Burton-Mann v. Colvin
1:15-cv-07392
S.D.N.Y.Aug 13, 2016Background
- Plaintiff June Burton-Mann applied for Disability Insurance Benefits (DIB) alleging disability from April 1, 2008; ALJ denied benefits on August 22, 2014; Appeals Council denied review, making ALJ decision final.
- Medical records show diagnoses including hypertension, chronic lower back pain with L5–S1 radiculopathy, migraines, and recurrent major depressive disorder treated by psychiatrist Dr. Virginia Contreras (medication management, PHQ‑9 = 19 in Oct. 2013, GAF 45 earlier).
- Consultative examiners (Dr. Pelczar‑Wissner and Dr. Mahony) found no significant physical limitations and only moderate depressive symptoms; a state psychiatric consultant assessed mild-to-moderate functional limits but ability to perform basic unskilled/semi‑skilled work.
- Dr. Contreras completed a treating-source medical opinion indicating marked workplace limitations but left the supporting findings section incomplete; treatment notes include medication changes, periods off medication, reports of visual hallucinations, and authorization for home health aide assistance.
- ALJ found severe impairments of hypertension, headaches, and depression; assessed RFC for less than full range of light work; relied on VE to find jobs existed in the national economy and denied benefits.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether ALJ failed to develop the record regarding gaps in treating psychiatrist’s opinion | Burton‑Mann: ALJ had duty to obtain missing supporting information from Dr. Contreras before discounting her opinion | Commissioner: ALJ permissibly relied on existing record and consultative opinions without contacting treating psychiatrist | Court: ALJ erred by not exploring or obtaining clarification for omitted findings; remand required to develop record |
| Whether ALJ properly weighed treating psychiatrist Dr. Contreras’s opinion | Burton‑Mann: Treating opinion entitled to substantial/controlling weight or at least more consideration given supporting treatment notes and ongoing care | Commissioner: ALJ reasonably gave little weight due to initial nature of the assessment and apparent inconsistency with other treatment notes | Court: ALJ gave legally insufficient reasons; treating opinion should have received greater weight and ALJ should have resolved inconsistencies before rejecting it |
| Whether ALJ considered totality of impairments and medication side effects | Burton‑Mann: ALJ failed to account for combined effects and medication side effects on RFC | Commissioner: Not addressed in depth at district court level; argued record supported RFC | Court: Declined to reach merits; these issues may be considered on remand |
| Remedy — whether to remand or affirm | Burton‑Mann: Remand for further development and reassessment of treating opinion | Commissioner: Affirm administrative decision | Court: Vacated Commissioner’s decision and remanded for further proceedings consistent with opinion |
Key Cases Cited
- Richardson v. Perales, 402 U.S. 389 (1971) (standard for substantial evidence review)
- Echevarria v. Secretary of HHS, 685 F.2d 751 (2d Cir. 1982) (ALJ’s duty to develop record)
- Pratts v. Chater, 94 F.3d 34 (2d Cir. 1996) (Commissioner must develop complete medical record)
- Rosa v. Callahan, 168 F.3d 72 (2d Cir. 1999) (remand where ALJ failed to obtain treating records)
- Clark v. Comm’r of Soc. Sec., 143 F.3d 115 (2d Cir. 1998) (ALJ’s duty to develop record in SSI/DIB contexts)
- Butts v. Barnhart, 388 F.3d 377 (2d Cir. 2004) (remand appropriate when record inadequately developed)
- Burgess v. Astrue, 537 F.3d 117 (2d Cir. 2008) (five‑step disability evaluation framework)
- Shaw v. Chater, 221 F.3d 126 (2d Cir. 2000) (treating physician rule discussion)
- Diaz v. Shalala, 59 F.3d 307 (2d Cir. 1995) (definition of substantial evidence)
- Bauer v. Astrue, 532 F.3d 606 (7th Cir. 2008) (caution against over‑reliance on isolated improvement when chronic illness present)