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Julia Martinez-Paulino v. Michael J. Astrue

August 20, 2012

JULIA MARTINEZ-PAULINO, PLAINTIFF,
v.
MICHAEL J. ASTRUE, COMMISSIONER OF SOCIAL SECURITY, DEFENDANT.



The opinion of the court was delivered by: Robert P. Patterson, Jr., U.S.D.J.

OPINION & ORDER

On August 8, 2011, Plaintiff Julia J. Martinez-Paulino ("Plaintiff") filed this action pursuant to § 205(g) and § 1631(c)(3) of the Social Security Act, 42 U.S.C. §§ 405(g), 1383(c)(3), challenging the final decision of the Commissioner of Social Security (the "Commissioner") denying her Supplemental Security Income ("SSI") benefits under the Social Security Act (the "Act"). (Compl. ¶ 1-8.) On December 16, 2011, the Commissioner filed an answer to Plaintiff's complaint. (Answer ¶ 1-9.) On February 8, 2012, Plaintiff filed a motion pursuant to Rule 12(c) of the Federal Rules of Civil Procedure ("Fed. R. Civ. P.") for a judgment on the pleadings and for denial of the Commissioner's cross-motion. (Pl.'s Mem. in Opp. to the Def.'s Cross-Mot. for J. on the Pleadings and in Supp. of Her Mot. for J. on the Pleadings ("Pl.'s Br.") at 1.) On April 11, 2012, the Commissioner opposed Plaintiff's motion and cross-moved for a judgment on the pleadings affirming the Commissioner's decision that the Plaintiff was not disabled. (Mem. in Supp. of the Commissioner's Cross-Mot. for J. on the Pleadings and in Opp. to Pl.'s Mot. for J. on the Pleadings ("Def.'s Br.") at 1.) On May 14, 2012, Plaintiff filed a reply to the Commissioner's motion. For the foregoing reasons, the Commissioner's motion is granted.

I.BACKGROUND

A.Procedural History

On July 15, 2008, Plaintiff filed an application for SSI benefits under Title II and Title XVI of the Act. (Tr. of the Administrative R. ("Tr.") at 70-73.) Therein, Plaintiff sought benefits retroactive to July 1, 2008, the date of the alleged onset of her disability, (Tr. at 10, 70), due to depression, headaches, forgetfulness, back pain, and stomach pain, (Tr. at 83.) Plaintiff's application was denied by the Commissioner on October 22, 2008. (Tr. at 37-48.)

On November 19, 2008, Plaintiff filed a written request for a hearing. (Tr. at 10.) On December 15, 2009, Plaintiff, represented by paralegal Anastasia Eccles, appeared before Administrative Law Judge Wallace Tannenbaum (the "ALJ") for a hearing. (Tr. at 10, 21-35.) On January 21, 2010, the ALJ issued a letter decision finding Plaintiff "not disabled" under the Act, and denying Plaintiff's claim for SSI benefits. (Tr. at 7-16.) Plaintiff requested review by the Appeals Council, and on June 14, 2011, the Appeals Council denied Plaintiff's request, making the ALJ's decision the final decision of the Commissioner. (Tr. at 1-4, 113-16.) On August 8, 2011, Plaintiff filed the instant action in this court.

B.Non-Medical Evidence

Plaintiff was born on July 21, 1972, in the Dominican Republic, and completed schooling through the eighth grade before immigrating to the United States in 1989. (Tr. at 23-24.) Her primary language is Spanish, though she is able to understand some English. (Tr. at 24, 82.) She was 36 years old on July 1, 2008, the date of the alleged onset of her disability. (Tr. at 25.)

At the December 15, 2009 hearing before the ALJ, Plaintiff indicated that she was last employed in a grocery store from 2006 to 2008. (Tr. at 25.) Plaintiff stated that she worked seven to eight hours a day, five days per week. (Tr. at 26.) Her responsibilities included cleaning, taking care of customers, and occasionally working as a cashier. (Id.) Plaintiff was unable to recall the exact date that she stopped working, but testified it was in the beginning of 2008.*fn1 (Id.) Plaintiff stated that she stopped working because she was unable to fulfill her duties because of her depression, but upon clarification, Plaintiff reported that she was fired from the job due to her bad temper. (Id.) Plaintiff stated that she had not sought further employment since that time because she was very nervous and suffered from stomach problems. (Tr. at 26-27.) When asked the same question later in the hearing, however, Plaintiff responded that she had not sought further employment because she suffered from depression. (Tr. at 31.)

Plaintiff reported that she lived in an apartment with her four children, aged four, twelve, thirteen, and seventeen. (Tr. at 22-23.) Plaintiff testified that she did the cooking for herself and her children, the cleaning and laundry with help from her daughter and cousin, and went shopping with her children. (Tr. at 29.) Plaintiff stated that she was able to use public transportation, such as the bus, by herself, but did not take trains because she was afraid to go by herself and did not know how to navigate them. (Tr. at 30-31.) Plaintiff indicated that she visited her cousin's house once per week, and occasionally went to her children's schools, but generally did not like going outside. (Tr. at 23, 33.) Plaintiff also reported recently traveling to the Dominican Republic for five days. (Tr. at 30-31.)

Plaintiff stated that she attended a monthly clinic for her stomach problems, and saw a therapist biweekly and a psychiatrist once a month for depression and anxiety. (Tr. at 27-28.) Plaintiff reported difficulties sleeping, trouble getting out of bed in the morning, and memory lapses, such as forgetting why she went into a room and not remembering her dreams. (Tr. at 32-33.) Plaintiff stated that the medications prescribed to her for her various ailments were only slightly helpful. (Tr. at 32.)

C.Medical Evidence

The administrative record contains six separate medical reports. These are: (1) a biopsychosocial evaluation at the Federation Employment and Guidance Service ("F.E.G.S."), dated April 22, 2008 to May 7, 2008, (Tr. at 126-43), (2) an examination by Plaintiff's primary care physician, Dr. Virgilo Valdez, M.D., dated August 26, 2008, (Tr. at 117-22), (3) an internal medicine exam by Dr. Jerome Caiati of Industrial Medicine Associates, P.C., dated October 2, 2008, (Tr. at 144-47), (4) a consultative psychiatric evaluation by Dr. Haruyo Fujiwaki, Ph.D. of Industrial Medicine Associates, dated October 2, 2008, (Tr. at 149-52), (5) a psychiatric and residual functional capacity assessment by state agency review psychologist Dr. T. Harding, dated October 20, 2008, (Tr. at 153-72), and (6) an unsigned and undated report for claim of disability due to mental impairment, covering the period of August 24, 1998 to November 3, 2009, (Tr. at 181-87).

1.Federation Employment and Guidance Service ("F.E.G.S.")

Report Between April 22, 2008 and May 7, 2008, Plaintiff underwent a "biopsychosocial" evaluation at F.E.G.S. (Tr. at 126.) Plaintiff arrived to the April 22, 2008 appointment by taxi, and told the examiner she was unable to travel alone because she gets lost. (Tr. at 132.) Plaintiff reported that she was capable of washing dishes, doing laundry, sweeping and mopping the floor, making beds, cooking meals, and taking care of her personal needs. (Tr. at 133.) Plaintiff stated that she was unable to vacuum, shop for groceries, or socialize. (Id.) Plaintiff indicated that she liked to use the computer. (Id.) Plaintiff reported she had stomach pain, back pain, and an ulcer. (Tr. at 133, 136.) Plaintiff denied current suicidal ideations or hallucinations, but admitted to attempting suicide three times in 1998 by ingesting poison, suffering an alcohol problem until 1998, and previously hearing voices and hallucinating. (Tr. at 131.) Plaintiff reported receiving mental health services at Upper Manhattan Mental Health Clinic since 1998 for major depressive disorder. (Tr. at 132.) Plaintiff stated that she frequently felt hopeless, had difficulty sleeping, felt lethargic, had poor self-esteem, and was restless. (Tr. at 131-32.) Plaintiff indicated no loss of appetite or overeating. (Tr. at 132.) Plaintiff's Patient Health Questionnaire-9 ("PHQ-9") Score, which relied on self-reported answers, yielded a score of sixteen, indicating a depression rating of moderate to severe. (Id.)

Dr. Arnold Blank performed a medical examination on Plaintiff. (Tr. at 136-39, 140-43.) He found Plaintiff's abdomen to be soft and non-tender, and her overall physical examination to be normal. (Tr. at 136, 143.) A mental status examination revealed orientation in three spheres. (Id.) Dr. Blank found that Plaintiff was cooperative, but that she was not alert, that her recent and remote memories were not intact, that she was easily distracted, that her speech and fund of knowledge were abnormal, and that she appeared depressed. (Tr. at 136, 139, 143.) Dr. Blank did not assess Plaintiff's work limitations because her psychiatrist, Dr. Yvonne Kury, submitted a letter requesting that Plaintiff be given a four-month exemption from work for treatment of her depression. (Tr. at 137-38.)

2.Dr. Virgilio Valdez, Primary Care Physician

On July 14, 2008, Plaintiff was examined by her primary care physician, Dr. Virgilo Valdez, M.D. On August 26, 2008, Dr. Valdez issued a medical report regarding his treatment of Plaintiff. (Tr. at 117-22.) He reported that he had treated Plaintiff for gastroesophogeal reflux disease ("GERD"), gastritis-duodenitis, and anxiety-depression since January 2003. (Tr. at 117.) Dr. Valdez stated that Plaintiff's symptoms at the time of the exam included epigastric pain, bloating, and nausea, and that Plaintiff had a history of depression, heartburn, bloating, and regurgitation. (Tr. at 117-18.) There was no history of trauma, joint inflammation, muscle spasm, or sensory or motor deficits. (Tr. at 118-19.) Dr. Valdez prescribed Plaintiff Prilosec, and noted that Plaintiff was also taking medications prescribed by her gastroenterologist (though she was unaware of the exact medications), as well as Lexapro and Ambien, both of which were prescribed by her psychiatrist. (Tr. at 118.) Dr. Valdez reported Plaintiff's only functional limitations to be an inability to frequently lift and carry more than fifteen pounds. (Tr. at 121) He cited no other limitations to Plaintiff's ability to stand, walk, sit, push, pull, or otherwise carry out work-related physical activities. (Id.)

3.Dr. Jerome Caiati, Industrial Medicine Associates, P.C.

On October 2, 2008, Plaintiff underwent an internal medicine exam by consultative examiner, Dr. Jerome Caiati, M.D. (Tr. at 144-47.) Plaintiff reported to Dr. Caiati that she was diagnosed with and hospitalized for depression in 1998, had had peptic ulcer disease and H. pyloric gastritis since 1985, and developed low back pain in 2008. (Tr. at 144.) Dr. Caiati's report indicated that Plaintiff was taking eight different medications at the time of the examination.*fn2 (Id.)

Plaintiff reported that she was able to cook, clean, do laundry, go shopping, care for her children, shower and dress herself, watch television, and go out shopping. (Id.) Dr. Caiati observed that Plaintiff was in no acute distress, and that her gait and stance were normal. (Tr. at 145.) Plaintiff was able to squat fully, and required no assistance changing for the examination, or getting on or off the examination table. (Id.)

A physical and neurological examination yielded normal results. (Tr. at 145-46.) Plaintiff's abdomen was soft and non-tender, and her bowel sounded normal. (Tr. at 146.) Dr. Caiati found no evidence of scoliosis, kyphosis, or other abnormality in Plaintiff's thoracic spine. (Id.) An X-ray of Plaintiff's lumbosacral spine taken on October 2, 2008, was also negative. (Tr. at 146, 148.) Dr. Caiati observed that Plaintiff had full range of motion in her spine and other extremities, and that she had full grip strength and fine motor activity in her hands and fingers bilaterally. (Tr. at 146.) Dr. Caiati concluded that Plaintiff had no restrictions for sitting, standing, walking, reaching, pushing, pulling, climbing, bending, and lifting. (Tr. at 147.)

4.Dr. Haruyo Fujiwaki, Industrial Medicine Associates, P.C.

Also on October 2, 2008, Plaintiff underwent a consultative psychiatric evaluation by Dr. Haruyo Fujiwaki, Ph.D. (Tr. at 149-52.) The evaluation was conducted using an Industrial Medicine Associates interpreter. (Tr. at 149.) Plaintiff arrived to the appointment by train, travelling approximately two hours. (Id.)

Plaintiff indicated to Dr. Fujiwaki that she was hospitalized in 1998 for depression, and had been seeing a psychiatrist once per month and psychologist once per week at the Upper Manhattan Mental Health Center. (Id.) Plaintiff reported ongoing stomach problems and back pain. (Id.) Dr. Fujiwaki's report noted that Plaintiff was taking five different medications at the time of the evaluation.*fn3 (Id.)

Plaintiff reported that she had difficulty falling asleep and loss of appetite. (Id.) Plaintiff stated that she had suffered from depression since 1998, and had the following symptoms: dysphoric moods, crying spells, loss of usual interests, loss of energy, concentration difficulties, and social withdrawal. (Id.) Plaintiff reported that two months prior to the October 2, 2008 evaluation, she "felt something," and fell to the floor trembling, dizzy, and unconscious. (Tr. at 149-50.) Plaintiff denied suffering frequent anxiety attacks or manic symptoms. (Tr. at 150.) Plaintiff reported experiencing auditory and visual hallucinations. (Id.) Plaintiff denied current suicidal ideation, intent, or plan, and reported no drug or alcohol history. (Id.)

Dr. Fujiwaki observed Plaintiff to be responsive and cooperative. (Id.) He indicated her manner of relating, social skills, and overall presentation to be fair. (Id.) Plaintiff was adequately groomed, and her gait and posture were normal. (Id.) Dr. Fujiwaki reported Plaintiff's motor behavior was lethargic, but eye contact was appropriately focused and speech was adequate. (Id.) Plaintiff's thought processes were coherent and goal directed, with no evidence of hallucinations, delusions, or paranoia. (Id.) Dr. Fujiwaki observed Plaintiff's affect to be depressed and her mood dysthymic. (Id.) Plaintiff was oriented in three spheres, and her sensorium was clear. (Id.)

Plaintiff's attention, concentration, and recent and remote memory skills were mildly impaired, possibly due to emotional distress resultant to depressed mood and limited intellectual function. (Tr. at 151.) Plaintiff had difficulty with serial threes. (Id.) Dr. Fujiwaki assessed Plaintiff's intellectual functioning to be below average, and her general fund of information was somewhat limited. (Id.) Plaintiff's insight was fair, but her judgment was poor. (Id.)

Plaintiff reported that she was able to dress, bathe, and groom herself, and do the cooking and cleaning once per week. (Id.) Plaintiff indicated that, if not depressed, she was also able to do laundry and grocery shopping. (Id.) Plaintiff reported difficulty managing money, and that she was unable to take public transportation alone. (Id.) Plaintiff stated that she socialized occasionally, and had a good relationship with three of her four children. (Id.) Plaintiff denied having any hobbies or interests, and stated she spent her days taking care of her children. (Id.)

Dr. Fujiwaki assessed that Plaintiff was able to follow and understand simple directions and instructions. (Id.) He reported that Plaintiff could perform simple tasks, but required supervision. (Id.) He observed Plaintiff to have difficulty maintaining attention and concentration, and that she could not maintain a regular schedule due to depressed mood. (Id.) He indicated that Plaintiff may have great difficulty learning new tasks, performing complex tasks, and making appropriate decisions, due to depressed mood and limited intellectual function. (Id.) He assessed that Plaintiff could relate with others and deal with stress "to a certain extent." (Id.) Dr Fujiwaki stated that the ...


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