United States District Court, D. New Jersey
JOSE L. LINARES, District Judge.
Currently before the Court is Plaintiff Kevin Green ("Plaintiff")'s appeal of Administrative Law Judge ("ALJ") Richard West's decision denying Plaintiff's application for supplemental security income. The Court has considered the submissions made in support of and in opposition to the instant appeal and decides this matter without oral argument. Fed.R.Civ.P. 78. For the reasons set forth below, the Court remands for further proceedings consistent with this opinion.
A. Plaintiff's Physical Impairments
Plaintiff maintains that he was disabled from November 27, 2006 through April 15, 2009, the day before he was able to return to work as a case manager. (R. at 527). Plaintiff's impairments are set forth below, chronologically, based upon the medical evidence contained in the record.
Plaintiff began seeking treatment from Thalody Medical Associates in 2004 for bone pain. (Id. at 341, 497-98). A bone density test was performed and revealed no left hip bone density loss, but showed evidence of osteopenia. As a result, Dr. Thalody recommended that the Plaintiff take calcium supplements. (Id. ). Plaintiff was treated for pain in his hips in August 2006, at which point, tests results revealed no bone density loss and minimal osteoarthritis. (Id. at 343). Dr. Thalody prescribed medication and physical therapy for Plaintiff's bone pain and muscle spasms. (Id. at 263-65, 333).
Plaintiff suffers from a seizure disorder. As such, in 2005, Dr. Thalody prescribed Dilantin and phenobarbital for the treatment of said disorder. (Id. at 339).
Plaintiff also suffers from HIV. Medical records reflect that in 2005 his HIV was under control and his viral count was undetectable. (Id. ).
In October 2005, Plaintiff was treated at Trinitas Hospital Emergency Room for a headache and followed up with Dr. Thalody who ordered an MRI, which revealed no harmful results. (Id. at 196). At a February 2006 appointment with Dr. Thalody, Plaintiff again complained of headaches and was given a referral to seek treatment from a neurologist. (Id. at 494-495). Subsequently, Plaintiff underwent an EEG in March 2006; his results were normal. (Id. at 195). At Plaintiff's February 2006 appointment with Dr. Thalody, the physician completed a disability form for one year - from February 20, 2006 through February 20, 2007. (Id. at 494).
On December 8, 2006, Plaintiff sought treatment at Trinitas Hospital Clinic, complaining of palpitations, anxiety, memory problems, and an inability to focus. (Id. at 202). Plaintiff was diagnosed with medication toxicity due to elevated levels of Dilantin in his blood, and was advised to not take the medication for 2 days. (Id. at 206-214).
On December 28, 2006, Plaintiff completed a Seizure Questionnaire, a Function Report, and a Disability Report. (Id. at 100-01). Plaintiff reported that he was having multiple seizures every month for the last 6 months, but could not indicate how long the seizures lasted. (Id. ). The same seizure questionnaire was sent to the Plaintiff's case manager, per the state agency's request, and the case manager indicated that she had not witnessed any of Plaintiff's seizures, but was aware that he was taking medication to treat a seizure disorder. (Id. at 102). In the Function Report, Plaintiff indicated that he had no limitations caring for his personal needs, used public transportation to travel, was able to cook himself dinner, and was able to remember to take his medication without assistance. (Id. at 103-12). Plaintiff listed his daily activities as including: making breakfast, taking his medication, going to church, resting, attending doctors' appointments if necessary, reading the bible, attending spiritual groups, and cooking himself dinner. (Id. ). Plaintiff further indicated that his impairments affect his ability to lift, walk, climb stairs, understand, squat, squat, sit, bend, kneel, stand, talk, reach, and concentrate. (Id. ). Additionally, Plaintiff noted that his impairments affect his memory, ability to follow directions, and complete tasks. (Id. ). The Disability Report shows that Plaintiff last worked in December 2000, and that the employment was discontinued because it was temporary. (Id. at 122).
The Plaintiff, who suffers from Hepatitis C in addition to his seizure disorder and HIV, is also seen by Dr. Uwe Schmidt, a physician at the HIV Services - Early Intervention Program at Trinitas Hospital. (Id. at 125). Dr. Schmidt regularly monitors Plaintiffs blood levels, and in March 2007 a blood test showed Plaintiff's HIV was under control, with a CD4 of 666 and a viral load of less than 50. (Id. at 379). In July 2007, Plaintiffs test results show a CD4 of 877 and a viral load of less than 50. (Id. at 375-76). A January 2008 blood test revealed a CD4 of 725 with a viral load of less than 50, and a follow up blood test in August of 2008 showed a CD4 of 739 and a viral load of less than 50 as well. (Id. at 465, 475-76). Plaintiff's final relevant blood test performed in February 2009 showed a CD4 of 794 and a viral load of less than 48. (Id. at 455-56).
At the July 2009 hearing, Plaintiff testified that his HIV, Hepatitis C, and seizures prevented him from working during the relevant time period. (Id. at 31).
B. Mental Impairments
In October 2006, Plaintiff was seen at the Trinitas Hospital Department of Behavioral health for an intake assessment. (Id. at 413). According to the Plaintiff, at that time he lived alone in an apartment and performed daily activities such as Bible reading, spiritual readings, attending AA meetings, volunteering with HIV patients, and speaking at schools regarding HIV and AIDS prevention. (Id. at 413-23). At the time of intake, Plaintiff also indicated that he graduated from high school, was in the Army for a year and a half, worked in the past as a welder, but was currently unemployed. (Id. at 113, 416). The intake clinician indicated that Plaintiff was calm, cooperative, well groomed, and had a neutral mood. (Id. at 419). She also noted that Plaintiff's intelligence was average, his attention, concentration, and judgment were good, and his thought process was intact. (Id. ). Additionally, the intake clinician reported that Plaintiff's speech was normal, his memory and cognition were intact, and his insight was fair. (Id. ). Plaintiff also reported that he was not experiencing hallucinations. (Id. ). The intake clinician diagnosed Plaintiff with generalized anxiety disorder, and set out a treatment plan which included developing coping skills to decrease anxiety and depression, and to feel comfortable in social situations. (Id. at 422). The clinician assigned a GAF score of 61. (Id. ). As a result of the assessment, Plaintiff agreed to meet for therapy on a weekly or bi-weekly basis, but refused ...