Ortiz v. Colvin, Civil Action No. 16–1642 (SDW)

227 F.Supp.3d 350

Rose M. ORTIZ, Plaintiff,

v.Carolyn W. COLVIN, Commissioner of Social Security, Defendant.

Civil Action No. 16–1642 (SDW)

United States District Court, D. New Jersey.

Signed January 4, 2017

James Langton, Langton & Alter, Esqs., Rahway, NJ, for Plaintiff.

Naomi B. Mendelsohn, Social Security Administration—Office of General Counsel, Region III, Philadelphia, PA, for Defendant.

OPINION

WIGENTON, District Judge.

Before this Court is Plaintiff Rose M. Ortiz's ("Plaintiff" or "Ortiz") appeal of the final administrative decision of the Commissioner of Social Security ("Commissioner") that Plaintiff is not disabled under section 1614(a)(3)(A) of the Social Security Act (the "Act"). This appeal is decided without oral argument pursuant to Federal Rule of Civil Procedure 78. This Court has subject matter jurisdiction pursuant to 42 U.S.C. § 405(g). Venue is proper under 28 U.S.C. § 1391(b). For the reasons set forth below, the Commissioner's decision is VACATED and REMANDED for further proceedings.

I. PROCEDURAL AND FACTUAL HISTORY

A. Procedural History

On August 9, 2012, Plaintiff applied for Supplemental Security Income Benefits ("SSIB") alleging disability as of April 1, 2012 due to asthma, hypertension, anxiety, and aortic valve prolapse. (R. 55, 139–44.) Plaintiff's application for SSIB was denied both initially and upon reconsideration. (R. 77–81, 85–87.) Plaintiff's subsequent request for a hearing before an administrative law judge ("ALJ") was granted, and a hearing was held before ALJ Donna A. Krappa ("ALJ Krappa") on June 11, 2014. (R. 6–8, 26–53.) On November 12, 2014, ALJ Krappa issued a decision finding Plaintiff was not disabled and denying her application for benefits. (R. 9–25.) On January 27, 2016, the Appeals Council denied Plaintiff's request for review of ALJ Krappa's November 12, 2014 decision, making it the Commissioner's final decision. (R. 1–5.)

Plaintiff now requests that this Court reverse the Commissioner's decision and remand for an award of SSI benefits. (Compl. 3.)

B. Factual History

1. Personal and Employment History

Plaintiff was 40 years old at the time of ALJ Krappa's decision in 2014. (R. 126.) She currently resides in Elizabeth, New Jersey with her five children, ages 21, 18, 12, 8 and 6. (R. 31.) Plaintiff received her GED in 1994 and has previously worked as a babysitter and a sales associate starting in 1998, but stopped in 2000 to stay home and raise her children. (R. 154, 157–58.) She has not had significant employment in the past 16 years. (Id. )

2. Medical History

Plaintiff alleged in her original "Disability Report" that she is unable to work due to both physical ailments and psychiatric ailments. (R. 153–163.) Specifically, Plaintiff contends that she suffers from "asthma, hypertension, anxiety, and aortic valve prolapse." (R. 157.) Plaintiff testified that she has suffered from these ailments prior to the date of disability, but applied for disability benefits in 2012 when her symptoms worsened. (R. 38.)

1. Physical Impairments

Plaintiff has seen Lorna B. Bayes, M.D. ("Dr. Bayes") for annual examinations from June 2006 through July 2012. (R. 209–28.) Over the course of treatment, Dr. Bayes diagnosed Plaintiff with hypertension, asthma, headaches, leg edema and diabetes. (Id. )

During her first annual exam in 2006, Plaintiff complained of headaches that started in August of 2005, but have increased in frequency and were accompanied by nausea. (R. 228.) Dr. Bayes prescribed Fioricet to help with Plaintiff's pain and ordered a CT scan of her head. (Id. ) In 2009, Plaintiff stated she was still suffering from headaches about twice a week and in 2012, Plaintiff was admitted to the hospital after complaining of a slow onset headache with pain rated at a 7 out of 10, and swelling of her legs. (R. 197, 222, 224.) She was diagnosed with a headache and leg edema, then discharged the same day. (R. 204.)

Dr. Bayes' progress notes also indicate that Plaintiff was obese. (R. 209–228.) Over the course of treatment, Plaintiff has gained over 60 pounds and currently has a BMI of 40.¹ (R. 39–40, 209–228.) On multiple occasions, Dr. Bayes discussed weight loss and healthy diet options with Plaintiff to improve her overall health. (R. 216, 219.)

Dr. Bayes' progress notes consistently report that Plaintiff had high blood pressure, which occasionally caused chest pain and edema in her lower extremities. (R. 42, 46, 209–228.) She diagnosed Plaintiff with hypertension, which has subsequently been controlled by medication. (Id. ) However, Plaintiff testified that her blood pressure was not under control and her medications had not been stabilized because of side effects such as drowsiness, dizziness and swelling. (R. 42, 46, 166.)

In 2011, Plaintiff went to the Emergency Room via ambulance after experiencing severe chest pain. (R. 187.) During the evaluation, her respiratory and neurological examinations were normal, there were no abnormal cardiovascular sounds, murmurs or heart rhythms. (R. 190.) She was diagnosed with hypertension and chest pain. (R. 195.) On two separate occasions in 2012, Plaintiff was again admitted to the hospital with similar complaints of chest pain. (R. 231–38.) An electrocardiogram("ECG") was abnormal and Plaintiff was diagnosed with hypertension and atypical chest pain, which subsided spontaneously. (R. 238–39.)

In June 2012, Plaintiff was referred to Meeta Bhaat, M.D., Ph.D ("Dr. Bhaat") for a sleep study after reporting she was feeling excessively tired during the daytime and snoring while asleep. (R. 218.) After an evaluation, Dr. Bhaat diagnosed Plaintiff with obstructive sleep apnea with hypersomnia. (R. 207.) She advised Plaintiff that losing weight would positively impact her disorder and additional tests should be performed. (Id. )

From 2006 through 2012, Dr. Bayes consistently noted that Plaintiff suffered from asthma, (R. 209–227), which was so severe Plaintiff testified that she could not go outside in the summer. (R. 39.) Plaintiff was prescribed an Albuterol Inhaler, as well as Advair Diskus to reduce her symptoms, which she takes to this day. (R. 174, 177, 209–227.)

In 2013, Plaintiff was admitted to the hospital with flu-like symptoms, as well as shortness of breath, coughing, wheezing, and chest tightness. (R. 248.) She was diagnosed with an infection, which exacerbated her asthma. (Id. ) After administration of medication, Plaintiff saw improvement in her asthmatic symptoms and was discharged four days later. (R. 249.) Her final diagnoses included asthma, hypertension, obesity and suspected obstructive sleep apnea. (R. 248.)

Later that year, Plaintiff was prescribed Prednisone, in addition to her Albuterol inhaler (Ventolin ) and Advair Diskus to better manage her asthma. (R. 29.) The Prednisone treatment raised Plaintiff's blood sugar and consequently caused diabetes.² (Id. ) Plaintiff's diabetes has since been managed with medication. (R. 174–180.)

2. Mental Impairments

Plaintiff has experienced mental ailments prior to her alleged onset date of disability and has a history of abuse and trauma. (R. 258.) During her childhood, she reported being sexually abused by her step-father starting at the age of 7 and she attempted suicide at 15. (R. 255, 269, 271.) Plaintiff was also assaulted and knocked unconscious during the commission of a robbery at her job in 2000. (R. 262.)

In a 2009 annual exam, Plaintiff reported experiencing anxiety and depression about two times per month. (R. 224.) Later that year, Plaintiff stated that she felt as if "something was squeezing her heart" and Dr. Baynes diagnosed her with acute anxiety and prescribed Xanax, which Plaintiff continues to take. (R. 222, 247.)

On January 27, 2014, Dr. Bayes referred Plaintiff to Trinitas Regional Medical Center, Outpatient Psychiatric Unit, due to symptoms of anxiety and depression. (R. 262.) Plaintiff reported sleeping all day, having crying spells, feeling panicked and suffocated, and having little energy, but denied suicidal or homicidal thoughts. (R. 262–63.) She further stated that she had been feeling this way for about a year. (R. 263.) Dr. Kelly McEwen diagnosed Plaintiff with depressive disorder, posttraumatic stress disorder ("PTSD") and an anxiety disorder, and assessed Plaintiff with a Global Assessment of Functioning ("GAF") of 50.³ (R. 257.) She was then admitted to the Outpatient Psychiatrist Unit for further evaluation. (Id. )

During a February 11, 2014 mental status examination, Dr. Nicholas King, Ph.D., the psychiatrist at the Outpatient Psychiatric Unit, noted that Plaintiff's mood was depressed, but her thoughts were relevant and goal directed, she appeared well-groomed and well-dressed, she was cooperative, accessible and related well. (R. 254.) He diagnosed Plaintiff with major depressive disorder and an anxiety disorder. (R. 256.) She was further assessed with a GAF of 55. (Id. ) Plaintiff has since seen Dr. King once a month for pharmaceutical and therapeutic treatment. (R. 45, 253.)

3. Hearing Testimony

At a hearing conducted by ALJ Krappa on June 11, 2014, Plaintiff testified about her education, previous employment, medical conditions, treatment and daily activities. (R. 30–47.)

Plaintiff stated she is currently unable to work because it is difficult for her to concentrate, she loses her train of thought and is constantly dizzy. (R. 33.) As to her physical abilities, she testified that she cannot walk half a block because she gets winded easily due to her asthma. (R. 34.) Further, she asserted she cannot stand for more than 30 minutes due to sciatic pain and she can sit for only 15 minutes before she starts to feel tingling and numbness in her feet. (R. 34–35.)

In lieu of a function report, Plaintiff testified she generally wakes up around 7:30 a.m., checks her blood glucose levels, and takes her medications. (R. 36.) Her oldest daughter helps the younger children get ready for school and Plaintiff stays home and naps until they return around 3:00 p.m. (R. 36–7.) Plaintiff...