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Sandra Perez-Rodriguez v. Michael J. Astrue

December 21, 2011

SANDRA PEREZ-RODRIGUEZ, PETITIONER,
v.
MICHAEL J. ASTRUE, COMMISSIONER OF SOCIAL SECURITY, RESPONDENT.



NAOMI REICE BUCHWALD UNITED STATES DISTRICT JUDGE

Sandra Perez-Rodriguez ("plaintiff" or "claimant") brings this action pursuant to Section 205(g) of the Social Security Act, 42 U.S.C. § 405(g), challenging the final decision of the Commissioner of Social Security ("Commissioner") to deny her application for Supplemental Security Income ("SSI") benefits. Both parties have moved for judgment on the pleadings pursuant to Federal Rule of Civil Procedure 12(c). For the reasons set forth below, we remand the case for a new administrative hearing.

MEMORANDUM AND ORDER - against -

BACKGROUND*fn1

Plaintiff applied for SSI benefits on June 17, 2008, claiming that she was disabled due to various physical and mental conditions. (Tr. 101-104.) The application was denied administratively on October 8, 2008, and plaintiff subsequently requested a hearing before an Administrative Law Judge ("ALJ"). (Tr. 51-58.) The hearing was held on February 3, 2010 before ALJ Seth I. Grossman. (Tr. 24-47.) In a June 10, 2010 decision, the ALJ found that plaintiff was not disabled and thus not eligible for SSI benefits. (Tr. 6-23.) Plaintiff appealed the ALJ's decision, and on October 18, 2010, the Social Security Appeals Council denied plaintiff's request for review, rendering the Commissioner's decision final. (Tr. 1-5.) Plaintiff filed the instant action on December 15, 2010.

I.Non-Medical History

Plaintiff was born in 1971 in Puerto Rico. (Tr. 32, 101.) Plaintiff suggests that she left Puerto Rico in 2007 with her three children to flee an abusive husband. (Tr. 32, 222.) She further asserts that as a child in Puerto Rico, she was raped repeatedly by her two older brothers. (Tr. 224-226.)

Plaintiff graduated high school in Puerto Rico but has limited ability to speak and understand English. (Tr. 32-34.) She previously worked as a cashier and a manicurist in Puerto Rico but has not worked since arriving in the United States in 2007. (Tr. 37, 41, 156.)

II.Medical History

A.Physical Conditions

1.Dr. Nader Hanna

Between January 2008 and April 2008, plaintiff was treated by Dr. Nader Hanna for pain and numbness in her hands. (Tr. 122.) On January 18, 2008, Dr. Hanna performed nerve conduction studies on plaintiff that "reveal[ed] evidence of a moderate bilateral nerve neuropathy at the wrist." (Tr. 173-176.) Dr. Hanna noted that this finding was consistent with a clinical diagnosis of Carpal Tunnel Syndrome. (Tr. 174.)

On March 18, 2009, Dr. Hanna completed a medical assessment form at the request of the Social Security Administration. (Tr. 196-201.) Dr. Hanna indicated on the form that plaintiff could never lift or carry up to ten pounds. (Tr. 196.) With respect to plaintiff's right hand, Dr. Hanna indicated that plaintiff could never handle, finger, push, or pull, and could only occasionally reach and feel. (Tr. 198.) With regard to plaintiff's left hand, Dr. Hanna wrote that plaintiff could never handle, push or pull, could occasionally finger, feel, and reach overhead, and could frequently reach otherwise. (Tr. 198.) Dr. Hanna also wrote that plaintiff could sort, handle, and use paper and files. (Tr. 201.) Finally, Dr. Hanna assessed that plaintiff could sit for eight hours in a workday and stand and walk for five hours in a workday, but while plaintiff could sit for eight hours continuously, she could only stand and walk for two hours continuously. (Tr. 197.)

2.Dr. William Lathan

On August 8, 2008, Dr. William Lathan performed a consultative physical examination of plaintiff. (Tr. 213-216.) Dr. Lathan found that plaintiff had full range of motion of her shoulders, elbows, forearms, and wrists bilaterally, and that she had strength of 5/5 in her upper and lower extremities and grip strength of 5/5 bilaterally. (Tr. 215.) Dr. Lathan also found that plaintiff had a moderate restriction for repetitive grasping and hand and wrist motion with her right hand. (Tr. 215.)

3.Dr. Lorenza Freddo

Since at least May 2009, plaintiff has been treated by Dr. Lorenza Freddo, a neurologist at St. Barnabas Hospital. (Tr. 39, 269.) On May 26, 2009, Dr. Freddo ordered an MRI to test for the possibility that plaintiff suffered from multiple sclerosis. (Tr. 269.) The MRI, along with an additional subsequent test, ruled out this possibility. (Tr. 269-272.)

On February 8, 2010 -- after the hearing before the ALJ but before the ALJ's ruling -- Dr. Freddo completed a medical source statement concerning plaintiff. (Tr. 277-282.) Dr. Freddo wrote that plaintiff had been diagnosed with reflex sympathetic dystrophy ("RSD"). (Tr. 282.) Dr. Freddo assessed that plaintiff is unable to sort, handle, or use paper and files, but he declined to complete the other areas of the form regarding plaintiff's physical capabilities, stating that these assessments should be made "by physical therapy." (Tr. 277-282.)

4.Dr. David Marshak

On three occasions between January 2010 and April 2010, plaintiff was treated by Dr. David Marshak, a physician in the pain management anesthesia department of St. Barnabas Hospital. (Tr. 283-291.) Dr. Marshak's treatment notes indicate that plaintiff suffers from RSD and that prior attempted treatments had proven ineffective. (Tr. 284-289.) In addition, Dr. Marshak's notes from two of plaintiff's visits rate her level of pain as a "9" and a "10" respectively on a scale from 1 to 10. (Tr. 284, 287.) Dr. Marshak's April 2010 notes indicate that plaintiff had declined an IV lidocaine/ketamine infusion treatment because she preferred to first try physical therapy. (Tr. 289.)

5.Occupational Therapy

The Union Community Health Center conducted an initial evaluation of plaintiff on April 21, 2010 and determined that plaintiff should receive occupational therapy twice a week for a period of six to eight weeks. (Tr. 293.) The treatment was to consist of "hot/cold pack, manual therapy, therapeutic exercise, therapeutic activities, pain management and HEP." (Tr. 293.)

B.Mental Conditions

1.Fordham Tremont Community Health Center

In early 2008, plaintiff visited the emergency room of St. Barnabas Hospital several times due to feelings of depression. (Tr. 179-192.) Plaintiff was referred to the Fordham Treatment Community Health Center (the "Center"), where she received treatment between March 2008 and November 2008. (Tr. 193-195, 221-243.)

Upon plaintiff's initial visit to the Center, the treating clinician assessed plaintiff to be depressed with "anxiety, sleep disturbance, [and] suicidal ideation." (Tr. 228.) In a subsequent psychiatric evaluation, Dr. Luis C. Ang assigned plaintiff a Global Assessment Functioning score of 55, which reflects "[m]oderate symptoms (e.g., flat affected and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflict with peers or co-workers)." (Tr. 233.)

Plaintiff was also treated at the Fordham Tremont Center by Maria Kumagay, a social worker. Kumagay would later complete a medical source statement at the request of the Social Security Administration. In that statement, Kumagay indicated that plaintiff has no impairment in her ability to understand, remember, and carry out simple instructions or in her ability to make judgments on simple work-related decisions. (Tr. 193.) Kumagay assessed that plaintiff has "moderate" impairment with respect to her ability to perform these tasks for complex instructions or decisions. (Tr. 193.) Kumagay concluded that plaintiff would have "mild" limitations in her ability to interact with the public, supervisors, or co-workers as well as in her ability to respond appropriately to usual work situations and changes in a routine work setting. (Tr. 194.)

2.Dr. Dimitri Bougakov

On August 8, 2008, Dr. Dimitri Bougakov performed a consultative psychiatric evaluation of plaintiff. Dr. Bougakov assessed that plaintiff can follow and understand simple instructions and can perform simple tasks independently, but he noted that her recent and remote memory skills were mildly impaired. (Tr. 210.) Dr. Bougakov opined that the results of the examination "appear to be consistent with some psychiatric problems, but in itself, this does not appear to be significant enough to interfere with the claimant's ability to function on a daily basis." (Tr. 210.) Dr. Bougakov added that plaintiff's psychiatric problems appeared to be under control with her current treatment, which included prescribed medication. (Tr. 210.)

3.Dr. Z. Mata

On October 1, 2008, Dr. Z. Mata, a non-examining psychiatrist, assessed plaintiff's mental condition based on a review of her medical record. (Tr. 244-257, 264-266.) Dr. Mata expressed the belief that plaintiff is "moderately impaired" in her ability to understand, remember, and carry out detailed instructions but is not significantly impaired with respect to other cognitive capabilities. (Tr. 264-266.) Dr. Mata concluded that "[plaintiff] ...


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