United States District Court, W.D. New York
the Plaintiff: Justin M. Goldstein Kenneth R. Hiller Law
Offices of Kenneth Hiller
the Defendant: Susan J. Reiss Social Security Administration
Office of General Counsel, Kathryn L. Smith, A.U.S.A. Office
of the United States Attorney
DECISION AND ORDER
CHARLES J. SIRAGUSA United States District Judge
an action brought pursuant to 42 U.S.C. § 405(g) to
review the final determination of the Commissioner of Social
Security (“Commissioner” or
“Defendant”), which denied the application of
Sabrina Jones (“Plaintiff”) for Disability
Insurance Benefits and Supplemental Security Income Benefits.
Now before the Court is Plaintiff's motion (Docket No.
[#9]) for judgment on the pleadings and Defendant's
cross-motion [#13] for judgment on the pleadings.
Plaintiff's application is granted and Defendant's
application is denied.
reader is presumed to be familiar with the parties'
submissions, which contain detailed recitations of the
pertinent facts. The Court has reviewed the administrative
record [#7] and will offer only a brief summary of those
November 26, 2012, Plaintiff filed for benefits, claiming to
have become disabled from working on June 9, 2011. Plaintiff
stated that her impairments were physical in
nature. In that regard, the record indicates that
on June 9, 2011, Plaintiff was working as a
housekeeper at Strong Memorial Hospital, when she
tripped over her cleaning-supply cart and fell to the floor,
resulting in pain in her left knee, left hip and left thumb.
See, e.g., (181, 223, 234). Plaintiff described the
impairment as “a burning and aching feeling in [her]
hip and knee and [an “aching feeling” in her]
subsequently added depression to this list of impairments. In
that regard, Plaintiff stated that she feels depressed
because she cannot continue working in her chosen field as a
cleaner, due to her physical pain. (46, 50-51). Although
Plaintiff has not worked as a cleaner since her accident, she
subsequently became certified as a daycare provider, and
cares for three children in her home, whose ages are one,
seven and ten. (40).
the medical evidence shows that Plaintiff received
conservative medical care following her accident, and that
her injuries have improved, but that she still claims to
experience disabling pain. Plaintiff's hip and knee
injuries were treated with rest, pain treatments and physical
therapy, while her thumb injury required surgery. For her
pain, Plaintiff uses ibuprofen, lidoderm patches and a
transcutaneous electric nerve stimulation
(“TENS”) unit, as needed.
December 16, 2011, Brian Giordano, M.D.
(“Giordano”) reported that Plaintiff continued to
have tenderness upon palpation over her left hip joint, but
that she had full “pain free” movement of the
hip. (177). On January 10, 2012, Plaintiff told Giordano that
her knee pain had improved overall, and Giordano noted that
after exhausting “all conservative measures”
“her [knee] symptoms [were] manageable for her.”
(175). Plaintiff stated that the knee bothered her
“occasionally with kneeling, sitting for prolonged
periods of time or strenuous activities.” (175).
Giordano reported that Plaintiff was “walking with a
minimally antalgic gait, not using an assistive
device.” (175). On January 30, 2012, Giordano reported
that Plaintiff was complaining of pain in the left knee and
hip, but that she was still capable of working light duty,
with lifting restrictions. (169). On October 17, 2012,
Giordano indicated that Plaintiff was in no acute distress,
and had only “mild” limitations in her ability to
move her left hip and left knee joints. (156). On October 15,
2012, Giordano indicated that Plaintiff had reached maximum
medical improvement, with only mild residual limitations.
(153). Giordano noted that Plaintiff was using
“conservative modalities” to treat her pain, and
that he had advised her to follow up with him as needed.
thumb injury consisted of a ligament injury that was
initially treated non-operatively. (165). Plaintiff
subsequently developed “trigger thumb, ” and on
December 22, 2011, she had surgery. On July 12, 2012, John
Elfar, M.D. (“Elfar”) reported that Plaintiff had
reached maximum medical improvement following surgery on her
thumb six months earlier. (160). Elfar stated that the
surgery had “largely resolved” Plaintiff's
trigger thumb condition. (160). Plaintiff reported that her
pain was “a lot less” than before the surgery,
and that she was “doing well overall.” (160).
Elfar stated that, “[o]verall, she has excellent use of
her thumb.” (160). A nurse practitioner noted that
Plaintiff “ha[d] good range of motion in her thumb,
” and no pain. (164). The same nurse practitioner
indicated that any disability relating to Plaintiff's
thumb was “mild.” (165).
April 3, 2012, Andre Lefebvre, M.D. (“Lefebvre”)
issued a report that summarized the various treatments that
Plaintiff received following her accident, as well as his own
physical examination of Plaintiff. (180-192). At the
conclusion of the report, Lefebvre opined that while
Plaintiff still had some physical limitations relating to the
accident, they were temporary, and that Plaintiff retained
the ability to work. (191).
February 25, 2014, a hearing was conducted before an
Administrative Law Judge (“ALJ”). Plaintiff
appeared without a representative, and the ALJ explained to
her that she had the right to a representative. The ALJ
stated that if Plaintiff chose to proceed pro se,
the ALJ herself would “obtain the necessary medical and
other evidence.” (30). Plaintiff elected to represent
testified that she took ibuprofen as needed for her hip and
knee pain, and also used lidoderm patches and a TENS unit.
(48, 50). Plaintiff indicated that those treatments were
helpful, but did not completely alleviate her pain. (50).
Plaintiff stated that she stopped attending counseling
sessions for depression in 2012, and that she was not
currently taking medication for depression. (46-51).
Plaintiff stated, though, that her doctor planned to place
her back on depression medication at a later time. (52).
ALJ was reviewing the evidence that had been submitted, she
stated, “we don't have all current medical
evidence, ” and told Plaintiff that she would
“request updated medical records from Highland Family
Medicine so that we can get additional evidence[.]”
(32-33, 38). In that regard, Plaintiff had indicated that she
continued to receive treatment from Highland Family Medicine,
but the ALJ observed that the file was missing treatment
notes from December 2012 onward. (38-39). The ALJ told
Plaintiff that she would request additional records from
Highland Family Medicine, and would provide Plaintiff with a
copy of whatever was received, and that Plaintiff would have
the opportunity to “to request a supplemental
indicated that, apart from Highland Family Medicine, she had
not received any other treatment since 2012:
Q. Other than Highland Family Medicine, have you receive[d]
any other treatment through 2013 or to the present?
Q. Okay. Have you gone to any emergency rooms or anything
(38-39). Plaintiff noted that her workers' compensation
case had remained pending until May 2013, when it was
settled, but she did not indicate that she had been seen by
any workers' compensation doctors during 2013 or 2014.
Family Medicine is a department of Highland Hospital, which
is under the umbrella of the University of Rochester Medical
Center (“URMC”). Presently, the URMC website
indicates that medical records pertaining to treatment at
Highland Hospital must be requested from one address, while
records pertaining to “clinic or office visits”
must be requested from a different address. Specifically, the
address for Highland Hospital is 1000 South Avenue, Box 55,
Rochester, New York 14620, while the current address for
Highland Family Medicine is 777 South Clinton Avenue,
Rochester, NY 14620. However, some of the earlier records
from Highland Family Medicine in the record, from 2010-2012,
bear the same address as Highland Hospital, which is 1000
South Avenue, Box 55, Rochester NY 14620. (Exhibit 11F,
492-505). The ALJ requested additional medical records from
Highland Family Medicine, but sent the request ...