Louise D. v. O'Malley

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Louise D., Plaintiff, v. Martin O'Malley,^[1] Commissioner of Social Security, Defendant.

CIVIL No. 3:22-cv-01465-MPS

United States District Court, D. Connecticut

February 29, 2024

RECOMMENDED RULING ON PENDING MOTIONS

Hon Thomas O. Farrish United States Magistrate Judge

The Plaintiff, Louise D.,^[2] appeals the decision of the Commissioner of Social Security (“Commissioner” or “Defendant”), rejecting her application for Disability Insurance (“DI”) benefits under Title II of the Social Security Act. (Compl., ECF No. 1.) She seeks an order reversing the Commissioner's decision and remanding her case “for an award and calculation of benefits,” or “for a de novo hearing.” (Pl.'s Memo. of L. in Support of Pl.'s Mot. To Reverse the Decision of the Comm'r, ECF No. 16-2, at 26) (“Pl.'s Memo.”). The Commissioner has moved for an order affirming the decision. (Def.'s Mot. for an Order Affirming the Decision of the Comm'r, ECF No. 19.) Chief United States District Judge Michael P. Shea referred the case to me, United States Magistrate Judge Thomas O. Farrish “for all purposes including issuing a Recommended Ruling” on any dispositive motions. (ECF No. 12.)

The Plaintiff claims that the Administrative Law Judge (“ALJ”) made three principal errors in deciding her case. First, she says that “the treating physician rule was not followed” in this pre-March, 2017 case. (Pl.'s Memo., at 1-12.) Second, she claims that her “impairments were inadequately evaluated,” principally because the ALJ did not “grasp[] the severity of the functional impairments caused by [her] executive function disorder” and did not “adequately consider [her] physical impairments.” (Id. at 12-18.) Third, she argues that “the ALJ's Step Five findings [were] unsupported,” in part because he lacked a sufficient basis for his conclusions about her physical capabilities. (Id. at 18-23.) The Commissioner responds that “substantial evidence supports the ALJ's findings and the ALJ applied the correct legal standards.” (Memo. in Supp. Of Def.'s Mot. For an Order Affirming the Comm'r's Decision ECF No. 19-1, at 1) (“Def.'s Memo.”).

Having carefully reviewed the parties' submissions, and having carefully reviewed the entire, 2,189-page administrative record, the Court agrees with the Commissioner. Because this is a Title II case, the Plaintiff bore the burden to prove that she was disabled prior to her date last insured (“DLI”), March 31, 2015. The ALJ concluded that she had not met that burden, and his conclusion is supported by substantial evidence and free from legal error. I will therefore recommend that the District Judge deny the Plaintiff's Motion to Reverse (ECF No. 16) and grant the Commissioner's Motion to Affirm. (ECF No. 19.)

I. Factual and Procedural Background

The Plaintiff is a (now) sixty-three-year-old woman from Waterbury, Connecticut who formerly worked as a customer service specialist for a manufacturing company. (R. 213-14.) In 2014 she began exhibiting strange behaviors, and she began to fall without explanation. She went to the Waterbury Hospital emergency room at least four times before someone thought to order a CT scan of her head. (R. 314-15.) When doctors performed that scan on August 29, 2014, they discovered a “large, bifrontal . . . intracranial mass” - in other words, a brain tumor. (R. 315.)

The Plaintiff had the tumor removed at Yale New Haven Hospital on September 3, 2014. (R. 394-95.) The hospital discharged her on September 7, 2014. (R. 412.) At her first postoperative outpatient appointment, the Plaintiff was “notably anxious with regards to her progress.” (R. 416.) But her neurosurgeon reassured her that, although she had “one of the largest tumors we have seen,” she had done “quite well following surgery.” (R. 417.) The doctor conducted a physical exam, during which the Plaintiff “move[d] all extremities with 5/5 strength.” (R. 416.) “[H]appy with her progress,” the doctor scheduled her to come back in three months. (R. 417.)

The Plaintiff treated with several different health care providers in September and October of 2014. Complaining of “[a]nxiety symptoms” and “[p]anic attacks,” she went to see a Licensed Clinical Social Worker (“LCSW”) named Marta Maresco on September 26, 2014. (R. 660-61.) She also began treating with a new primary care physician, Dr. Nahida Khan, on October 6, 2014. (R. 599-602.) On October 21, 2014, she underwent a psychiatric evaluation by Dr. Sunil Saxena. (R. 664-65.)

The Plaintiff applied for DI benefits with the Social Security administration (“SSA” or “Administration”) on October 22, 2014. (R. 79.) She claimed to have been disabled by her brain tumor, and she alleged a disability onset date of June 30, 2014. (Id.) After it obtained her medical records, the SSA referred her file for review by a physician, Dr. Virginia Rittner, and a psychologist, Dr. Pamela Fadakar. (R. 79-88.) Dr. Rittner observed “objective neuro[logical] exams [within normal limits],” and concluded that a “medical[] durational denial is appropriate based on objective evidence in [the] file.” (R. 85.) Dr. Fadakar concluded that although the Plaintiff suffered from a medically determinable affective disorder, the resulting impairment was not severe because it did “not significantly limit physical or mental ability to do basic work activities.” (R. 86-87.) A disability claims examiner then determined that the Plaintiff was “not disabled.” (R. 87.) She wrote that although the Plaintiff's tumor was severe, “it has improved and did not keep [her] from working for 12 months in a row.” (R. 88.) The examiner added that the Plaintiff's “condition was not disabling on any date through 3/31/2015, when [she] w[as] last insured for disability benefits.” (Id.)

The Plaintiff requested reconsideration (R. 107), and the SSA referred her file to Tarun Ray, M.D., and Susan Uber, Ph.D. (R. 97-98.) Dr. Ray read the medical records as indicating that the “Claimant was coming along quite well,” and that any neurological issues “would be non severe 12 months from the date of surgery.” (R. 97.) The doctor noted an allegation of “severe memory loss,” but wrote that it “could not be confirmed by the available” medical evidence of record. (Id.) Dr. Uber joined Dr. Fadakar in assessing the Plaintiff with a medically determinable affective disorder, but she concluded that the disorder led to only mild limitations in mental functioning. (R. 98.) With these opinions in the file, the reconsideration disability examiner found the Plaintiff “[n]ot [d]isabled,” because her “condition did not result in significant limitations in [her] ability to perform basic work activities on or before” the DLI. (R. 99.)

The Plaintiff then requested a hearing before an ALJ (R. 114-15), and ALJ John Aletta held a hearing on August 8, 2017. (R. 38.) On September 1, 2017, he issued a thirteen-page decision holding that the Plaintiff “was not under a disability, as defined in the Social Security Act, at any time from June 30, 2014, the alleged onset date, through March 31, 2015, the date last insured.” (R. 19-31.) The Plaintiff then requested review by the Appeals Council (R. 172), but the Council denied her request. (R. 1.) She therefore appealed to this Court (see Compl., ECF No. 1, 3:19-cv-00067 (AVC)), and the SSA answered her complaint by filing the administrative record. (ECF No. 11, No. 3:19-cv-00067 (AVC)). After reviewing the record, however, the SSA evidently reconsidered its position, because it consented to have the case remanded for further proceedings. (ECF No. 19, No. 3:19-cv-00067 (AVC)). Upon remand, the Appeals Council instructed the ALJ to conduct additional analysis of the Plaintiff's claimed mental impairments; attempt to obtain a full copy of an opinion from Dr. Khan, only a fragment of which had yet made it into the file; and consider whether another hearing was warranted. (R. 1150-52.)

Before the second hearing, the SSA obtained additional medical evidence. Relevant here, the Administration obtained a letter from Dr. Joseph Trettel, a Hartford neuropsychiatrist with whom the Plaintiff had begun treating in 2016. (R. 1387.) In an earlier letter, Dr. Trettel had opined that the Plaintiff “suffers from cognitive impairments including executive dysfunction, slow processing speed, memory difficulty, and visuospatial deficits.” (R. 924) (letter of Apr. 3, 2017). In the new letter, dated October 26, 2017, Dr. Trettel elaborated that the Plaintiff had developed “a striking and severe behavioral syndrome consistent with damage to both frontal lobes” of the brain. (R. 1387.) He stated that the Plaintiff's then “current clinical presentation is dominated by impulsivity, perseveration of thought, inability to weigh consequences of actions, severely impaired judgment, short-term memory deficits and very severe impairments in executive functions.” (Id.) He provided his “medical opinion” that “in no way is this individual able to maintain employment,” and he contended that “these changes began immediatly [sic] after the tumor resection and were not present prior, implicating a causative relationship between the resection and her symptoms.” (Id.) (emphases in original).

The ALJ held a second hearing on July 12, 2022 (R. 1078), and on August 5, 2022 he issued a twenty-three page decision. (R 1045-67.) As will be discussed below, ALJs are required to follow a five-step sequential process in evaluating Social Security disability claims, and the ALJ's written decision followed that format. At Step One, he concluded that the Plaintiff had not engaged “in substantial gainful activity during the period from her alleged onset date of June 30, 2014 through her date last insured of March 31, 2015.” (R. 1048.) At Step Two, he determined that the Plaintiff suffered from...