Opinion
No. CV-02-2283 (RJD).
March 31, 2004
MEMORANDUM ORDER
Pro se plaintiff Maria Garcia seeks review pursuant to 42 U.S.C. § 405(g), challenging the final determination of the Commissioner of Social Security Administration ("the Commissioner") that denied her disability insurance benefits ("DI") and supplemental security income ("SSI") benefits. Pursuant to Rule 12(c) of the Federal Rules of Civil Procedure, the Commissioner moves for judgment on the pleadings, affirming the Administrative Law Judge's ("ALJ's") determination that the plaintiff's impairments did not preclude her from performing substantial gainful activity. The plaintiff has not opposed the motion. For the reasons that follow, the ALJ's decision is remanded.
BACKGROUND
A. Procedural Background
The plaintiff was born on October 17, 1951 in Puerto Rico, and came to the United States in 1967. Tr. 42. Although the plaintiff testified that she completed two years of high school, she reported elsewhere that she was a high school graduate. Tr. 48, 98, 198. The plaintiff worked as a postal worker and a bus matron. She worked as bus matron for seven years until she resigned in 1993. Tr. 43, 198, 280. She applied for SSI on June 12, 1997 and for disability benefits on May 15, 1998, alleging disability since December 3, 1993. Tr. 76-78, 292-304. She alleged an inability to work due to a heart murmur, angina, arthritis, asthma, and a nervous condition. Tr. 93, 293. The plaintiff's applications were denied initially (Tr. 52-53, 55-58, 305-09) and on reconsideration. Tr. 54, 63-66, 310-17. The plaintiff requested a hearing (Tr. 67-68), and on August 10, 1999, the plaintiff appeared and her non-attorney representative before Administrative Law Judge Jonathan E. Jacobs. Tr. 40-51. The ALJ issued a decision on August 15, 1999, finding that Garcia was incapable of performing her past relevant work as a postal worker and bus matron, but concluding that she had the residual functional capacity to perform sedentary work with some environmental restrictions. Tr. 30-31. Based on the plaintiff's exertional capacity for sedentary work and her age, education, and work experience, the ALJ concluded that the plaintiff was not disabled within the meaning of the Act. Tr. 31. The ALJ's decision became the Commissioner's final decision when the Appeals Council denied Garcia's request for review of the ALJ's decision on February 14, 2002. Tr. 8-10.
B. Medical Background
The plaintiff's extensive medical history is set forth in the administrative record and will not be generally repeated. On her disability application, the plaintiff listed two treating sources: Dr. Sixto Caro, an internist, and Dr. Chi Ping Margaret Chu, a psychiatrist. Tr. 94. The plaintiff began seeing Dr. Caro on January 31, 1995. Tr. 173. On August 5, 1997, Dr. Caro reported that the plaintiff was suffering from depression, hypertension, chronic bronchial asthma, and G.E.R.D. (Gastroesophegal reflux disease). Tr. 185. He stated that the plaintiff was totally disabled and unable to work because of her afflictions. Id.
On June 9, 1998, Dr. Caro completed a disability assessment for the New York State Office of Temporary and Disability Assistance. Tr. 173-76. He reported that the plaintiff could lift or carry a maximum of five pounds, and that she could stand or walk for less than 2 hours per day. Tr. 175. Dr. Caro further reported that Ms. Garcia could sit for less than six hours a day and that she was limited in her ability to push and or pull. Tr. 176.
On July 22, 1999, Dr. Caro completed a medical report for the Social Security Administration. Tr. 283-90. He noted that he had been treating the plaintiff since 1995 for her chest pain, epigastric heartburn, recurring chronic headaches, and depression. Tr. 283. Upon examination, he reported diffuse rhonchi in plaintiff's lungs and regular sinus rhythm. Tr. 284. There were muscle spasms evident in her lumbar spine. Id. She had no edema. Id. Dr. Caro listed the plaintiff's diagnoses as: depression, hypertension, chronic bronchial asthma, generalized arthralgias and osteoarthritis, peptic ulcer disease, gastritis and G.E.R.D., chronic headaches, and chronic allergic rhinitis. Tr. 286.
In the report, Dr. Caro assessed the plaintiff's ability to perform work-related activities. Tr. 287-90. He reported that the plaintiff was limited to carrying or lifting five to ten pounds, standing and or walking for up to two hours, and sitting a total of four hours. Tr. 287-88. He also stated that the plaintiff's fatigue secondary to depression impaired her daily activities. Tr. 290.
DISCUSSION
A. Standard of Review
In reviewing the ALJ's finding that a plaintiff is not disabled, a district court "may only set aside a determination which is based upon legal error or not supported by substantial evidence." Barry v. Schweiker, 675 F.2d 464, 467 (2d Cir. 1982). The Supreme Court has defined "substantial evidence" in Social Security cases as "more than a mere scintilla" and that which "a reasonable mind might accept as adequate to support a conclusion." Richardson v. Perales, 402 U.S. 389, 401 (1977) (quoting Consolidated Edison Co. v. NLRB, 305 U.S. 197, 229 (1938)). Furthermore, "it is up to the agency, not th[e] court, to weigh the conflicting evidence in the record." Clark v. Commissioner of Social Security, 143 F.3d 115, 118 (2d Cir. 1998). If the court finds that there is substantial evidence to support the Commissioner's determination, the decision must be upheld, even if there is substantial evidence for the plaintiff's position. Jones v. Sullivan, 949 F.2d 57, 59 (2d Cir. 1991). This court "may not substitute its own judgment for that of the Secretary, even if it might justifiable have reached a different result upon a de novo review." Id. (quoting Valente v. Sec'y of Health and Human Servs., 733 F.2d 1037, 1041 (2d Cir. 1984)).
B. Treating Physician Rule
The opinion of a treating physician is controlling if it is "well supported by medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with the other substantial evidence in [the] . . . record." 20 C.F.R. § 404.1527(d)(2). The ALJ must provide "good reasons" for not assigning controlling weight to the treating physician's diagnosis. Schaal v. Apfel, 134 F.3d 496, 505 (2d Cir. 1998);see also Snell v. Apfel, 177 F.3d 128, 133 (2d Cir. 1999). When the treating physician's opinion is not given controlling weight a number of factors are used to determine what weight the opinion deserves, including 1) the length of the treatment relationship and the frequency of examination; 2) the nature and extent of the treatment and the relationship; 3) the evidence in support of the opinion; 4) the opinion's consistency with the record as a whole; and 5) whether the opinion is from a specialist. 20 C.F.R. § 404.1527(d)(2); Schisler v. Sullivan, 3 F.3d 563, 567 (2d Cir. 1993). "Failure to provide `good reasons' for not crediting the opinion of a claimant's treating physician is a ground for remand" Snell, 177 F.3d at 133.
Here, the administrative record contains reports and records from the plaintiff's treating physicians, Dr. Caro and Dr. Chu. In his decision, the ALJ discusses Dr. Chu's August 1997 report and the medical evaluations performed by consultative physicians Drs. Holladay, Park, DeLeon, and Robotti. Tr. 25-27. The ALJ, however, never mentions Dr. Caro or his disability assessment. Thus, not only did the ALJ err in failing to provide good reasons for not crediting Dr. Caro's opinion, he erred in not providing any reason at all for discounting Dr. Caro's opinion. See Truesdale v. Barnhart, No. 03-0063, 2004 WL 235260, at *6 (S.D.N.Y. Feb. 6, 2004) (concluding that the ALJ failed to provide good reasons for not crediting the opinion's of claimant's treating physicians where the ALJ did not even discuss the treating physicians opinions).
The Court notes that the Commissioner acknowledges Dr. Caro's opinion that the plaintiff was totally disabled in her brief.See Commissioner's Brief at 23. The Commissioner argues, however, that Dr. Caro's opinion is contradicted by substantial clinical findings and medical opinions of record, and thus the ALJ did not have to accord it much weight. See id. While it does appear that Dr. Caros' opinion is not supported by the medical evidence, it is not for the Commissioner to make that determination; it is the ALJ who has the responsibility to assess, and ultimately weigh, the treating physician's opinion in the first instance.
CONCLUSION
Because the ALJ failed to explain why he did not credit the opinion of Dr. Caro, the proceeding is remanded for further administrative proceedings pursuant to the fourth sentence of 42 U.S.C. § 405(g).
SO ORDERED.
JUDGMENT
A Memorandum and Order of Honorable Raymond J. Dearie, United States District Judge, having been filed on March 31, 2004, remanding the matter for further administrative proceedings, pursuant to the fourth sentence of 42 U.S.C. § 405(g); it isORDERED and ADJUDGED that judgment is hereby entered remanding the matter for further administrative proceedings, pursuant to the fourth sentence of 42 U.S.C. § 405(g).