Serrano v. Comm'r of Soc. Sec.

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CARMEN MILAGROS SERRANO, Plaintiff, v. COMMISSIONER OF SOCIAL SECURITY, Defendant.

Civil Action No. 22 Civ. 5627 (JPO) (SLC)

United States District Court, S.D. New York

July 24, 2023

REPORT AND RECOMMENDATION

SARAH L. CAVE, UNITED STATES MAGISTRATE JUDGE

TO THE HONORABLE J. PAUL OETKEN, United States District Judge:

I. INTRODUCTION

Plaintiff Carmen Milagros Serrano (“Ms. Serrano”) commenced this action pursuant to Section 205(g) of the Social Security Act (the “Act”), as amended, 42 U.S.C. § 405(g), seeking review of the April 25, 2022 decision by the Commissioner (the “Commissioner”) of the Social Security Administration (“SSA”), denying her application for Supplemental Security Income (“SSI”) benefits under the Act. (ECF No. 1). Ms Serrano contends that the decision of the Administrative Law Judge (“ALJ”) was erroneous, not supported by substantial evidence, and/or contrary to law, and asks the Court to modify the decision to grant the SSI payments, or remand for a new hearing to reconsider the evidence. (Id. at 2).

Ms Serrano moved, and the Commissioner cross-moved, for judgment on the pleadings, both pursuant to Federal Rule of Civil Procedure 12(c). (ECF Nos. 21 (“Ms. Serrano's Motion”); 25 (the “Commissioner's Motion”), together, the “Motions”)). The Motions have been referred to me for a report and recommendation. (ECF No. 7). For the reasons set forth below I respectfully recommend that Ms. Serrano's Motion be DENIED and the Commissioner's Motion be GRANTED.

II. BACKGROUND

A. Factual Background

On August 22, 2014 (the “Onset Date”), Ms. Serrano filed an application for SSI benefits (the “Application”), claiming that her “mental problems” rendered her unable to work as of that date. (SSA Administrative Record (“R.”) 67-75, 311-16 (ECF Nos. 16-16-4)). On October 21, 2014, the SSA denied Ms. Serrano's Application, finding that she was not disabled. (R. 66; 74).

1. Non-medical evidence

Ms. Serrano was born in 1967 and was nearly 47 years old at the time of her Application. (R. 67, 311, 1470). She lives alone in an apartment and has three grown sons, who have “isolated” from her. (R. 56, 58, 1470). She attended school up to the sixth or seventh grade in Puerto Rico, and moved to the continental United States in 1983. (R. 57, 1471). She has “tried” to learn English but “cannot get it.” (R. 1471). Her last employment was as a cleaning person in “around 2013.” (R. 1472; see R. 57). She was fired from that position after she “lost control” and “was very upset.” (R. 1472-73). After she was fired, Ms. Serrano “started to get depressed.” (R. 1473). She does not want to leave her house, becomes “overwhelmed when [she is] around people,” and “like[s] to be alone.” (Id.; see R. 58). She does not have visitors, does not clean, and makes simple meals for herself. (R. 57-58). Ms. Serrano feels “anger” and “rage” that “make[] it very difficult to communicate with people.” (R. 61). She “hate[s] reading,” is not able to follow a television show from beginning to end, and has “one friend.” (Id.) In December 2013, Ms. Serrano's former partner subjected her to verbal abuse and “put a gun to [her] head.” (R. 6263). Her psychiatric condition worsened after that incident. (R. 63).

In a function report completed on July 3, 2019 by her counsel (the “Function Report”), Ms. Serrano described her daily activities as staying at home and going to doctor visits every other week. (R. 1690, 1694, 1697). Although she prepares simple meals for herself, a friend buys her food for her. (R. 1692). On a “good day,” she can do cleaning and laundry. (Id.) She socializes on the phone once per month, but no longer goes out with family. (R. 1694-95). Ms. Serrano described fear caused by her depression as a reason for staying at home. (R. 1697; see R. 1690).

2. Medical evidence

a. New Beginnings Community Counseling Center

i. Dr. Sanchez

On May 6, 2014, Ms. Serrano underwent an outpatient psychiatric evaluation (the “May 2014 Evaluation”) performed by Antonio Alberto Sanchez, M.D. (“Dr. Sanchez”) of New Beginnings Community Counseling Center in Bronx, New York (“New Beginnings”). (R. 462-63). Dr. Sanchez noted that Ms. Serrano reported that she had been depressed for about one year following her relationship with a man who caused her to become estranged from her adult children. (R. 462). Ms. Serrano described feeling depressed and anxious, and having difficulty sleeping. (Id.) She reported that she was referred for therapy at Lincoln Hospital but stopped after three sessions because she did not feel that they helped her. (Id.)

Dr. Sanchez noted that Ms. Serrano appeared her stated age, was thin, “almost underweight,” and with “fair to good” grooming. (R. 463). Dr. Sanchez indicated that Ms. Serrano was “fidgety,” “alert,” with a “negativistic, but cooperative” attitude, “average” intellectual functioning, and a “constricted and mildly labile, but appropriate” affect. (Id.) Dr. Sanchez noted that Ms. Serrano's mood appeared “moderately depressed and anxious,” but she had “no evident psychotic features” or suicidal or homicidal ideations. (Id.) While her insight was fair, her judgment and impulse control seemed mildly impaired. (Id.)

Dr. Sanchez diagnosed Ms. Serrano with depressive disorder not otherwise specified and anxiety disorder not otherwise specified. (R. 463). Dr. Sanchez ruled out major depressive disorder and adjustment disorder with mixed anxiety and depressed mood, chronic. (Id.) Dr. Sanchez recommended a regimen of Prozac, the dosage of which would increase after two weeks, Trazadone at bedtime, and psychotherapy involving cognitive behavioral therapy (“CBT”). (Id.)

The New Beginnings records included a two-page medication record with Dr. Sanchez's notes concerning prescriptions for Prozac, Trazodone, and Wellbutrin for the period from May 6, 2014 to September 10, 2014. (R. 464-65).

Dr. Sanchez completed a form entitled “Medical Source Statement About What the Claimant Can Still Do Despite Medical Impairment(s),” dated November 13, 2015 (“Dr. Sanchez's Medical Source Statement”). (R. 475-79). Dr. Sanchez's Medical Source Statement leaves blank the field concerning “frequency and length of contact,” and does not indicate the extent of Dr. Sanchez's treatment of or relationship with Ms. Serrano, or when he last provided her medical care. (See id.) In a field providing for a “yes” or “no” response concerning whether Ms. Serrano had a “low [intelligence quotient (“IQ”)]” or reduced intellectual functioning, Dr. Sanchez wrote “unknown” and elaborated, “no test[] results available.” (R. 476). Dr. Sanchez' Medical Source Statement identifies Ms. Serrano as suffering from depressive disorder and anxiety disorder, and identifies her symptoms on a “yes/no” basis, answering yes to, inter alia, poor memory, sleep disturbance, personality change, mood disturbance, loss of intellectual ability in excess of 15 I.Q. points,^[1]delusions or hallucinations, recurrent panic attacks, difficulty thinking or concentrating, perceptual disturbances, oddities of thought, perception, speech, or behavior, social withdrawal or isolation, manic syndrome, obsessions or compulsions, hostility and irritability. (R. 475). Of 32 symptoms, Dr. Sanchez's form indicates that Ms. Serrano suffered from 29. (Id.)

Dr. Sanchez's Medical Source Statement also addressed the impact of Ms. Serrano's condition on her ability to work. (R. 476-78). Dr. Sanchez checked off that Ms. Serrano's impairments could, on average, cause her to be absent from work “more than 3 times a month” and identified a “marked loss” in her ability to understand, remember, and carry out detailed instructions, maintain attention and concentration for extended periods, maintain regular attendance, sustain an ordinary routine without special supervision, deal with the stress of semiskilled and skilled work, complete a normal workday or workweek without interruptions from psychologically-based symptoms, perform at a consistent pace without an unreasonable number and length of rest periods, set realistic goals or make plans independently of others, and travel in unfamiliar places (which was characterized as a moderate to marked loss). (Id.)

Dr. Sanchez also indicated mostly “moderate loss” in the degree to which Ms. Serrano could work with others without being unduly distracted, interact appropriately with the public, accept instructions and receive feedback from supervisors, respond appropriately to changes in a routine work setting, be aware of normal hazards, and use public transportation. (R. 477-78).

Finally, Dr. Sanchez deemed that there was a loss between moderate and “no/mild loss” in Ms. Serrano's ability to remember locations and work procedures, understand, remember, and carry out very short and simple instructions, make simple work-related decisions, ask simple questions or request assistance, and get along with co-workers and peers without unduly distracting them or exhibiting behavioral extremes. (Id.) Dr. Sanchez indicated that Ms. Serrano's condition existed since 2013. (R. 479).

ii. Dr. Pellowe

On November 10, 2016, Arthur Pellowe, M.D. (“Dr Pellowe”), completed a Medical Source Statement form (“Dr. Pellowe's Medical Source Statement”). (R. 516-21). Dr. Pellowe noted in the field for frequency and length of contact “weekly therapy monthly medication” without specifying with whom the therapy occurred or the period of his relationship with Ms. Serrano. (R. 517). Dr. Pellowe's Medical Source Statement identified Ms. Serrano as suffering from depressive disorder, psychosis, and anxiety disorder. (Id.) Of 32 possible symptoms, Dr. Pellowe's form indicated that Ms. Serrano suffered from twelve, in contrast to the 29 that Dr. Sanchez indicated two-and-a-half...