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Dejesus v. Colvin

United States District Court, Third Circuit

January 10, 2014

SONIA DEJESUS, Plaintiff
v.
CAROLYN W. COLVIN, Acting Comm'r of Soc. Sec., Defendant

MEMORANDUM

SYLVIA H. RAMBO, District Judge.

In this appeal from a decision of the Commissioner of Social Security denying Disability Insurance Benefits, Plaintiff claims the administrative decision concluding that she has not been under a disability as defined by the Social Security Act is not supported by substantial evidence and contains errors of law. For the following reasons, the court will affirm the decision of the Commissioner.

I. Background

A. Procedural History

On July 18, 2006, Plaintiff, Sonia DeJesus, protectively filed applications for Disability Insurance Benefits ("DIB") under Title II of the Social Security Act. ( See Doc. 8-5, p. 4 of 31.) Plaintiff claimed disability beginning on January 1, 2003. ( Id. ) The Social Security Administration initially denied Plaintiff's application by decision dated September 27, 2006. (Doc. 8-4, p. 4 of 118.) On November 12, 2006, Plaintiff requested a hearing before an Administrative Law Judge ("ALJ"). ( Id. at p. 9 of 118.) ALJ George Yatron held a hearing on February 27, 2008, at which Plaintiff and Daniel M. Rapucchi, a vocational expert, testified. (Doc. 8-2, pp. 40-70 of 104.) ALJ Yatron issued an unfavorable decision to Plaintiff on April 25, 2008 (Doc. 8-3, pp. 19-28 of 33), and Plaintiff filed an appeal with the Appeals Council on June 13, 2008 (Doc. 8-4, pp. 25-27 of 118).

While the claim was pending on appeal, Plaintiff filed another application for DIB on May 8, 2009. ( See Doc. 8-5, pp. 23-31 of 31.) In this application, Plaintiff claimed disability beginning on April 26, 2008. ( Id. at p. 25 of 31.) The Social Security Administration initially denied this second application by decision dated July 2, 2010. (Doc. 8-4, pp. 105-09 of 118.) On July 8, 2010, Plaintiff requested another hearing before an ALJ. ( Id. at pp. 117-18 of 118.) The Appeals Council remanded the first claim, and directed the ALJ to adequately consider Plaintiff's maximum residual functional capacity during the entire period at issue, and, in so doing, to evaluate the opinion of Plaintiff's treating psychiatrist. (Doc. 8-3, pp. 30-31 of 33.) The Appeals Council further directed the first and second claims be consolidated. ( Id. )

On January 5, 2011, ALJ Yatron held a second hearing on the consolidated action, at which time both Plaintiff and Patricia Scott, an impartial vocational expert, testified. ( See Doc. 8-2, pp. 71-106 of 106.) The ALJ denied the consolidated action in its entirety on March 10, 2011 ( Id. at pp. 21-32 of 106), and Plaintiff filed an unsuccessful appeal with the Appeals Council ( Id. at p. 18 of 106). The Appeals Council denied Plaintiff's request on September 21, 2012 ( Id . at p. 2 of 106), and Plaintiff commenced the instant action on November 20, 2012 (Doc. 1).

B. Plaintiff's General Background

Plaintiff is a citizen of the United States, and was born on September 18, 1971 (Doc. 8-5, p. 25 of 31), and, at all times relevant to this matter, was considered a "younger individual, "[1] whose age would not seriously impact her ability to adjust to other work. 20 C.F.R. ยง 404.1563(c). Plaintiff completed secondary school and is able to communicate in English. (Doc. 8-2, p. 44 of 106.) As of the date of the hearings, Plaintiff was approximately five feet and four inches tall, and weighed 225 pounds as of the first hearing, and 178 pounds as of the second hearing.[2] (Doc. 8-2, pp. 43, 76 of 106.) Plaintiff lived with her five children, four of whom were considered minors as of the date of the second hearing. ( Id. at p. 76 of 106.) Plaintiff had prior relevant work experience as a hand packager, in which capacity she was last employed in 2002, and housekeeper, in which capacity she was last employed in 2004. ( Id . at pp. 46 of 106.)

C. Medical Records

The gravamen of Plaintiff's instant action is the ALJ's assessment of her psychological impairments. ( See Doc. 13, pp. 5-11 of 14.) Nevertheless, the record contains evidence concerning Plaintiff's physical medical conditions, and demonstrates Plaintiff has several physical impairments.

1. Physical Impairments

Plaintiff received treatment by her primary care physician for various physical ailments, including gastroesophageal reflux disease, obesity, osteoarthritis, fibromyalgia, and cold/exercise-induced asthma. ( See Doc. 8-7, p. 152 of 177.) Plaintiff was advised that losing weight could help her physical ailments, and exercising and altering her diet caused a decrease in her weight. ( Id. at p. 173 of 177.) Plaintiff also suffered discomfort due to the weight of her breasts ( Id. at p. 151 of 177), and was evaluated for a breast reduction surgery in 2006 ( See id. at p. 5 of 177). Dr. Thomas Dibenedetto determined that Plaintiff did not have any musculoskeletal reason for her experiencing pain in her back apart from her over-sized breasts. ( Id .)

In 2009, Plaintiff sought medical attention for chronic intermittent pain in her hands, elbows, back, and knees. (Doc. 8-9, p. 67 of 95.) Plaintiff was diagnosed with having fibromyalgia by her primary care physician. ( Id . at pp. 66-67 of 95.) Plaintiff's rhematologic laboratory test results were negative, and Plaintiff was prescribed several medications to assist with the pain. ( Id . at p. 66 of 95.)

2. Psychological Impairments

With regard to Plaintiff's mental health issues, records show that Plaintiff was evaluated in early 2005, and diagnosed as having a major depressive affective disorder, recurrent without psychotic features. ( See Doc. 8-7, p. 123 of 177.) Plaintiff saw John Illingworth, LCSW, and Heather Zettlemoyer, LSW, for individual psychological therapy from February 2005 through August 2008. ( See generally id. at p. 123 of 177; Doc. 8-9, pp. 78-83 of 95.) During these sessions, Plaintiff's therapists generally noted that Plaintiff had a depressed mood and occasionally reported feeling anxious. (Doc. 8-7, p. 46 of 177.) Plaintiff had an inconsistent history of attending therapy sessions, and frequently cancelled scheduled appointments. ( See, e.g. , id. at pp. 51, 73 of 177.)

Plaintiff was treated by Dr. Kishorkumar Dedania, M.D., and Jennifer Morrison, PA-C, for medication management between May 2005 and April 2009. ( See generally Doc. 8-7, p. 118 of 177; Doc. 8-9, p. 88 of 95.) Plaintiff continually reported feeling depressed, anxious, and stressed, and attributed these feelings to her having five children whom she raises herself. ( See, e.g. , Doc. 8-9, p. 89 of 95.) During the course of treatment, Dr. Dedania prescribed various medications, including Xanax, Abilify, and antidepressants, such as Zoloft, Wellbutrin, and Effexor. ( See, e.g. , Doc. 8-9, p. 92 of 95.) Although Plaintiff reported that, while on medication, she was doing much better and experienced less depression and anxiety ( see, e.g. , Doc. 8-8, p. 13 of 42 ("[Plaintiff] stated that she's less depressed and less anxious as long as she takes her medication."), Plaintiff inconsistently took the medication ( see, e.g. , Doc. 8-7, p. 78 ("Taking Xanax infrequently."), 79 ("Stated that she stopped taking Zoloft and Abilify because of the weight problems and now she's been having more mood swings and depression.") of 177).

Plaintiff was examined by Dr. Dedania on April 18, 2006, January 17, 2008, and April 7, 2009, for annual psychiatric evaluations. (Doc. 8-7, p. 79 of 177; Doc. 8-8, p. 38 of 42; Doc. 8-9, p. 93 of 95.) On April 18, 2006, Dr. Dedania reported that Plaintiff had an anxious mood and complained about feeling depressed, which was in part attributed to Plaintiff's unilateral decision to stop taking medications. (Doc. 8-7, p. 79 of 177.) Dr. Dedania further reported that Plaintiff was appropriately dressed and groomed, maintained good eye contact, had intact attention, concentration, and memory, had an appropriate affect, had average intellectual functioning, and had fair judgment and insight. ( Id. ) At this time, Dr. Dedania reported Plaintiff had a global assessment functioning score of 46, and again diagnosed Plaintiff as having major depression, without psychotic features, and noted that financial concerns were Plaintiff's Axis IV psycho-social and environmental problems. ( Id .)

On January 17, 2008, Dr. Dedania reported that Plaintiff had an anxious mood and was still mildly depressed. (Doc. 8-8, p. 38 of 42.) Dr. Dedania further reported that Plaintiff was cooperative, alert, oriented, appropriately dressed and groomed, had a fairly intact attention and concentration, and fair memory, intellectual functioning, judgment, and insight. ( Id .) At this time, Dr. Dedania reported Plaintiff had a global assessment functioning score of 48, diagnosed Plaintiff as having major depression, without psychotic features, and an anxiety disorder not otherwise specified, and noted that financial and family concerns were Plaintiff's Axis IV psycho-social and environmental problems. ( Id .)

On April 7, 2009, Dr. Dedania reported that Plaintiff had an anxious mood and was still mildly depressed. (Doc. 8-9, p. 93 of 95.) Dr. Dedania further reported that Plaintiff was cooperative, alert, oriented, appropriately dressed and groomed, had intact concentration and attention, and fair memory, intellectual functioning, judgment, and insight. ( Id .) At this time, Dr. Dedania reported Plaintiff had a global assessment functioning score of 48, diagnosed Plaintiff as having major depression, without psychotic features, and an anxiety disorder not otherwise specified, and again noted that financial and family concerns were Plaintiff's Axis IV psycho-social and environmental problems. ( Id .)

On February 2, 2007, Dr. Dedania completed a medical source statement. ( See generally Doc. 8-7, pp. 130-135 of 177.) According to Dr. Dedania's answers, she diagnosed Plaintiff with major depression. ( Id . at p. 130 of 177.) Moreover, Dr. Dedania identified Plaintiff as having poor memory, sleep and mood disturbances, emotional lability, difficulty thinking or concentrating, decreased energy, generalized persistent anxiety, and somatization unexplained by organic disturbance. ( Id. ) Dr. Dedania opined that Plaintiff's impairments would cause her to be absent from work more than three times per month. ( Id . at p. 132 of 177.) He further opined that Plaintiff was seriously limited, but not precluded, in her ability to maintain attention for two hour segments, maintain regular attendance, sustain an ordinary routine without special supervision, work with others without being unduly distracted, make simple work related decisions, complete a normal workweek without interruptions, perform at a consistent pace without an unreasonable number and length of rest periods, ask simple questions or request assistance, accept instructions and respond appropriately to criticism from supervisors, get along with co-workers or peers without unduly distracting them or exhibiting behavioral extremes, respond appropriately to changes in a routine work setting, deal with normal work stress, be aware of normal hazards and take appropriate precautions. ( Id. at p. 133 of 177.) Dr. Dedania's explanation, including the medical and clinical findings that supported his assessment of the foregoing, was limited to a single word: "Depression." ( Id .) Dr. Dedania provided the same to explain his opinions that Plaintiff had a "fair" ability to: understand and remember detailed instructions, carry out detailed instructions, set realistic goals or make plans independently of others, deal with stress of semiskilled and skilled work, interact appropriately with the general public, maintain socially acceptable behavior, adhere to basic standards of neatness and cleanliness, travel in an unfamiliar place, and use public transportation. ( Id .) Indeed, Dr. Dedania failed to explain or identify the findings that supported his opinion that Plaintiff's suffering from depression would cause Plaintiff to be seriously limited in the abilities to do unskilled work. ( Id .)[3] However, Dr. Dedania opined that Plaintiff had a satisfactory ability to remember work-like procedures, and understand, remember, and carry out very short and simple instructions. ( Id .)

Dr. Dedania further opined that Plaintiff had marked limitations in activities of daily living, difficulties in maintaining social functioning, difficulties of concentration, persistence, or pace, and had three episodes of decompensation. ( Id . at p. 134 of 177.) On January 17, 2008, Dr. Dedania represented that Plaintiff's condition, symptoms, and limitations had not changed since February 27, 2007. ( Id. at p. 160 of 177.)

Dr. Sidney Segal, Ed.D., a state agency psychologist, performed an evaluation of Plaintiff as part of a review for the Social Security Administration on September 27, 2006, and completed a psychiatric review technique form and a mental residual functional capacity assessment. ( Id. at pp. 28-44 of 177.) Dr. Segal opined that Plaintiff had mild restriction of activities of daily living, mild difficulties in maintaining social functioning, moderate difficulties in maintaining concentration, persistence, or pace, and no episodes of decompensation. ( Id. at p. 38 of 177.) Dr. Segal also opined that Plaintiff's limitations were due to her physical pain rather than psychological problems. ( Id. at p. 40 of 177.) In assessing Plaintiff's RFC, Dr. Segal found Plaintiff to be, at most, moderately limited. ( Id . at pp. 41-42 of 177.) Specifically, Dr. Segal found that Plaintiff's ability to understand and remember detailed instructions, carry out detailed instructions, maintain attention and concentration for extended periods, complete a normal workweek without interruptions, perform at a consistent pace without unreasonable periods of rest, and ...


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