Purpura v. Comm'r of Soc. Sec.

DEREK PURPURA, Plaintiff, v. COMMISSIONER OF SOCIAL SECURITY, Defendant.

Case # 19-cv-01717

UNITED STATES DISTRICT COURT WESTERN DISTRICT OF NEW YORK

October 16, 2020

DECISION AND ORDER

INTRODUCTION

On April 4, 2014, Plaintiff Derek Purpura protectively applied for Disability Insurance Benefits under Title II of the Social Security Act (the "Act") and for Supplemental Security Income under Title XVI of the Act. Tr.¹ 159. The Social Security Administration ("SSA") denied his claim and Plaintiff appeared at one hearing before Administrative Law Judge Rosanne Dummer. Tr. 34-67. Plaintiff and a vocational expert testified. On October 7, 2016, ALJ Dummer issued an unfavorable decision. Tr. 18-33. The Appeals Council denied Plaintiff's request for review, making ALJ Dummer's decision the final decision of the SSA. Tr. 1-6. Plaintiff appealed to this Court.

On February 22, 2018, this Court remanded the case pursuant to a stipulation between the parties. Tr. 1011. The Appeals Council then issued an order directing the ALJ upon remand to (i) "give further consideration to the medical opinion evidence pursuant to the provisions of 20 CFR 404.1527 and 416.927, and explain," (ii) "evaluate the claimant's medical impairments in accordance with the special technique described in 20 CFR 404.1520a and 416.920a," (iii) "give further consideration to the claimant's maximum residual functional capacity and provide appropriate rationale with specific references to evidence of record," and (iv) if warranted, "obtain supplemental evidence from a vocational expert to clarify the effect of the assessed limitations on the claimant's occupational base." Tr. 1015-1016. Administrative Law Judge William Weir (the "ALJ") held a second hearing and issued an unfavorable decision on August 30, 2019. Tr. 956-972. Plaintiff again appealed to this Court.²

LEGAL STANDARD

I. District Court Review

When it reviews a final decision of the SSA, it is not the Court's function to "determine de novo whether [the claimant] is disabled." Schaal v. Apfel, 134 F.3d 496, 501 (2d Cir. 1998). Rather, the Court "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) (citing 42 U.S.C. §§ 405(g), 1383(c)(3)) (other citation omitted). The Commissioner's decision is "conclusive" if it is supported by substantial evidence. 42 U.S.C. §§ 405(g), 1383(c)(3). "Substantial evidence means more than a mere scintilla. It means such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Moran v. Astrue, 569 F.3d 108, 112 (2d Cir. 2009) (citations omitted).

II. Disability Determination

To determine whether a claimant is disabled within the meaning of the Act, an ALJ follows a five-step sequential evaluation: the ALJ must determine (1) whether the claimant is engaged in substantial gainful work activity; (2) whether the claimant has any "severe" impairments that significantly restrict her ability to work; (3) whether the claimant's impairments meet or medically equal the criteria of any listed impairments in Appendix 1 of Subpart P of Regulation No. 4 (the "Listings"), and if they do not, what the claimant's residual functional capacity ("RFC") is; (4) whether the claimant's RFC permits him or her to perform the requirements of his or her past relevant work; and (5) whether the claimant's RFC permits him or her to perform alternative substantial gainful work which exists in the national economy in light of her age, education, and work experience. See Bowen v. City of New York, 476 U.S. 467, 470-71 (1986); Rosa v. Callahan, 168 F.3d 72, 77 (2d Cir. 1999); see also 20 C.F.R. § 404.1520.

DISCUSSION

I. The ALJ's Decision

The ALJ analyzed Plaintiff's claim for benefits using the process described above. At step one, the ALJ found that Plaintiff had not engaged in gainful activity since the alleged onset date. Tr. 959. At step two, the ALJ found that Plaintiff has the following severe impairments: posttraumatic stress disorder, generalized anxiety disorder, and depressive symptoms. Tr. 959-60. At step three, the ALJ found that Plaintiff's impairments did not meet or medically equal any Listings impairment. Tr. 960-62. The ALJ found that Plaintiff retained the RFC to perform a full range of work at all exertional levels but that he can only perform simple tasks. He would be further limited by the inability to perform any complex work and could tolerate only up to one change per day in tasks or settings. The ALJ also determined that Plaintiff can have no public contact, only incidental co-worker contact, and occasional supervisory contact. Tr. 962.

In formulating the RFC, the ALJ gave "greater weight" to the opinion of the consultative medical evaluator, Dr. Elizabeth Kalb, because he found her to be "an unbiased health medical expert who has a thorough understanding of Social Security disability," and her opinions were "consistent with the overall record, well-reasoned and supported by appropriate findings." Tr. 970. The ALJ gave "little to no weight" to Plaintiff's treating physician, Dr. Mark Varallo, because he determined the "opinion is inconsistent with the overall record and . . . limitations were based on the claimant's self-reports." Tr. 968.

At steps four and five, the ALJ concluded that considering the Plaintiff's age, education, work experience and RFC, there were jobs within the national economy that Plaintiff could perform. Thus, the ALJ concluded Plaintiff was not disabled.

II. Analysis

Plaintiff takes issue with the ALJ's treatment of the medical opinion evidence. He argues that the ALJ did not comply with the Appeals Council's remand instructions by (1) failing to adequately explain how the RFC was consistent with Dr. Kalb's opinion and (2) failing to properly weigh the opinion of Dr. Varallo, Plaintiff's treating physician. See ECF No. 9-1 at 18-26. Because the Court agrees that remand is required under Plaintiff's first argument, it will not address Plaintiff's other argument.

An ALJ is required to "take any action that is ordered by the Appeals Council." 20 C.F.R. §§ 404.977(b), 416.1477(b). Accordingly, an "ALJ's failure to comply with the Appeals Council's order constitutes legal error, and necessitates a remand." Scott v. Barnhart, 592 F. Supp. 2d 360, 371 (W.D.N.Y. 2009) (citations omitted). The Appeals Council previously remanded ALJ Dummer's decision in this matter for further consideration on the basis that the decision, inter alia, did not explain how the RFC finding adequately incorporated Plaintiff's need for a low stress environment and did not explain how the RFC incorporated Plaintiff's need to work around others given he was limited to brief and superficial contact with others. Tr. 1014. On remand, the ALJ again failed to address these concerns.

It is well established that stress is highly individualized and therefore requires an ALJ to make "specific findings about the nature of [Plaintiff's] stress, the circumstances that trigger it, and how those factors affect [his] ability to work." Dukes v. Comm'r of Soc. Sec., No. 18-cv-6438, 2019 WL 6251191, at *8 (W.D.N.Y. Nov. 22, 2019) (quoting Stadler v. Barnhart, 464 F. Supp. 2d 183, 189 (W.D.N.Y. 2006)); see also Smith v. Astrue, No. 9-cv-470, 2011 WL 6739509, at *7 (N.D.N.Y. Nov. 4, 2011) ("The ALJ did not make sufficient finds concerning Plaintiff's particularized ability to deal with stress, other than to generically conclude that she was limited to 'low stress' work."); Welch v. Chater, 923 F. Supp. 17, 21 (W.D.N.Y. 2006) ("Although a particular job may appear to involve little stress, it may, in fact, be stressful and beyond the capabilities of an individual with particular mental impairments."). As such, an ALJ must "specifically inquire and analyze [an individual's] ability to manage stress." Booker v. Colvin, 14-cv-407s, 2015 WL 4603958, at *3 (W.D.N.Y. July 30, 2015) (citing Haymond v. Colvin, No. 1:11-cv-0631, 2014 WL 20148172, at *8-9 (W.D.N.Y. May 19, 2014)).

Throughout the decision, the ALJ cited several records which suggest some of Plaintiff's stress triggers include finances, his child, and his girlfriend's mental health. Tr. 965. The ALJ also noted Plaintiff's stress increased when his daughter was yelling and screaming, he had feelings of inadequacy as a father and partner, and was worried he could not provide for his family. Tr. 966. When Plaintiff's stress was increased, he testified he would typically have a panic attack or flashback and would require time away to regain his composure. See, e.g., Tr. 989 (Plaintiff testifying that if he could tell a panic attack was coming on he would remove himself from the situation, try to distract himself, and/or take his medication); Tr. 999 (Plaintiff testifying that if his daughter did something to induce panic, he would need his mother to watch his daughter "while [he] regained [his] composure"). The record also demonstrates most of Plaintiff's anxiety stems from his everyday fears, especially surrounding something happening to his daughter or other family members. Tr. 987-88. Plaintiff also testified that while he can have stress related problems by being around people, he also has significant problems being alone, and finds that time alone often causes intrusive thoughts triggering his PTSD and depression. Tr. 991. In fact, Plaintiff stated part of the reason for his difficulty driving is because the time he spends alone in the car triggers depressive thoughts, including self-harm. Tr. 991-92.

The extent of the ALJ's inquiry into Plaintiff's ability to manage and cope with stress involved Plaintiff's ability to watch and care for his daughter, but nowhere did the ALJ address this in his decision. Nor did the ALJ explain how Plaintiff's individual stress is triggered or how mechanisms of coping would allow him to perform a full range of work, limited only to...