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Collins v. Berryhill

United States District Court, E.D. New York

January 2, 2018

DAVID R. COLLINS, Plaintiff,
v.
NANCY A. BERRYHILL, [1] Acting Commissioner of Social Security, Defendant.

          ORDER

          PAMELA K. CHEN, United States District Judge:

         Plaintiff David R. Collins (“Plaintiff”) brings this action under 42 U.S.C. § 405(g), seeking judicial review of the Social Security Administration's (“SSA”) denial of his claim for Disability Insurance Benefits (“DIB”). The parties have cross-moved for judgment on the pleadings. (Dkts. 8, 12.) Plaintiff seeks reversal of the Commissioner's decision and an immediate award of benefits, or alternatively, remand for further administrative proceedings. The Commissioner seeks affirmation of the denial of Plaintiff's claims. For the reasons set forth below, the Court grants Plaintiff's motion for judgment on the pleadings and denies the Commissioner's motion. The case is remanded for further proceedings consistent with this Order.

         BACKGROUND

          I. PROCEDURAL HISTORY

         On January 3, 2015, Plaintiff filed an application for DIB, claiming that he was disabled beginning on February 19, 2014. (Tr. 23.)[2] After his claim was denied (Tr. 85-90), Plaintiff requested and appeared at a hearing before an administrative law judge (“ALJ”), Margaret A. Donaghy, on November 3, 2015 (Tr. 43-79). The ALJ issued a decision on January 27, 2016, finding that Plaintiff was not disabled from February 19, 2014, his alleged onset date, through the date of the ALJ's decision.[3] (Tr. 23-36.) The ALJ's decision became the final decision of the Commissioner when the Appeals Council denied Plaintiff's request for review on September 30, 2016. (Tr. 1-7.)

         II. STANDARD OF REVIEW

         Unsuccessful claimants for disability benefits under the Social Security Act (the “Act”) may bring an action in federal district court seeking judicial review of the Commissioner's denial of their benefits. 42 U.S.C. § 405(g). In reviewing a final decision of the Commissioner, the Court's role is “limited to determining whether the SSA's conclusions were supported by substantial evidence in the record and were based on a correct legal standard.” Talavera v. Astrue, 697 F.3d 145, 151 (2d Cir. 2012) (quotation omitted). “Substantial evidence is more than a mere scintilla. It means such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” Selian v. Astrue, 708 F.3d 409, 417 (2d Cir. 2013) (alterations and internal quotation marks omitted) (quoting Richardson v. Perales, 402 U.S. 389, 401 (1971)). In determining whether the Commissioner's findings were based upon substantial evidence, “the reviewing court is required to examine the entire record, including contradictory evidence and evidence from which conflicting inferences can be drawn.” Id. (quotation omitted). However, “it is up to the agency, and not this court, to weigh the conflicting evidence in the record.” Clark v. Comm'r of Soc. Sec., 143 F.3d 115, 118 (2d Cir. 1998). If there is substantial evidence in the record to support the Commissioner's findings as to any fact, those findings are conclusive and must be upheld. 42 U.S.C. § 405(g); see also Cichocki v. Astrue, 729 F.3d 172, 175-76 (2d Cir. 2013).

         III. ELIGIBILITY STANDARD FOR SOCIAL SECURITY DISABILITY BENEFITS

         To receive DIB, claimants must be disabled within the meaning of the Act. Claimants establish disability status by demonstrating an inability “to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months.” 42 U.S.C. §§ 423(d)(1)(A), 1382c(a)(3). The claimant bears the initial burden of proof on disability status and must demonstrate disability status by presenting medical signs and findings, established by “medically acceptable clinical or laboratory diagnostic techniques, ” as well as any other evidence the Commissioner may require. 42 U.S.C. §§ 423(d)(5)(A), 1382c(a)(3)(D). However, the ALJ has an affirmative obligation to develop the administrative record. Lamay v. Comm'r of Soc. Sec., 562 F.3d 503, 508-09 (2d Cir. 2009). This means that the ALJ must seek additional evidence or clarification when the claimant's medical reports contain conflicts or ambiguities, if the reports do not contain all necessary information, or if the reports lack medically acceptable clinic and laboratory diagnostic techniques. Demera v. Astrue, No. 12 Civ. 432, 2013 WL 391006, at *3 (E.D.N.Y. Jan. 24, 2013); Mantovani v. Astrue, No. 09 Civ. 3957, 2011 WL 1304148, at *3 (E.D.N.Y. Mar. 31, 2011).

         In evaluating disability claims, the ALJ must adhere to a five-step inquiry. The claimant bears the burden of proof in the first four steps in the inquiry; the Commissioner bears the burden in the final step. Talavera, 697 F.3d at 151. First, the ALJ determines whether the claimant is currently engaged in “substantial gainful activity.” 20 C.F.R. § 404.1520(a)(4)(i). If the answer is yes, the claimant is not disabled. If the claimant is not engaged in “substantial gainful activity, ” the ALJ proceeds to the second step to determine whether the claimant suffers from a “severe impairment.” 20 C.F.R. § 404.1520(a)(4)(ii). An impairment is determined to be severe when it “significantly limits [the claimant's] physical or mental ability to do basic work activities.” 20 C.F.R. § 404.1520(c). If the impairment is not severe, then the claimant is not disabled within the meaning of the Act. However, if the impairment is severe, the ALJ proceeds to the third step, which considers whether the impairment meets or equals one of the impairments listed in the Act's regulations (the “Listings”). 20 CFR § 404.1520(a)(4)(iii); see also 20 C.F.R. Pt. 404, Subpt. P, App. 1. If the ALJ determines at step three that the claimant has one of the listed impairments, then the ALJ will find that the claimant is disabled under the Act. On the other hand, if the claimant does not have a listed impairment, the ALJ must determine the claimant's “residual functional capacity” (“RFC”) before continuing with steps four and five. The claimant's RFC is an assessment which considers the claimant's “impairment(s), and any related symptoms . . . [which] may cause physical and mental limitations that affect what [the claimant] can do in the work setting.” 20 C.F.R. § 404.1545(a)(1). The ALJ will then use the RFC determination in step four to determine if the claimant can perform past relevant work. 20 C.F.R. § 404.1520(a)(4)(iv). If the answer is yes, the claimant is not disabled. Otherwise the ALJ will proceed to step five where the Commissioner then must determine whether the claimant, given the claimant's RFC, age, education, and work experience, has the capacity to perform other substantial gainful work in the national economy. 20 C.F.R. § 404.1520(a)(4)(v). If the answer is yes, the claimant is not disabled; otherwise the claimant is disabled and is entitled to benefits. Id.

         IV. RELEVANT FACTS AND MEDICAL RECORDS

         Plaintiff's claims of psychiatric disability, including major depressive disorder, post-traumatic stress syndrome (“PTSD”), and panic disorder with agoraphobia (Tr. 25) stem from Plaintiff's military service.[4] He was a diesel mechanic in the United States Army from April 2007 until his honorable discharge in September 2010. (Tr. 51.) Plaintiff experienced two notable traumatic situations while he was deployed in Iraq from April 2009 to April 2010 (Tr. 434): first, one of his friends was killed after agreeing to switch positions with Plaintiff (Tr. 423); second, he “was surrounded by [fifteen] Iraqi nationals whom he was tasked with escorting” and whom he later discovered were insurgents (Tr. 342, 346, 347, 351). Plaintiff “date[s] all” of his psychiatric symptoms to this second incident. (Tr. 342.) Plaintiff later attempted suicide by “put[ting] a gun in his mouth with the intent of killing himself”, but was saved because a friend intervened. (Tr. 343.) Six months into his deployment, he was sent home due to anxiety and depression; he began psychiatric treatment at Fort Drum until his discharge in 2010. (Tr. 383-84.)

         After his discharge, he received an automotive certificate in 2011 from Apex Technical School. On February 23, 2011, Plaintiff presented to the New York Veterans Affairs Medical Center (“VAMC”) with the following issues:

[I]ncreasing levels of stress in the past 6 months since being discharged from the Army. . . . Reports general anxiety and worry and panic attacks that are increasing in frequency to daily. Describes 30 minute period where he feels weak, dizzy and faint, sweaty, shaky, trouble breathing and as though things are closing in on him. Comes on without warning and needs to leave the situation and sit in order to have it pass. Having trouble sleeping, now maybe 5 hours per night, low energy, trouble concentrating in school and has seen his grades drop from A's to B's as a result.

(Tr. 441.) Plaintiff also reported feeling “stressed, sometimes get[ting] very anxious, feeling shaky, when he gets stressed. Reports he has been feeling this way over past month. Says he has lots of problems that are making him nervous.” (Tr. 445.) Plaintiff was diagnosed with anxiety disorder with panic, and prescribed Paxil, Klonopin, and Seroquel. (Tr. 443, 444, 448.)

         On March 1, 2011, Plaintiff returned to the VAMC for a refill of Paxil, Klonopin, and Seroquel. (Tr. 438-39.) He stated that he was “doing fine until today when I ran out of med[ication], now I have the same thing, I feel anxious and dizzy.” (Tr. 439.) He was diagnosed with anxiety disorder not otherwise specified (NOS) and depressive disorder NOS. (Id.) Two days later, on March 3, 2011, Plaintiff returned to the VAMC for a physical assessment. He tested positive on a PTSD screen and reported that he “[d]oes not like crowds and experiences panic attacks [daily] especially if he is not taking his meds.” (Tr. 434.) He told hospital staff that he was currently at Queensborough Community College studying accounting. (Id.)

         On March 23, 2011, Plaintiff presented to David M. Matalon, M.D., at the VAMC for a psychiatric consultation. (Tr. 423, 786-90, 969-73.) He reported daily intrusive memories, insomnia, hypervigilance which led to severe anxiety, exaggerated startle response, occasional nightmares, avoidance, and that he “[wa]s isolating somewhat from social activity”. (Tr. 423, 425, 786.) Dr. Matalon prescribed Ambien, Seroquel, Klonopin, and Celexa, and diagnosed PTSD and generalized anxiety disorder (“GAD”). (Tr. 424-25.) The next day, on March 24, 2011, Plaintiff visited the VAMC again, and Dr. Matalon found that Plaintiff “suffers from generalized anxiety by frequent worrying and physical symptoms” and “presents with post-traumatic features as evidenced by repeated intrusive thoughts of traumatic event with hypervigilance.” (Tr. 419.) Similar symptoms were noted during Plaintiff's Traumatic Brain Injury Consultation. (Tr. 781.) On April 13, 2011, Plaintiff missed a mental health intake evaluation scheduled at the VAMC. (Tr. 779.) On May 27, 2011, while Plaintiff was in the VAMC after a motorcycle accident, the treating physician noted that Plaintiff had “intrusive thoughts and hypervigilance daily which interfered with his interactions with others. Is currently in school. He states he does not have a network of emotional support but does occasionally speak to his grandfather.” (Tr. 418.)

         Between 2012 and August 2013, Plaintiff attended school full-time for his Master Auto Body and Collisions Certificate, and worked as a gym manager. (Tr. 49-50, 306, 389.) He stated that “even in school, it was hard. I would have to explain to my teachers, hey I need--sometimes I have to leave the room if it gets too strenuous for me. Or, you know, I would have to work on something by myself.” (Tr. 57.) On April 2, 2013, Plaintiff underwent a Biopsychosocial Assessment in connection with a hospital stay following an allergic reaction. He reported having “strong family, personal relationships or supports in the community” (Tr. 390), but also reported that he had “little relationships/social interaction” (Tr. 718).

         On April 8, 2013, Plaintiff saw his primary care physician, Dr. Lawrence De Weil, for anxiety and insomnia. (Tr. 381, 385, 698-704, 1012-15.) Plaintiff stated that “he ran out of medication; over past few [weeks], noted increasing anxiety for unclear reasons . . . he seeks care of anxiety and insomnia.” (Tr. 381.) Dr. De Weil previously saw Plaintiff in 2011 for anxiety and PTSD, but Plaintiff did not “follow up in mental health clinic because of schedule and fear of group sessions.” (Id.) Dr. De Weil assessed panic attacks, anxiety, and PTSD, and prescribed Klonopin and Seroquel. (Tr. 383.) He also noted that while on Clonazepam and Seroquel, Plaintiff should do “no driving[, ] operating dangerous machinery[, ] engaging in dangerous activity[, ] or activity requiring full attention”. (Tr. 700.) Plaintiff's case manager stated that Plaintiff reported that he “does not like to be in crowds or around others. Reports he just goes to school and stays home.” (Tr. 385.) On April 12, May 17, and June 21, 2013, Plaintiff missed mental health intake evaluations scheduled at the VAMC. (Tr. 691, 697-98.) On September 28, 2013, Plaintiff presented to the VAMC Emergency Department with complaints of anxiety, tingling in his fingers and toes, hyperventilation, and intermittent pain in the left pectoral area. (Tr. 374.) He looked “very anxious” and was diagnosed, in part, with GAD. (Tr. 463.)

         After Plaintiff graduated from school, from October 2013 to February 19, 2014-the date of the onset of his disability-he worked as a diesel mechanic at an airport eight hours a day, five days a week. (Tr. 53, 203.) He stated that he stopped, in part, because he “[could not] be around too many people. . . . I actually almost passed out on the job from anxiety.” (Tr. 53-54.) He further stated that “[t]he planes were giving me anxiety” (Tr. 349), and “[u]sually, when there's more than one person talking to me, I get this bad anxiety and I ...


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