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16-3421 

Guillen v. Berryhill

 

UNITED STATES COURT OF APPEALS 

FOR THE SECOND CIRCUIT 

SUMMARY ORDER 

RULINGS BY SUMMARY ORDER DO NOT HAVE PRECEDENTIAL EFFECT. CITATION TO A 

SUMMARY ORDER FILED ON OR AFTER JANUARY 1, 2007, IS PERMITTED AND IS GOVERNED 

BY FEDERAL RULE OF APPELLATE PROCEDURE 32.1 AND THIS COURT’S LOCAL RULE 32.1.1. 

WHEN CITING A SUMMARY ORDER IN A DOCUMENT FILED WITH THIS COURT, A PARTY 

MUST CITE EITHER THE FEDERAL APPENDIX OR AN ELECTRONIC DATABASE (WITH THE 

NOTATION “SUMMARY ORDER”). A PARTY CITING A SUMMARY ORDER MUST SERVE A COPY 

OF IT ON ANY PARTY NOT REPRESENTED BY COUNSEL. 

 At a stated Term of the United States Court of Appeals for the Second Circuit, held at the 

Thurgood Marshall United States Courthouse, 40 Foley Square, in the City of New York on the 

27th day of September, two thousand seventeen. 

Present: JON O. NEWMAN, 

 GUIDO CALABRESI, 

 ROSEMARY S. POOLER, 

 Circuit Judges. 

_____________________________________________________ 

KAREN M. GUILLEN, 

 Plaintiff-Appellant, 

 v. 16-3421 

NANCY A. BERRYHILL1

, ACTING COMMISSIONER 

OF SOCIAL SECURITY, 

 Defendant-Appellee. 

_____________________________________________________ 

 

Appearing for Appellant: Carolyn A. Kubitschek, Lansner & Kubitschek, New York, N.Y. 

Appearing for Appellee: Rebecca H. Estelle, Special Assistant U.S. Attorney (Marc H. 

Silverman, Assistant United States Attorney, on the brief), for

Deirdre M. Daly, United States Attorney for the District of 

Connecticut, New Haven, CT 

 

1 Nancy A. Berryhill is automatically substituted as the respondent in this case pursuant to 

Federal Rule of Appellate Procedure 43(c)(2). 
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Appeal from the United States District Court for the District of Connecticut (Covello, J.). 

ON CONSIDERATION WHEREOF, IT IS HEREBY ORDERED, ADJUDGED, 

AND DECREED that the judgment of said District Court be and it hereby is VACATED and 

REMANDED. 

 Karen M. Guillen appeals from the August 31, 2016 judgment of the United States 

District Court for the District of Connecticut denying her motion to reverse or remand the 

decision of the Commissioner of the Social Security Administration denying her applications for 

supplemental security income benefits and supplemental security income benefits and granting 

the motion of the Commissioner for an order affirming her decision. We assume the parties’ 

familiarity with the underlying facts, procedural history, and specification of issues for review. 

When this Court reviews the Commissioner’s denial of Social Security benefits, “our 

focus is not so much on the district court’s ruling as it is on the administrative ruling.” Brault v. 

Soc. Sec. Admin., Comm’r, 683 F.3d 443, 447 (2d Cir. 2012) (citation omitted). “[I]t is not our 

function to determine de novo whether a plaintiff is disabled.” Id. Rather, “‘we conduct a plenary 

review of the administrative record to determine if there is substantial evidence, considering the 

record as a whole, to support the Commissioner’s decision and if the correct legal standards have 

been applied.’” Id. (quoting Moran v. Astrue, 569 F.3d 108, 112 (2d Cir. 2009)). 

Guillen argues that the administrative law judge failed to adequately develop the record 

below. We agree. “[W]here there are deficiencies in the record, an ALJ is under an affirmative 

obligation to develop a claimant’s medical history even when the claimant is represented by 

counsel or by a paralegal.” Rosa v. Callahan, 168 F.3d 72, 79 (2d Cir.1999) (internal alterations 

and quotation marks omitted). The ALJ’s duty to develop the record reflects “the essentially 

non-adversarial nature of a benefits proceeding.” Pratts v. Chater, 94 F.3d 34, 37 (2d Cir. 1996). 

Where, as here, the claimant proceeds pro se, “the ALJ’s duties are heightened.” Moran v. 

Astrue, 569 F.3d 108, 113 (2d Cir. 2009) (internal quotation marks omitted). “The ALJ must 

adequately protect a pro se claimant’s rights by ensuring that all of the relevant facts are 

sufficiently developed and considered and by scrupulously and conscientiously probing into, 

inquiring of, and exploring for all the relevant facts.” Id. (internal quotation marks and brackets 

omitted). However, “where there are no obvious gaps in the administrative record, and where the 

ALJ already possesses a complete medical history, the ALJ is under no obligation to seek 

additional information in advance of rejecting a benefits claim.” Rosa, 168 F.3d at 79 n.5 

(internal quotation marks omitted). An ALJ’s failure to develop the record warrants remand. See 

id. at 79–80. 

 Here, the ALJ failed to obtain a medical source statement from Guillen’s treating 

physician, or to encourage Guillen to do so herself. The Commissioner argues such a statement 

was twice requested but never received, and that in any event, remand for a treating physician’s 

report “is not always required when an ALJ fails in his duty to request opinions, particularly 

where . . . the record contains sufficient evidence from which an ALJ can assess the petitioner’s 

residual functional capacity.” Tankisi v. Comm’r of Soc. Sec., 521 Fed. App’x 29, 34 (2d Cir. 

2013). Unlike Tankisi, the medical records obtained by the ALJ do not shed any light on 

Guillen’s residual functional capacity, and the consulting doctors did not personally evaluate 
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Guillen. The medical records discuss her illnesses and suggest treatment for them, but offer no 

insight into how her impairments affect or do not affect her ability to work, or her ability to 

undertake her activities of everyday life. The ALJ relied on this absence when noting that “no 

physician has opined that the claimant is disabled.” Admin. R. at 14. As Guillen argues, it is, at 

a minimum, unclear from the record whether Guillen’s treating physician understood that the 

ALJ was seeking an answer to that question. Indeed, it is unclear from the record that such a 

request was even made. 

 The ALJ also improperly rejected the treating physician’s diagnosis of lupus. The ALJ 

states that “while this diagnosis was noted as a possibility, the medical record contains no formal 

diagnosis or treatment for this impairment.” Admin. R. at 12. This statement is at odds with the 

diagnosis of lupus set forth in the medical records provided by the treating physician. It is wellsettled that “the opinion of a claimant’s treating physician as to the nature and severity of the 

impairment is given controlling weight so long as it is well-supported by medically acceptable 

clinical and laboratory diagnostic techniques and is not inconsistent with the other substantial 

evidence in the case record.” Burgess v. Astrue, 537 F.3d 117, 128 (2d Cir. 2008) (internal 

quotation marks and brackets omitted). Further, given “the ALJ’s affirmative duty to develop the 

administrative record, an ALJ cannot reject a treating physician’s diagnosis without first 

attempting to fill any clear gaps in the administrative record,” id., and then proceeding to 

“carefully weigh” that record. Id. (internal quotation marks omitted). 

 We thus vacate the decision of the district court and remand to the district court with 

instructions to remand the matter to the Commissioner for further proceedings consistent with 

this order, including directing the Commissioner to (1) provide a new administrative law judge to 

consider Guillen’s application; (2) request a medical source statement from Guillen’s treating 

physician, including an assessment of Guillen’s limitations vis-à-vis her ability to work; as well 

as a clarification of the putative lupus diagnosis; (3) allow Guillen to supplement the record with 

any additional relevant medical records; (4) reassess Guillen’s credibility in light of any newly 

obtained relevant information; (5) reassess Guillen’s residual functional capacity in light of the 

expanded record; and (6) if warranted by the expanded record, obtain evidence from a vocational 

expert to clarify the effect of the assessed limitations on the claimant’s occupational choices. 

Accordingly, the judgment of the district court hereby is VACATED and this matter 

REMANDED for further proceedings consistent with this order. 

 FOR THE COURT: 

 Catherine O’Hagan Wolfe, Clerk