United States District Court, D. New Jersey
KEVIN McNULTY, District Judge.
Neva Ford brings this action pursuant to 42 U.S.C. § 405(g) and 5 U.S.C. § 706 to review a final decision of the Commissioner of Social Security that denied her applications for Title II disability insurance benefits ("DIB") and for Title XVI Supplemental Security Income ("SSI") under the provisions of 42 U.S.C. § 423 and 1382. Compl. (Docket No. 1). These applications, which sought benefits starting in September 2005, alleged that Ford was disabled because of congestive heart failure (cardiomyopathy), diabetes, and morbid obesity. For the reasons set forth below, the Commissioner's decision is affirmed.
On February 9, 2007,  the Plaintiff, Neva Ford, first applied for disability insurance benefits and supplemental security income benefits. Record of Proceedings ("R __") (Docket No. 11) at 142-46. She alleged that, because of her disabling conditions - congestive heart failure, diabetes, and high blood pressure - she became unable to work as of September 15, 2005. R 144. These applications were originally denied on July 24, 2008. Ford then filed a request for reconsideration, which was denied on October 1, 2008. Compl. ¶ 5; R 90-95, 82-84. She filed a request for a hearing, which was held before Administrative Law Judge Leonard Olarsch (the "ALJ") on February 18, 2010. Compl. ¶ 6; R 97-139. On February 25, 2010, the ALJ rendered a decision finding that Ford was not disabled. R 23-36. After the ALJ's unfavorable decision, Ford requested review by the Appeals Council. On March 9, 2012, the Appeals Council denied Ford's request for review. This rendered the ALJ's February 25, 2010 decision a final decision of the Commissioner of Social Security, reviewable in this Court. R 4-9.
Ford now appeals the denial of her February 2007 DIB and SSI applications. The government submits that the ALJ's denial of benefits is supported by substantial evidence.
A. Ford's Testimony and Non-Medical Evidence
Ford was born October 20, 1970, and was 34 years old on the alleged disability onset date. She completed the twelfth grade. R 101. She has two school-aged children who live with her. Her last job was as a human services technician on the mental ward of Greystone Psychiatric Hospital. R 100. Her duties included keeping track of and assisting patients with various daily tasks and activities. R 101-02. Ford testified that her weight made her job more difficult, as she was required to do constant walking and frequent lifting. She testified that she was often short of breath when walking with patients and that her knees would give out from "time-to-time." R 102-03. Ford left this job after being hurt on the job when a patient came up behind her and took her down to the ground. R 103. In the fall, she injured her knees, back, and shoulders. R 104. A doctor excused her from work for a couple of months and she filed a Worker's Compensation claim. Id.
Ford never returned to work after this incident. After she stopped receiving Worker's Compensation benefits, she began receiving welfare benefits, such as food stamps and rental assistance. R 109-10. She testified that her diabetes "kicked in" after the incident and that she suffers from chest pain, dizziness, headaches, shortness of breath, numbness in her fingers, hands, legs, and feet, and swelling in her legs. R 106-08. She also complains of being thirsty all of the time and having blurry vision even with glasses. R 108.
Ford testified that she does little on a daily basis and that all her household chores are done by her children and by her mother. When the children are at school, her mother, who lives four blocks away, drives over to clean and cook for Ford. Her mother also does the grocery shopping, from "time-to-time" accompanied by Ford. R 113-15. Ford says she attends church on Sundays, but must get up several times during the three-hour service and generally leaves early. She testified that she has no hobbies and does not participate in any activities other than watching the news on TV. R 116-17, 125. She testified that she cannot complete personal grooming without the help of her daughter, R 122, and that her legs would give out if she were to walk half a block. R 118. She says that she is constantly drained and sleepy. R 115, 122.
B. Ford's Medical Record and Objective Evidence
Ford submitted evidence that she has been on various medications, including Digoxin, Diovan, Bidil, Amlodipine, Carvedilol, Zetia, Furosemide, Levemir Flexpen, Humalog, and Pramipexole. R 200. These medications are used to treat her cardiac condition, high blood pressure, high cholesterol, swelling, diabetes, and sleep apnea. Id. Before the ALJ, Ford submitted that she is disabled as a result of cardiomyopathy, diabetes mellitus, and obesity. The objective evidence, as found in Ford's medical records and as summarized by the medical expert appearing at the hearing, is summarized below.
1. Evidence Regarding Cardiomyopathy
While Ford was hospitalized due to a failed pregnancy in August of 2005, an echocardiogram ("EKG") showed that she had a "normal sinus rhythm" and "nonspecific wave abnormality." R 207. The report noted that the test revealed an "abnormal EKG." Id. A discharge summary following a November 2006 hospital stay noted that Ford was hospitalized for folliculitis and that she also complained of shortness of breath. R 239. The same report noted an "impression" of cardiomyopathy and that Ford was a "high risk patient" for cardiovascular mortality and morbidity. Id. Ford was only diagnosed, however, with right auxiliary folliculitis and uncontrolled diabetes mellitus. R 240. A consultative report completed by Dr. Kyu C. Chae during this hospital stay noted that Ford had "[n]o history of congestive heart failure or heart disease." R 243. An EKG taken on November 22, 2006, was "borderline." R 239.
A June 24, 2008 EKG report showed that Ford had a normal sinus rhythm, but that the EKG was "abnormal." R 269. A June 24, 2008 physical consultative evaluation conducted by Dr. Rhambai Patel (as requested by the Social Security Administration) found that Ford had normal breathing sounds, a regular sinus rhythm without murmur or gallop, and a normal-sized heart. R 267. According to a July 16, 2008 physical examination report completed by Dr. Robert Roland, while Ford had a 2/6 systolic murmur, she had a regular heart beat rate and rhythm without extra systoles or gallops R 325. The same report noted that Ford had a history of congestive heart failure. R 324.
A July 15, 2008 diagnostic imaging report noted that a chest x-ray showed Ford's heart to be normal and did not show any congestion or effusion. R 356. Similarly, a November 6, 2009 chest x-ray report noted that Ford's heart size was within normal limits. R 440. A November 2009 EKG resulted in a "borderline" result. R 442-43. Finally, a July 14, 2010 exercise stress test report stated that Ford had an exercise capacity of 7 METs and produced normal EKG findings. Ford's results from this test showed an ejection fraction of 57%. R 444-57.
A July 8, 2008 handwritten note by Ford's primary care physician, Dr. Darshi Sunderam, stated that Ford had severe cardiomyopathy and severe neuropathy and noted that Ford should be on permanent disability. R 271, 327. EKG results that appear to be attached to this note show a "normal" EKG and normal sinus rhythm. R 332.
2. Evidence Regarding Diabetes Mellitus
A May 22, 2006 hospital discharge summary report completed by Dr. Sunderam noted that, despite Ford's diabetes, she had a soft abdomen, no organomegaly (abnormal enlargement of the organs), and no neurological deficits. R 280-81. She was hospitalized again in November 2006 for uncontrolled diabetes mellitus and cellulitis. R 299. A November 2006 hospital report also noted that she did not have organomegaly and did not have focal neurological deficits. R 241. Ford was also admitted to the hospital on July 15, 2008, for poorly controlled diabetes and various skin infections. R 312, 316. During this July 2008 hospital visit, it was similarly found that Ford had no organomegaly, no mass effect, and no evidence of diminished sensations. R 319.
There is evidence that Ford has a history of being noncompliant with her diabetes medication regimen. The May 22, 2006 discharge summary report noted that Ford was admitted to the hospital for uncontrolled diabetes and that Ford was "notoriously noncompliant" with respect to her diabetes medication. R 280. A November 23, 2006 admission report also noted that Ford was consistently noncompliant with her diabetes maintenance medication regime. R 241, 302 ("notoriously noncompliant... with her medications, her diet, office visits"). Similarly, a July 2008 History and Physical report noted that Ford was "notoriously noncompliant" and "does not take her medications." R 322; see also R 431 (again noting that Ford was "notoriously non-compliant").
3. Evidence of Morbid Obesity
Ford also has a history of morbid obesity. According to a February 18, 2010 letter from Ford's then-counsel, Ford's weight fluctuated between 223 and 307 pounds during the period from March 2005 through December 2009. R 201 (Exhibit 8E). Ford stands 5 feet, 1 inch tall. Id. Despite the stress on her body, a June 24, 2008 physical consultative evaluation conducted by Dr. Rhambai Patel found that Ford was slightly obese but not in acute distress. Patel noted normal vision, a normal gait, normal breathing sounds, a normal heart, normal grip strength, and slightly diminished sensations in both of her lower extremities. R 267. A study provided to the ALJ after the hearing (but included on his List of Exhibits, R 36) found that Ford suffers from obstructive sleep apnea syndrome. It recommended weight loss. R 469.
4. Hearing Testimony Summarizing Medical Record
Dr. Gerald Gaist, board-certified in general internal medicine and cardiology, testified at the February 2010 hearing. Before the hearing, he reviewed all of the medical evidence. Dr. Gaist testified that Ford had diabetes and suffered from morbid obesity, which were well-documented by the medical records. R 130. Noting that Ford's primary care physician, Dr. Sunderam, had referred to Ford's severe cardiomyopathy, Dr. Glast found no evidence of cardiomyopathy other than the fact that Ford had been prescribed medication normally used to treat it. Id. Dr. Gaist specifically cited to an EKG taken the month before the hearing that showed normal left ventricular function with normal ejection fraction, and did not show evidence of heart failure. Id. (citing Exhibit 16-F).
Dr. Galst also testified that multiple chest x-rays consistently showed a normal-sized heart with no evidence of lung congestion. He opined that Ford's shortness of breath might have been caused by her obesity, but found no evidence that it was caused by either systolic or diastolic heart failure. He noted that there were no neurological studies done to determine whether Ford suffered from diabetic neuropathy. He testified that her overall renal function was normal and that she is not in any heart failure. R 132-33, 137. He also stated that her condition of morbid obesity was not disabling and that he did not see any reason why Ford could not do sedentary work. R 138.
Ford's claims for DIB and SSI were denied by ALJ Olarsch after application of the five-step analysis described below. To qualify for Title II DIB benefits, a claimant must meet the insured status requirements of 42 U.S.C. Section 423(c). To be eligible for SSI benefits, a claimant must meet the income and resource limitations of 42 U.S.C. Section 1382. To qualify under either statute, a claimant must show that she is unable to engage in substantial gainful activity by reason of any medically determinable physical or mental impairment that can be expected to result in death or that has lasted (or can be expected to last) for a continuous period of not less than twelve months. 42 U.S.C. § 423(d)(1)(A), 1382c(a)(3)(A).
On appeal to this Court, Ford raises two claims of error with respect to the substance of ALJ Olarsch's decision. First, she argues that the ALJ improperly evaluated the medical evidence. Ford contends that the ALJ failed to give "proper credence" to Ford's complaints concerning her chronic and severe pain, numbness to her extremities, pitting edema, and overall weakness and physical limitations. Pl. Br. at 10. Second, Ford submits that the ALJ erred in failing to properly assess her Residual Function Capacity ("RFT"). Id. at 14. Each will be fully addressed below. I find that the ALJ's opinion is supported by substantial evidence. Accordingly, I will affirm his opinion of February 25, 2010.
A. Legal Framework
1. The Five-Step ...