BRENDA L. ST. JEAN, Plaintiff,
COMMISSIONER OF SOCIAL SECURITY, Defendant.
Richard Lowell Frankel, Esq. BROSS & FRANKEL, PA, Cherry Hill, NJ, Attorney for Plaintiff.
Paul J. Fishman, UNITED STATES ATTORNEY, David L. Brown, Special Assistant U.S. Attorney Social Security Administration Office of the General Counsel, New York, NY, Attorney for Defendant.
JEROME B. SIMANDLE, Chief District Judge.
Plaintiff Brenda L. St. Jean brings this action pursuant to 42 U.S.C. § 405(g), seeking review of a partially favorable final decision issued by the Commissioner of the Social Security Administration. The Commissioner granted Plaintiff's application for supplemental security income benefits under Title XVI of the Social Security Act, 42 U.S.C. §§ 1381, et seq. ("the Act"), for the period of September 23, 2009, through September 19, 2011, but ruled that Plaintiff's disability ended on September 20, 2011, due to medical improvement. Plaintiff argues that the Administrative Law Judge ("ALJ") lacked substantial evidence to support his conclusion that her medical condition improved as of September 20, 2011, and she seeks remand to the ALJ for further consideration. Relatedly, Plaintiff argues that the ALJ erred in determining that her statements about her medical condition as of September 20, 2011, lacked credibility.
Because the Court agrees with Plaintiff that the ALJ lacked substantial evidence to find medical improvement and conclude that Plaintiff was not disabled as of September 20, 2011, the Court will remand the matter to the ALJ for further consideration.
A. Procedural history
Plaintiff protectively filed an application for social security disability benefits and supplemental security income benefits on September 23, 2009, alleging an onset of disability on June 15, 2005. (Pl. Br. at 1.) The claim was denied, as was a request for reconsideration. (Id.) The ALJ Frederick Timm held a hearing in this matter on October 24, 2011, and issued a partially favorable decision granting Title XVI benefits for the period from September 23, 2009, to September 19, 2011, and dismissing the claim for Title II disability benefits. (R. at 14-15.) The Appeals Council denied Plaintiff's request for review. (R. at 1.) Plaintiff filed the present action.
B. Medical history
The Court will recite only those portions of the record that are germane to the present motion. Plaintiff, who was 44 years old when she applied for benefits, suffers from multiple medical conditions, including Hepatitis C, discogenic and degenerative disorders of the back, affective mood disorders, anxiety disorders, and arthritis. (Pl. Br. at 2.) Beginning in 2005, Plaintiff sought repeated treatment from doctors for increasing pain in her left hip, leg, foot, groin, and buttock. ( Id. at 2-4.) At first, doctors had difficulty identifying the cause of Plaintiff's pain, ordering multiple tests, prescribing pain medication and administering injections to ease Plaintiff's symptoms. ( Id. at 2-6.) Over time, doctors identified a bulging disc in her spine and diagnosed her with chronic sciatica, and tinkered with her pain medications and therapy regimens. ( Id. at 4-8.)
In November 2006, an orthopedic surgeon detected an elevated rheumatoid factor in Plaintiff's blood and referred her to a rheumatologist. ( Id. at 8.) The rheumatologist examined Plaintiff, who had a strong family history of rheumatoid arthritis, but was not convinced of a rheumatoid arthritis diagnosis, noting that patients with Hepatitis C sometimes have elevated rheumatoid factors. (R. at 462-63.) Plaintiff sought opinions from other rheumatologists, who likewise did not affirmatively diagnose Plaintiff with rheumatoid arthritis. (Pl. Br. at 9.) Between 2007 and 2009, Plaintiff struggled at times with substance abuse, mental disorders and seizures, and she continued to complain of body pain and fatigue. (Pl. Br. at 10-12.)
In October 2009, Plaintiff experienced bilateral wrist pain and had x-rays of her hands and wrist. Dr. David Feinstein could not positively diagnose Plaintiff with rheumatoid arthritis but suspected "inflammatory polyarthritis with positive rheumatoid factor" and noted that Plaintiff's successful history with prednisone supports "the possibility of inflammatory arthritis." (R. at 1080.) Plaintiff's symptoms worsened in 2010. (R. at 1105.) Dr. Pamela Traisak examined Plaintiff and observed significant swelling and tenderness in the left hand and wrist, and noted that Plaintiff rated her pain as ten on a scale of ten. (Id.) Dr. Traisak concluded "it is likely that [Plaintiff] has rheumatoid arthritis with chronic hepatitis C infection, " noting that such a combination was difficult to treat because the recommended medications for arthritis should not be used by a patient with Hepatitis C. (Id.)
Dr. Ken Klausman examined Plaintiff on January 10, 2010, and observed reduced strength in Plaintiff's right hand and "markedly decreased" fine hand motor movements in her right hand. (R. at 858.) He observed "decreased sensation to fine touch and pinprick in a glove distribution of the right hand and the left hand has moderately decreased sensation to fine touch and pinprick." (R. at 859.)
Dr. Traisak followed up with Plaintiff in March 2011, and observed continued "severe joint symptoms particularly in her hands, wrists, knees, and hips, " and noted that Plaintiff reported "muscle cramping symptoms in her hands and feet...." (R. at 1103.) Plaintiff again reported that "she does get some relief from prednisone, " but Plaintiff was concerned about taking the medication chronically. (Id.) Dr. Traisak again declined to diagnose Plaintiff with rheumatoid arthritis, saying she has "diffuse joint pains and fatigue, " and observing that Plaintiff's "exam is slightly underwhelming in terms of an inflammatory arthritis. She is tender in the correct areas and she also does have an extensive family history of rheumatoid arthritis." (Id.) Dr. Traisak raised the possibility of ...