ALJ") Strauss dismissed the request as untimely. (Id. at 57--62). The Appeals Council vacated the ALJ's dismissal and remanded the case for an administrative hearing. (Id. at 68--74.) On April 24, 2008, Plaintiff appeared and testified before ALJ Strauss. (Id. at 289--360.) Following the hearing, Plaintiff's counsel submitted additional medical evidence. (Id. at 45.)

In a decision dated March 20, 2009, ALJ Strauss found plaintiff not disabled, and, therefore, not entitled to DIB, because she retained the capacity to perform a wide range of light and sedentary work. (A.R. 14.) Plaintiff appealed the decision. (Id. at 24--44.) On July 24, 2009, the Appeals Council denied Plaintiff's request for review, and the ALJ's decision became the Commissioner's final decision. (Id. at 4--6.) Plaintiff timely filed the instant action on September 28, 2009. (See generally Compl.¶¶ 1--15.)

II.Testimonial and Non-Medical Evidence

Plaintiff was born on April 28, 1964 in New York, and she has a college degree. (A.R. 293, 295.) She worked as a mail handler for the United States Postal Service ("U.S.P.S.") from February 1990 until her alleged disability onset in December 2002. (Id. at 301.) From 1990 to 1997, Plaintiff worked on regular duty for U.S.P.S., frequently walking, standing, lifting 10 to 25 pounds and pushing heavy carts of mail. (Id. at 95, 105, 112, 123.) Following a work injury and three-month medical leave in 1997, Plaintiff was assigned to light duty, where she repaired damaged mail, sorted mail in trays, lifted up to 30 pounds, and was occasionally required to push up to 145 pounds. (Id. at 304--09). She stopped working in December 2002 following a workplace accident that pinned her between two postal containers, thus injuring her back, neck and shoulders, as well as her hands. (Id. at 296--301.) Following the accident in 2002, Plaintiff received Worker's Compensation benefits in the amount of $2,200 per month, and subsequently received $1,266 per month in federal disability benefits through the United States Office of Personnel Management, due to cervical and lumbar radiculopathy, bilateral shoulder derangement, bilateral carpal tunnel syndrome and bilateral knee derangement. (Id. at 297--98.) She was receiving federal disability benefits at the time of the hearing.

Since her injury in 2002, Plaintiff has suffered from joint pain in her neck, back, shoulders, hands, knees, hips, ankles and elbows. Her neck and shoulders "locked up" and her range of motion was limited. (A.R. 315--17.) She experienced spasms in her neck and back, resulting in an inability to move, and alternating dull and stabbing pain in her lower back, which was exacerbated by changing positions and standing up. (Id. at 317.) According to Plaintiff, sometimes the pain was "so bad" when moving positions that she couldn't do anything but "stand and hold on and wait until it passe[d]." (Id. at 317.) She also suffered from occasional urinary incontinence, because of an inability to move quickly enough to get to the bathroom. (Id.) She testified that getting out of bed in the morning, washing up, and performing repetitive motions, like writing, caused her shoulders and elbows to "lock up," where her muscles hardened and she felt electrical shocks of pain. (Id. at 318.) Her hands also "locked up," she experienced swelling in her knees, and swelling, pain and inflammation in her hips due to arthritis. Plaintiff reported that she could stand anywhere from 3 to 25 minutes at a time, sit for up to 25 minutes at a time, and walk up to one block "on a good day," but was in constant pain whether sitting or standing. (Id. at 340.) She had difficulty sleeping due to her pain, testified that she woke up every two hours, and was unable to sleep for more than five hours during the night. (A.R. 347--48.) Plaintiff testified that she takes muscle relaxers and NSAIDs for pain. At the time of the hearing, she was prescribed Vicodin, Valium, Ibuprofen and Diazepam. (Id. at 321.) She reported some relief from pain with muscle relaxers, and, therefore, had to "stay on medication," taking it every day, to control spasms. (Id. at 321.) She experienced significant drowsiness from her medications.

Plaintiff resided in Jamaica, New York with her husband and two children, ages six and nine, at the time of the administrative hearing. (Id. at 293--94.) She testified that she lived in a three-family home with her mother and that her sister lived "around the corner." (Id. at 329.) Plaintiff's mother and sister helped out significantly with child-care duties. (Id. at 326.) Her husband worked a night shift and took the children to school in the mornings. Plaintiff's husband also did the household laundry and dishes, although Plaintiff warmed up meals in the microwave when he was not home and "wash[ed] a mug" on occasion. Plaintiff visited with her mother and sister, was driven to church by her husband two or three times per month, tried to visit her aunt every two months, and spoke to other friends and relatives on the telephone. (Id. at 329--30.) She did not take public transportation. (Id. at 332.) She occasionally used a non-prescribed cane, and wore wrist splints. (Id. at 333.) Plaintiff reported that she fed and dressed herself, "washed up" in the sink and required assistance to shower and wash her hair. (Id. at 337.) She testified that she could lift, and sometimes carry, approximately five pounds, but not ten. (Id. at 339.)

III.Medical Evidence

At the hearing, Plaintiff introduced medical evidence of her impairments. (A.R. 291--92.) Her attorney submitted additional documentation following the hearing.

A.Treating Physicians

1) Dr. Lambrakis

Plaintiff received treatment from Dr. Emmanuel Lambrakis from 2001, preceding her second work-related injury, through 2008.*fn1 (A.R. 194--99, 234--37.) The record reflects that Dr. Lambrakis, an internist and general surgeon, examined Plaintiff on at least six occasions, and diagnosed her with severe cervical and lumbar radiculopathy,*fn2 bilateral shoulder derangement, bilateral carpal tunnel syndrome and bilateral knee derangement. (Id.) Plaintiff stated that she met with Dr. Lambrakis every 30 or 45 days beginning in 2004, and also attended physical therapy sessions with him in 2006.*fn3 (Id. at 330.) In examining Plaintiff, he reviewed various diagnostic reports discussed infra, including Magnetic Resonance Imaging ("MRI") tests of the cervical and lumbar spines and both shoulders, (id. at 213--16), Electromyograms ("EMGs") of Plaintiff's hands and cervical spine, (id. at 205--07), and a lumbar spine computed tomography myelogram ("myelogram"). (A.R. 208--12.) In examining Plaintiff, Dr. Lambrakis observed limited mobility of the cervical spine, muscle spasm in the neck and back, decreased range of motion in both shoulders, bilateral positive straight leg raising and joint effusion in both knees. (Id. at 195.)

On March 27, 2008, Dr. Lambrakis also completed a Functional Assessment form in which he opined that Plaintiff was limited to less than two hours of standing and six hours of sitting per day, and could lift between five and ten pounds frequently and/or occasionally. (Id. at 236.) He noted that, due to her symptoms and medications' side effects, Plaintiff could not work eight hours in a day. She suffered from pain, needed bed rest during the day, had difficulty concentrating on tasks, and needed more than two sick days per month. (Id. at 236--37.) Dr. Lambrakis also noted that Plaintiff was "disabled for employment." (Id.) Dr. Lambrakis's examination of Plaintiff on March 27, 2008 is the most recent medical examination in the record. (Id. at 234--35.)

2) Dr. Miller

Dr. Paul Miller, an orthopedic surgeon, treated Plaintiff from August 2001 to March 2006. (A.R. 163--79, 200.) The record contains only limited notes regarding Dr. Miller's treatment. (Id. at 163--79.) Dr. Miller examined Plaintiff on two occasions preceding her alleged disability onset date, and subsequently in September and November of 2004 and in March 2006. (Id. at 163--79, 200.) In September 2004, Dr. Miller noted that cervical spine forward flexion was nearly complete, and Plaintiff had difficulty changing positions. Sensory and other reflexes were unremarkable, and examination of the lower back revealed limited forward flexion, limited extension and intact rotation. In November 2004, Dr. Miller noted pain on flexion of cervical spine, a limited range of extension with pain, limited forward flexion of lower back and limited bilateral straight leg raising. In March 2006, Dr. Miller relayed x-ray results, noting negative knee and ankle x-rays and spurring at the neck of the femoral head in the left hip resulting in "status post slipped epiphysis." (Id. at 200).

3) Dr. Ki-Ho Moon

Dr. Moon, an orthopedic surgeon, examined Plaintiff on January 28, 2003. (A.R. 238--40.) She reviewed the MRIs of Plaintiff's shoulders, lumbar and cervical spine, discussed infra, and conducted a physical examination. (Id.) On examination, Dr. Moon observed a full range of motion in the neck and lower back with no tenderness present, a normal gait and tiptoe/heel walking, negative straight leg raising and mild tenderness at the deltoid insertions of both shoulders. (Id. at 239.) Dr. Moon ...

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