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Mahmood Raja v. Michael J. Astrue

May 23, 2012

MAHMOOD RAJA,
PLAINTIFF,
v.
MICHAEL J. ASTRUE, COMMISSIONER OF THE SOCIAL SECURITY ADMINISTRATION,: DEFENDANT.



The opinion of the court was delivered by: James C. Francis IV United States Magistrate Judge

MEMORANDUM OPINION AND ORDER

In some Social Security cases, error by the Administrative Law Judge (the "ALJ") warrants reversal and an immediate award of benefits. In others, it is appropriate to remand so that evidentiary gaps may be filled. And in some cases, this one included, the fairest result is to reverse outright to the extent disability has been established but remand for further development of the record as to those issues that are still fairly contested.

Plaintiff Mahmood Raja seeks review under 42 U.S.C. §§ 405(g) and 1383(c) of a determination of the Commissioner of the Social Security Administration (the "Commissioner") denying his application for Supplemental Security Disability Insurance Benefits ("DIB") and Supplemental Security Income Benefits ("SSI"). The Commissioner opposes the plaintiff's motion for judgment on the pleadings and moves for remand of the case for further administrative proceedings regarding a determination of the plaintiff's disability, pursuant to the fourth sentence of 42 U.S.C. §§ 405(g) and 1383(c)(3). For the reasons that follow, the plaintiff's motion for judgment on the pleadings is granted in part, the Commissioner's motion for remand is granted in part, the decision of the Commissioner is reversed, and the case is remanded for calculation of benefits from January 1, 2005, and for a determination of whether Mr. Raja is entitled to an earlier disability onset date.*fn1 Background

Mahmood Raja was born on December 25, 1959 in Pakistan. (Administrative Record ("AR") at 108). He obtained a fifth-grade level education there, and although he can read and write in his native Urdu, his English communication skills are very limited. (AR at 33). The plaintiff's comprehension of English is poor, and he is unable to read or write anything except his name and address. (AR at 37-38). Mr. Raja moved to the United States in 1985 and became an American citizen. (AR at 33, 59). He worked full-time as an auto mechanic from 1992 to 2005, earning a regular salary (AR at 126-27), and he held a part-time position -- working an average of 10 hours per week -- in customer service in an auto repair shop from 2005 to 2007 (AR at 42, 56-57). The plaintiff stopped working altogether in September 2007. (AR at 44). A. Medical History In September 2003, Mr. Raja was diagnosed with severe heart disease of the left main artery, left circumflex artery, and right coronary artery. (AR at 245). He underwent triple coronary bypass surgery, which involved three veinal and arterial grafts and the placement of an intra-aortic balloon pump. (AR at 246). In May 2004, a follow-up examination showed no infiltrate, effusion, congestive heart failure, or cardiomegaly. (AR at 422).

Between 2005 and 2006, Mr. Raja was under the treatment of his primary care physician, Ajay Verma, M.D., whom he saw monthly, and his cardiologist, Rajiv Sindhwani, M.D. (AR at 46-47, 428). During this period, Dr. Verma noted increased tingling and numbness in Mr. Raja's legs, dizziness, and an abnormal sensation on the left side of his head and neck. (AR at 468, 471, 474). He was prescribed medications to treat high cholesterol, heart failure, high blood pressure, diabetes, dizziness, and pain in his left leg and arm. (AR at 44, 526).

On February 21, 2007, an ultrasound examination of Mr. Raja's carotid arteries found minimal plaque and no evidence of carotid stenosis. (AR at 490). On February 23, 2007, Dr. Sindhwani completed a residual functional capacity questionnaire. (AR at 79, 82). He listed Mr. Raja's medical impairments as high blood pressure and high blood sugar, with the following symptoms: chest pain, anginal equivalent pain, shortness of breath, fatigue, and weakness. (AR at 79). Mr. Raja's cardiac symptoms were severe enough to interfere occasionally with the attention and concentration needed to perform simple work tasks. (AR at 80). He could walk for 1-2 blocks and sit for two hours out of an eight-hour work day. (AR at 81). He would need to take 30 minute breaks to lie down every two to three hours. (AR at 81). Dr. Sindhwani opined that Mr. Raja could lift and carry less than ten pounds occasionally, and ten pounds rarely. He could rarely twist but never stoop, crouch or squat, climb ladders, or climb stairs. (AR at 81). Dr. Sindhwani estimated that Mr. Raja would have to miss more than four days of work per month because of his condition. (AR at 82).

Dr. Verma ordered or performed a series of tests in late May 2007. A chest x-ray found no signs of active disease, and an electrocardiogram revealed normal sinus rhythm and no ventricular or atrial ectopy. (AR at 493-95). Dr. Verma indicated that Mr. Raja's ability to lift and carry was severely limited: he could not lift any amount of weight occasionally, and the maximum amount of weight he could lift was three pounds. (AR at 255). He could stand and walk for two hours out of an eight-hour work day, but had no limitations on the amount of time he could sit. (AR at 255). In October 2007, and electrocardiogram noted "consider left atrial enlargement." (AR at 498).

In February 2008, an echocardiogram again indicated "consider left atrial enlargement," as well as "borderline [sinus tachycardia] elevation." (AR at 497). That same month, laboratory testing showed that Mr. Raja suffered from peripheral arterial disease ("PAD") in addition to heart disease. (AR at 487). This diagnosis included moderate stenosis of the left common and superficial femoral arteries as well as mild stenosis of the right superficial femoral artery, and buildup of bilateral arterial plaque, which caused intermittent claudication (i.e., cramping, discomfort, pain, and fatigue that results from decreased blood flow in the legs). (AR at 461, 486, 487).

In July 2008, another echocardiogram indicated "consider left atrial enlargement." (AR at 496). In October of that year, Dr. Verma completed a form assessing Mr. Raja's physical ability to perform work-related activities. (AR at 452). Dr. Verma found that Mr. Raja was able to walk for only 15 to 20 minutes, or up to two blocks, and to stand for five to ten minutes before having to rest. (AR at 453). He could sit for one hour without interruption. (AR at 453). In an eight-hour workday, the plaintiff could sit for six hours, stand for one hour, and walk for one hour. (AR at 453). He was unable to lift or carry anything weighing up to 10 pounds. (AR at 452). With his right hand he could occasionally reach, handle, finger, and feel, but could not push or pull. (AR at 454). With his left hand he could never reach overhead but could occasionally reach in other ways; occasionally handle, finger, and feel; and never push or pull. (AR at 454). While he could occasionally climb stairs, climb ramps, and balance, he could not climb ladders, stoop, kneel, crouch, or crawl. (AR at 455). Mr. Raja could not tolerate any exposure to dust or chemicals or extreme heat or cold. (AR at 456). The physician estimated that these limitations had existed since late 2002 to 2003. (AR at 457).

In November 2008, Dr. Verma reassessed Mr. Raja. (AR at 429, 432). He listed the plaintiff's conditions as hypertension, arteriosclerotic heart disease, diabetes mellitus, and PAD. (AR at 429). Dr. Verma opined that Mr. Raja's cardiac symptoms would occasionally interfere with the attention and concentration needed to perform simple tasks. (AR at 430). He could stand and walk for less than two hours in an eight-hour workday and sit for six hours with normal breaks. (AR at 431). Mr. Raja would need to take unscheduled breaks during the work day to lie down. (AR at 431). He could rarely carry less than ten pounds, and never more than ten. (AR at 431). His mobility was restricted so that he could rarely twist, stoop, crouch, squat, and climb stairs, and never climb ladders. (AR at 431). Dr. Verma asserted that Mr. Raja would need to miss work more than four days per month. (AR at 432). He could not tolerate any exposure to dust or chemicals or extreme heat or cold. (AR at 432). According to Dr. Verma, these limitations had existed since 2003. (AR at 432).

B. Applications for DIB and SSI

On January 30 and January 31, 2007, Mr. Raja filed applications for DIB and SSI, respectively, asserting a disability onset date of September 5, 2002. (AR at 108-114). Both applications were denied on June 22, 2007. (AR at 66-71). Mr. Raja requested review by an Administrative Law Judge, and a hearing was held on November 18, 2008, before ALJ Frank Borda. (AR at 32).

At the hearing, the plaintiff testified that he had continuous pain in his left arm and shoulder and pain and numbness in his left leg and both feet. (AR at 45, 48, 57). He said he was capable for sitting for 20 minutes at a time, could stand and walk for 10 to 15 minutes, and could walk for two blocks before he became short of breath. (AR at 51, 54). He stated that he could lift five to six pounds with his right hand, but nothing with his left. (AR at 52). He also said he suffered from shortness of breath and dizziness. (AR at 53).

ALJ Borda issued a ruling on January 14, 2009, finding that Mr. Raja was not disabled. (AR at 29). The Commissioner adopted the ALJ's decision as final when the Appeals Council denied the plaintiff's request for review on March 23, 2011. (AR at 1).

Applicable Law

A. Standard of Review A court reviewing the Commissioner's decision "may set aside a decision of the Commissioner if it is based on legal error or if it is not supported by substantial evidence." Hahn v. Astrue, No. 08 Civ. 4261, 2009 WL 1490775, at *6 (S.D.N.Y. May 27, 2009) (quoted source omitted); Longbardi v. Astrue, No. 07 Civ. 5952, 2009 WL 50140, at *21 (S.D.N.Y. Jan. 7, 2009); Bonet v. Astrue, No. 05 Civ. 2970, 2008 WL 4058705, at *2 (S.D.N.Y. Aug. 22, 2008). Judicial review, therefore, involves two levels of inquiry. First, the court must decide whether the Commissioner applied the correct legal standard. Tejada v. Apfel, 167 F.3d 770, 773 (2d Cir. 1999); Calvello v. Barnhart, No. 05 Civ. 4254, 2008 WL 4452359, at *8 (S.D.N.Y. April 29, 2008). Second, the court must decide whether the ALJ's decision was supported by substantial evidence. Rosa v. Callahan, 168 F.3d 72, 77 (2d Cir. 1999); Longbardi, 2009 WL 50140, at *21. Substantial evidence in this context is "'more than a mere scintilla.' It means such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Hahn, 2009 WL 1490775, at *6 (quoting Richardson v. Perales, 402 U.S. 389, 401 (1971)); see also Halloran v. Barnhart, 362 F.3d 28, 31 (2d Cir. 2004) (quoting Richardson, 402 U.S. at 401). "In determining whether ...


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