Congdon v. Saul
5:19-cv-00432
N.D.N.Y.Apr 29, 2020Background
- Plaintiff (b. 1960) applied for DIB and SSI alleging disability from July 10, 2012; ALJ denied benefits and Appeals Council declined review; plaintiff sued.
- Alleged impairments: fibromyalgia, obesity, cervical degenerative disc disease/stenosis/radiculopathy, IBS, GERD, bipolar disorder/depression/anxiety, and history of C. diff (resolved 2012).
- Exam/medical sources: consultative exams by Drs. Lorensen and Noia; treating rheumatologist Dr. Bonilla-Trejos; NP Eleanor Klein; records include MRI showing multilevel cervical spondylosis/protrusion.
- ALJ’s findings: severe impairments included obesity, polyarthritis, fibromyalgia, degenerative joint disease and cervical disorders; RFC—medium work with limits (no ladders, occasional overhead reach, frequent stoop, occasional kneel/crouch/crawl, no unprotected heights).
- ALJ found plaintiff could perform past LPN/aid work; alternatively, VE testimony supported other jobs; ALJ gave little weight to Dr. Rahner.
- District Court applied deferential substantial-evidence review and granted defendant’s motion, affirming the Commissioner and dismissing plaintiff’s complaint.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Step Two severity of IBS and urinary issues | IBS, incontinence, and urgency are severe and required explicit findings | ALJ properly screened non-severe conditions; records show symptoms controlled/episodic | Court: ALJ’s non-severity findings supported; plaintiff failed to meet burden and any error harmless because RFC considered non-severe impairments |
| Treating-source status/weight of Dr. Rahner | Rahner is a treating source and his opinions (limits, absenteeism) deserve controlling weight | Rahner lacked an ongoing treating relationship in the record; opinions inconsistent with other evidence | Court: ALJ reasonably declined treating-source status and permissibly discounted his opinions as inconsistent |
| RFC adequacy—bathroom access and medium exertion | RFC failed to account for diarrhea/need for frequent bathroom breaks; no medical opinion supports medium RFC | RFC is supported by consultative exam (Dr. Lorensen), conservative treatment, and benign findings; medical opinion not always required | Court: RFC supported by substantial evidence (Dr. Lorensen and records); plaintiff’s IBS largely controlled and distinguishable from cases requiring specific bathroom-break findings |
| Work pace/attendance (absenteeism/off-task) | ALJ failed to assess pace/attendance and ignored limitations in Rahner’s opinion | VE and record show ability to meet job requirements; Rahner’s opinion was not persuasive | Court: ALJ’s evaluation adequate; even if RFC erred, step‑five alternative finding of jobs in economy makes any error harmless |
Key Cases Cited
- Brault v. Social Security Administration, 683 F.3d 443 (2d Cir. 2012) (describing deferential substantial-evidence standard on review)
- Burgess v. Astrue, 537 F.3d 117 (2d Cir. 2008) (treating-source rule and factors for weighing treating opinions)
- Tankisi v. Commissioner of Social Security, [citation="521 F. App'x 29"] (2d Cir. 2013) (RFC must account for all relevant medical and other evidence)
- Dixon v. Shalala, 54 F.3d 1019 (2d Cir. 1995) (step two is de minimis screening; only the weakest cases are excluded)
- Coleman v. Shalala, 895 F. Supp. 50 (S.D.N.Y. 1995) (diagnosis alone does not establish severity)
- Spaulding v. Astrue, 702 F. Supp. 2d 983 (N.D. Ill. 2010) (ALJ must articulate findings on bathroom-break frequency where IBS limits vocational capacity)