United States District Court, S.D. New York
MEMORANDUM AND ORDER
P. KEVIN CASTEL, District Judge.
Plaintiff Keith Davis seeks review of a final decision of the Commissioner of Social Security (the "Commissioner") that he is not eligible for Disability Insurance Benefits ("DIB") under Title II of the Social Security Act (the "Act"), 42 U.S.C. § 401 et seq., because he is not disabled within the meaning of the Act. Plaintiff asserts that the decision of the Administrative Law Judge ("ALJ") was not supported by substantial evidence, contrary to law, and failed to make a full and fair inquiry into the facts. Specifically, plaintiff argues that the ALJ (1) failed to apply the treating physician rule properly; (2) failed to develop the record; and (3) wrongly assessed plaintiff's credibility. (Pl.'s Mem. 12, 19, 21.) Plaintiff and defendant have each moved for judgment on the pleadings under Rule 12(c) of the Federal Rules of Civil Procedure. For the reasons set forth below, the order denying disability benefits is reversed and the case is remanded to the Commissioner for further proceedings. Defendant's motion is denied.
I. PROCEDURAL HISTORY
On January 7, 2011, plaintiff applied to the Social Security Administration ("SSA") for DIB due to a pinched nerve, carpal tunnel syndrome in both hands, a torn shoulder ligament, and pain in the right wrist and right hand. (R. 150.) On April 14, 2011, the SSA determined that plaintiff's conditions were not severe enough to prevent him from working and denied his application (R. 95, 98.) The SSA notified plaintiff that his claim was disapproved and informed him of his right to request a hearing. (R. 95-97.)
On April 20, 2011, plaintiff timely requested a de novo hearing before an ALJ, which was held on November 10, 2011. (R. 73, 105-06.) Plaintiff appeared at the hearing and was represented by counsel. (R. 73.)
In a written decision dated November 23, 2011, the ALJ denied plaintiff's claim for benefits. (R. 52-65.) Applying the agency's sequential five-step test for determining whether an individual is disabled, the ALJ concluded that plaintiff was not disabled under sections 216(i) and 223(d) of the Social Security Act. (R. 55.) Based on the evidentiary record, he concluded that although plaintiff had several severe impairments, including "internal derangement of the bilateral knees status post-arthroscopic surgery, internal derangement of the left shoulder post-arthroscopic surgery, and carpal tunnel syndrome in the right hand, " plaintiff did "not have an impairment or combination of impairments that met or medically equaled one of the listed impairments in 20 CFR Part 404, Subpart P, Appendix 1." (R. 57.) The ALJ further concluded that plaintiff still had the "residual functional capacity to perform the full range of sedentary work defined in 20 CFR 404.1567(a)." (R. 58.) The ALJ gave little weight to the opinions of plaintiff's treating physicians and gave significant weight to the opinion of a consultative physician. (R. 60.) With respect to the credibility of plaintiff's allegations, the ALJ noted that "[plaintiff's] medically determinable impairments could reasonably be expected to cause the alleged symptoms; however, the [plaintiff's] statements concerning the intensity, persistence and limiting effects of these symptoms are not credible to the extent they are inconsistent with the above residual functional capacity assessment." (R. 61.)
On January 11, 2012, plaintiff requested review of the ALJ's decision. (R. 8-51.) The SSA Appeals Council denied the request for review on January 25, 2013, and the ALJ's decision thus became the final decision of the Commissioner. (R. 1.)
Plaintiff filed a timely action in this Court seeking review of the Commissioner's final decision. Both parties moved for judgment on the pleadings pursuant to Rule 12(c), Fed. R. Civ. P.
II. EVIDENCE BEFORE THE ALJ
At the hearing before the ALJ, plaintiff testified about his age, height, weight, education, daily activities, work history, medical treatment history, physical and psychiatric condition. (R. 75-92.) The ALJ reviewed documentary evidence including medical records from Mount Sinai Hospital of Queens (R. 205-08); progress and treatment reports from plaintiff's physicians, Drs. Thomas Scilaris, Christopher Kyriakides and other physicians affiliated with New York Orthopaedic Surgery and Rehabilitation; medical records from Saint Luke's Roosevelt Emergency Department (R. 347-354); a consultative examination report by Dr. Rahel Eyassu (R. 361-65); and a narrative report of plaintiff's medical history from treating physician, Dr. Eric Jacobson. (R. 411-416.)
a. Non-Medical Evidence
The plaintiff testified about his background. He was born on February 27, 1966 and was 44 years old on the alleged disability onset date, June 22, 2010. (R. 61.) He is six feet tall and weighs approximately 190 pounds. (R. 77.) He lives alone but occasionally stays with a friend or his mother. (R. 86.) Plaintiff drives a car to attend doctors' appointments and has difficulty using public transportation. (R. 77-78, 83.)
The plaintiff has at least a high school education and is able to communicate in English. (R. 78.) Plaintiff worked as a correction officer for more than 21 years. (R. 78.) Between November 2008 and June 2010, plaintiff was placed on light duty, which he described as a desk job, as a result of his injuries. (R. 79-80.) He stopped working in June of 2010 when his pain did not subside. (R. 79.)
b. Medical Evidence
The ALJ reviewed plaintiff's medical records, including records of Dr. Scilaris, Dr. Kyriakides, Dr. Liebowitz, and Dr. Capiola, who provided the plaintiff with ongoing medical treatment. These records included functional assessments and narrative reports written by Dr. Scilaris, Dr. Jacobson, and Dr. Kyriakides. (R. 411-36.) Additionally, he considered the report of a consulting evaluation conducted by Dr. Eyassu. (R. 361-65.)
i. Treating Physicians' Records
On November 19, 2009, plaintiff presented to Dr. Liebowitz with left shoulder pain subsequent to an injury that occurred on November 19, 2008, where he was attacked by an inmate while on duty as a correction officer. (R. 205-08, 225.) On December 15, 2009, the plaintiff underwent arthroscopic surgery to his left shoulder. (R. 226.) On January 8, 2010, Dr. Capiola conducted a post-operative examination of the patient and recommended physical therapy, prescribed Mobic and recommended that he return to work, performing light duty without heavy lifting. (R. 223.) Plaintiff returned to Dr. Capiola on February 4, 2010, and reported that the pain in his left shoulder had not subsided and that he was also experiencing pain in his right knee caused by the same November 2008 work-related accident. (R. 221.) On April 22, 2010, Dr. Capiola injected corticosteroid to the plaintiff's left shoulder for the pain. (R. 219.) On May 12, 2010, Dr. Capiola examined ...