Court Opinion

ID: 9378984
Source: CourtListenerOpinion
Date Created: 2023-03-14 14:00:27.091303+00
Date Added: 2024-06-11T17:16:28.331314
License: Public Domain

21-1935-cv
     Krystal Rivers v. Kilolo Kijakazi

                                  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.

 1           At a stated term of the United States Court of Appeals for the Second Circuit, held at the
 2   Thurgood Marshall United States Courthouse, 40 Foley Square, in the City of New York, on the
 3   14th day of March, two thousand twenty-three.
 4
 5   Present:
 6               JOHN M. WALKER, JR.,
 7               BARRINGTON D. PARKER, JR.,
 8               EUNICE C. LEE,
 9                     Circuit Judges.
10   _____________________________________
11
12   KRYSTAL RIVERS,
13
14                              Plaintiff-Appellant,
15
16                     v.                                                      21-1935-cv
17
18   KILOLO KIJAKAZI, Acting Commissioner
19   of Social Security,
20
21                     Defendant-Appellee.
22   _______________________________
23
24   For Plaintiff-Appellant:                          MARK SCHNEIDER,
25                                                     Plattsburgh, NY.
26
27   For Defendant-Appellee:                           CANDACE H. LAWRENCE, Special Assistant United
28                                                     States Attorney (Michael J. Pelgro, Regional Chief
29                                                     Counsel – Region I, Office of the General Counsel of
30                                                     the Social Security Administration, on the brief), for

                                                            1
 1                                                Carla B. Freedman, United States Attorney for the
 2                                                Northern District of New York, Boston, MA.

 3           Appeal from the United States District Court for the Northern District of New York

 4   (Lovric, M.J.).

 5           UPON DUE CONSIDERATION, IT IS HEREBY ORDERED, ADJUDGED, AND

 6   DECREED that the judgment of the district court is VACATED AND REMANDED.

 7           Plaintiff-Appellant Krystal Rivers filed an application pro se for Supplemental Security

 8   Income (“SSI”) on October 4, 2016, based on a claimed limited ability to work due to a spinal

 9   injury and mental health issues—including a substance abuse disorder, depression, and anxiety.

10   After her claim was initially denied, Rivers appealed and the matter was assigned to an

11   administrative law judge (“ALJ”). Although the ALJ found that Rivers had severe impairments

12   that significantly limited her ability to perform basic work activities, he ruled against her,

13   reasoning that the medical records before him showed that Rivers was able to work sufficiently

14   and thus was not disabled in a manner that qualified her for SSI.     Rivers filed suit in district court

15   against the Commissioner of Social Security, challenging the ALJ’s decision, and the United States

16   Magistrate Judge assigned to the matter affirmed the ALJ’s decision. We assume the parties’

17   familiarity with the underlying facts, procedural history, and issues and arguments on appeal.

18           On review of a “denial of Social Security benefits, our focus is not so much on the district

19   court’s ruling as it is on the administrative ruling.”   Brault v. Soc. Sec. Admin., Comm’r, 683 F.3d

20   443, 447 (2d Cir. 2012) (internal quotation marks omitted). “[I]t is not our function to determine

21   de novo whether a plaintiff is disabled.”     Id. (alteration marks omitted). Rather, “we conduct a

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

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

24   standards have been applied.”       Moran v. Astrue, 569 F.3d 108, 112 (2d Cir. 2009) (internal

                                                         2
 1   quotation marks omitted).

 2            Rivers argues that the ALJ failed to adequately develop the administrative record. We

 3   agree.

 4            “[W]here there are deficiencies in the record, an ALJ is under an affirmative obligation to

 5   develop a claimant’s medical history even when the claimant is represented by counsel or by a

 6   paralegal.” Rosa v. Callahan, 168 F.3d 72, 79 (2d Cir. 1999) (alterations and internal quotation

 7   marks omitted).     The ALJ’s duty to develop the record reflects “the essentially non-adversarial

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

 9   quotation marks omitted).     Where, as here, the claimant proceeds pro se, “the ALJ’s duties are

10   heightened.”     Moran, 569 F.3d at 113 (internal quotation marks omitted).           “The ALJ must

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

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

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

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

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

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

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

18   See id. at 79–80.

19            For claims filed prior to March 27, 2017, like this one, the ALJ’s findings of fact are

20   constrained by “the treating physician rule.”     Colgan v. Kijakazi, 22 F.4th 353, 359 & 359 n.2

21   (2d Cir. 2022) (citing 20 C.F.R. § 404.1527(c)(2)).        “The treating physician rule, as its name

22   connotes, states that the medical opinion of a claimant’s treating physician must be given

23   ‘controlling weight’ if it ‘is well-supported by medically acceptable clinical and laboratory

                                                        3
 1   diagnostic techniques and is not inconsistent with the other substantial evidence in the case

 2   record.’”   Id. at 359–60 (quoting Estrella v. Berryhill, 925 F.3d 90, 95 (2d Cir. 2019)).

 3          Here, the ALJ was on notice that Rivers had three treating physicians who had treated her

 4   for her spinal injury and back pain, and that Rivers had seen one of the three, Dr. Bonnabesse, as

 5   recently as a few weeks prior to her 2019 hearing before the ALJ.      The ALJ, however, did not

 6   contact any of these treating physicians for their medical opinion on the extent to which Rivers’s

 7   spinal injury impacted her ability to function. This failure to develop the record is legal error.

 8   Moran, 569 F.3d at 113.     Indeed, the ALJ had before him a 2014 report from Dr. Bonnabesse

 9   stating that Rivers was “classified with a 75% temporary marked partial disability with

10   restrictions” on her ability to move, Special App’x 16, and he knew that Dr. Bonnabesse had

11   thought Rivers’s condition had only gotten worse:     Rivers testified that Dr. Bonnabesse advised

12   her to apply for SSI because, after a recommended spinal surgery increased her back pain, he told

13   her that he did not know what else he could do to help her. Under these circumstances, the ALJ

14   should have contacted Dr. Bonnabesse for his opinion on the extent to which Rivers’s back pain

15   impeded her ability to work.   See Moran, 593 F.3d at 113; see also, e.g., Guillen v. Berryhill, 697

16   F. App’x 107, 108–09 (2d Cir. 2017) (vacating denial of SSI where ALJ “failed to obtain a medical

17   source statement from [pro se claimant]’s treating physician, or to encourage [pro se claimant] to

18   do so herself,” where the medical records did not opine on how claimant’s “impairments affect or

19   do not affect her ability to work”); Umansky v. Apfel, 7 F. App’x 124, 127 (2d Cir. 2001) (vacating

20   and remanding for failure “to develop the record” with material on “residual functional capacity”

21   because “the ALJ should have contacted” the clinic where pro se claimant had been treated).

22          Furthermore, in reviewing an ALJ’s findings, we assess whether “substantial evidence lies

23   in support of the ALJ’s determination.”    Colgan, 22 F.4th at 359.    “[T]he substantial evidence

                                                      4
 1   standard is also not merely hortatory: It requires relevant evidence which would lead a ‘reasonable

 2   mind’ to concur in the ALJ’s factual determinations.”    Id. (quoting McIntyre v. Colvin, 758 F.3d

 3   146, 149 (2d Cir. 2014)).    We take this approach in assessing how an ALJ considers “internal

 4   inconsistencies” in the medical records before him.   See id. at 362.   Here, the ALJ’s rejection of

 5   Rivers’s disability claim appears to rely in large part on an internally inconsistent report from a

 6   consulting physician hired by the Social Security Administration to assess Rivers’s functional

 7   capacity. The consulting physician’s report says Rivers “was unable to stand and walk on heels

 8   and toes.   She was unable to squat. Can walk on heels and toes without difficulty. Squat full.”

 9   Record on Appeal 1255.      Despite this plain contradiction, the ALJ gave this “opinion . . . some

10   weight” and read it as supporting the conclusion that Rivers is “less restricted” by her disability

11   because it found she “was able to walk on heels and toes.”   Special App’x 17.    The ALJ provides

12   no explanation of why he gave preference to the part of the report cutting against Rivers’s claim

13   over the preceding sentences that would support her claim.         Faced with such an obviously

14   contradictory medical opinion like this, the ALJ should have either sought clarification from the

15   consulting physician or, at minimum, given a cogent explanation in support of his reading of the

16   opinion.

17          Finally, an “ALJ cannot arbitrarily substitute his own judgment for competent medical

18   opinion.” Rosa, 168 F.3d at 79 (internal quotation marks omitted); see also Gavazzi v. Berryhill,

19   687 F. App’x 98, 100 (2d Cir. 2017) (citing Rosa and vacating and remanding).        Here, the ALJ

20   did just that, as his rejection of Rivers’s claimed impairments relies heavily on what he viewed as

21   her “ability to perform . . . adequate activities of daily living,” including caring “for two small

22   children,” as well as his view that “claimant has not generally received the type of medical

23   treatment for her alleged back pain one would expect for a totally disabled individual.”    Record

                                                      5
1    on Appeal 23.      This is legal error. The ALJ had no competent medical opinion before him on

 2   “the type of medical treatment . . . one would expect” of someone in Rivers’s claimed situation.

 3   And the claim about Rivers’s “daily living” is an oddity:     There is nothing inconsistent between

 4   her claim of debilitating back pain and her taking care of her children, especially given that she

 5   told the ALJ she “receive[s] assistance with childcare on a daily basis from her father, his girlfriend

 6   and [her] aunt.”    Id. at 16.   Furthermore, the ALJ’s conclusion is at odds with the evidence that

 7   Rivers’s medical condition impedes her ability to care for her family, such as how she cannot lift

 8   her three-year-old child above her head.

 9                                                     ***

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

11   REMANDED to the district court with instructions to remand the matter to the Commissioner for

12   further proceedings consistent with this order.    In particular, the Commissioner should attempt to

13   further develop the administrative record regarding Rivers’s functional capacity.

14                                                           FOR THE COURT:
15                                                           Catherine O’Hagan Wolfe, Clerk

                                                        6