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Ruberti v. Commissioner of Social Security

United States District Court, D. New Jersey

December 19, 2017


          Lauren S. Tovinsky, Esq., JACOBS SCHWALBE & PETRUZELLI PC, Attorney for Plaintiff

          Evelyn Rose Marie Protano Special Assistant U.S. Attorney SOCIAL SECURITY ADMINISTRATION Office of the General Counsel Attorney for Defendant


          HON. JEROME B. SIMANDLE, District Judge


         This matter comes before this Court pursuant to 42 U.S.C. § 405(g) for review of the final decision of the Commissioner of the Social Security Administration (“SSA”) denying Plaintiff Carrie Ruberti's (“Plaintiff”) application for disability benefits under Title XVI of the Social Security Act, 42 U.S.C. § 401, et seq. Plaintiff, who allegedly suffers from major depressive disorder, an anxiety related disorder, irritable bowel syndrome, headaches, and hypertension, was denied benefits for the period beginning on September 1, 2009, the alleged onset date of disability, to July 29, 2016, the date on which the Administrative Law Judge (“ALJ”) issued a written decision.

         In the pending appeal, Plaintiff argues that the ALJ's decision must be reversed and remanded on three grounds. To that end, Plaintiff contends that the ALJ erred by: (1) failing to properly weigh the medical evidence of record or explain medical evidence she dismissed, including the opinion of Plaintiff's treating physician, Dr. Kaczaj; (2) failing to take into account all of Plaintiff's medically determinable impairments; and (3) improperly discounting Plaintiff's testimony. For the reasons stated below, the Court will vacate the decision of the ALJ and remand for further proceedings consistent with this Opinion.


         A. Procedural History

         Plaintiff filed her application for Social Security disability benefits on February 23, 2013, alleging an onset date of September 1, 2009. (R. at 23.) Plaintiff's claim was denied by the Social Security Administration on July 3, 2013. (R. at 20.) Her claim was again denied upon reconsideration on April 3, 2014. (R. at 20.) Plaintiff next testified in person before ALJ Marguerite Toland on November 17, 2015. (R. at 20.) ALJ Toland issued an opinion on July 29, 2016, denying Plaintiff benefits. (R. at 32.) On November 9, 2016, the Appeals Council denied Plaintiff's request for review. (R. at 1.) This appeal timely follows.

         B. Medical History

         The following are facts relevant to the present motion. Plaintiff was 55 years old as of the date of the ALJ Decision. (R. at 226.) Plaintiff graduated from high school and earned 72 college credits. (R. at 30, 47.) She received her certification to become a nurse's aide and worked as a nurse's aide until 2002. (R. at 49-50.) Plaintiff last worked as the Assistant Director of a daycare until September 27, 2009, when she was let go following a disagreement with the daycare's owner. (R. at 50, 229.) Plaintiff currently lives in her daughter's home with her husband, daughter, son-in-law, and four grandchildren. (R. at 75-76.)

         1. Medical Treatment Prior to Alleged Disability

         On April 27, 2003, Plaintiff voluntarily admitted herself into Hampton Behavioral Health Center after reportedly feeling overwhelmed by depression, insomnia, and suicidal ideation. (R. at 289.) Once she was admitted, Plaintiff was diagnosed with and treated for major depressive disorder and irritable bowel syndrome, and assigned a Global Assessment of Functioning (“GAF”)[1] score of 20. (R. at 291-92.) By April 30, 2003, Plaintiff was no longer having suicidal ideation and was otherwise in an improved condition. (R. at 291.) When Plaintiff was discharged on May 1, 2003 she was assigned a GAF of 50. (R. at 291-92.)

         On July 15, 2009, Plaintiff was treated at South Jersey Healthcare for abdominal pain. (R. at 355.) An abdominal CT revealed a small cyst in Plaintiff's kidney and small fibroids in her uterus, but no acute inflammatory processes were seen involving her bowel and there was no evidence of free intraperitoneal air or fluid. (R. at 369-70.) On August 10, 2009, Plaintiff met with Dr. Malogorzata Connelly, again complaining of abdominal pain. (R. at 593.) Dr. Connelly performed an EKG on Plaintiff at this time. (R. at 593.)

         On August 26, 2009, Dr. Jonathan Gewirtz treated Plaintiff for abdominal and pelvic pain, observing that she had a tender abdomen and enlarged right ovary. (R. at 383.) Dr. Gewirtz recommended that Plaintiff undergo a total abdominal hysterectomy and bilateral salpingo-oophorectomy. (R. at 383.)

         2. Impairments During Period of Alleged Disability[2]

         On September 2, 2009, Plaintiff underwent a total abdominal hysterectomy at South Jersey Healthcare. (R. at 381.) Treatment notes at this time indicated Plaintiff had a history of irritable bowel syndrome. (R. at 384, 387.)

         Between September 16, 2009 and December 7, 2011, Plaintiff met with Dr. Connolly several times regarding continued abdominal pain. (R. at 578-82, 593.) Notably, on October 6, 2009, Plaintiff reported that her irritable bowel syndrome is “severe - never goes away” and that she had “constipation/ diarrhea on fiber.” (R. at 582.) On December 10, 2010, Plaintiff told Dr. Connolly she “can't find [a] job” and that, with regard to the irritable bowel syndrome she “feels like [she is] ready to pop!” (R. at 581.) On June 9, 2011, Plaintiff reported that her irritable bowel syndrome had gotten worse. (R. at 579.) Each time she met with Dr. Connolly, Plaintiff also reported depression and anxiety. (R. at 578-82.)

         On May 9, 2012, Plaintiff went to the emergency room with an “altered mental status.” (R. at 495.) Plaintiff's daughter explained to the treating physician that, when Plaintiff had called in the morning, she seemed confused and her speech “wasn't right.” (R. at 495.) Plaintiff was diagnosed with psychosis and eventually transferred from the hospital to Bridgeton Crisis for a psychiatric consult. (R. at 506-07.)

         On May 12, 2012, Plaintiff returned to the hospital due to anxiety. (R. at 404.) Her examination showed she had an “anxiety reaction” and urinary tract infection. (R. at 404.) The treating physician noted that Plaintiff's symptoms had “markedly improved after treatment.” (R. at 506.) When offered the opportunity to transfer to Bridgeton Crisis for a psychological evaluation, Plaintiff said she was feeling better and wanted to go home. (R. at 406.)

         Unfortunately, on May 19, 2012, Plaintiff had a third psychiatric emergency and was again hospitalized at South Jersey Healthcare for “severe anxiety.” (R. at 401.) Dr. Cathy Larrain observed that Plaintiff “presents with episode of acute psychosis as well as continued generalized anxiety disorder, ” and recommended that Plaintiff follow up for a psychiatry evaluation. (R. at 402-03.) The following day, Plaintiff consulted with Dr. Rajalla Prewitt, who upon evaluation, prescribed Plaintiff with Klonopin and recommended that she follow-up with the Brigeton IOP program and social services. (R. at 461-62.)

         On June 19, 2012, Plaintiff started treatments at the South Jersey Healthcare Behavior Wellness Center. (R. at 436.) At the initial consult, Plaintiff reported: “I am severely depressed. I don't like to leave the house anymore. I have anxiety of all social events & just want to hide. I am sad all the time, cry often, & am upset of my employment status.” (R. at 451.) Plaintiff then attended six therapy sessions and two medication sessions between June 26, 2012 and December 29, 2012 (R. at 437-450.) On December 29, 2012, Plaintiff was discharged from further tratments due to noncompliance. (R. at 436.)

         3. Primary Care Physician Treatment

         Since at least June 5, 2012, Plaintiff treated with her primary care physician, Dr. Olga Kaczaj. (R. at 419.) On January 25, 2013, Plaintiff met with Dr. Kaczaj and requested a letter to “confirm that [Plaintiff] is unable to work.” (R. at 417.) At this time, Dr. Kaczaj noted that Plaintiff “is very depressed” and “sometimes does [sic] wanna leave the house, also has headaches in the back of head for a while now.” (R. at 417.) On December 17, 2013, Dr. Kaczaj diagnosed Plaintiff as having “depression with anxiety.” (R. at 565.)

         On December 18, 2013, Dr. Kaczaj completed a check-list “Mental Assessment Form” on Plaintiff's behalf. (R. at 517-21.) Under the “Making Occupational Adjustments” section of the form, Dr. Kaczaj checked “Poor/None” in all of the spaces representing Plaintiff's ability to adjust to a job. (R. at 517-18.) Dr. Kaczaj further observed that Plaintiff is “unable to work in any work environment, fulfill any tasks . . . due to ongoing anxiety/depression; [and] has panic attacks, difficulty concentrating, forgetful, ‘moody.'” (R. at 518.) Under the “Making Performance Adjustments” portion of the form, Dr. Kaczaj checked “Poor/Fair” for complex job instructions and detailed, but not complex job instructions and “Good” for simple job instructions. (R. at 518.) In the “Making Personal-Social Adjustments” section, Dr. Kaczaj checked “Good” for Plaintiff's ability to maintain her personal appearance, “Fair” for her ability to behave in an emotionally stable manner and understand simple job instructions, and “Poor/None” for Plaintiff's ability to demonstrate reliability. (R. at 519.) Dr. Kaczaj also observed that Plaintiff has “difficulty getting along [with] coworkers due to irritability.” (R. at 519.) Dr. Kaczaj rated the impairments and limitations Plaintiff experienced as “Moderately Severe, ” except he rated Plaintiff's estimated degree of deterioration in personal habits as “Moderate” and Plaintiff's ability to perform competitive tasks as “severe.” (R. at 520-21.) Finally, Dr. Kaczaj opined that Plaintiff was “unable to maintain employment.” (R. at 521.)

         On October 2, 2014, Dr. Kaczaj met with Plaintiff and, again, diagnosed her with “depression with anxiety.” (R. at 564.) During a routine check up on June 5, 2015, Dr. Kaczaj diagnosed Plaintiff with “major depressive disorder, severe” and “anxiety disorder, generalized.” (R. at 563.) On September 22, 2015, Dr. ...

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