Coulter v. Colvin
1:15-cv-00849
W.D.N.Y.Sep 5, 2017Background
- Coulter applied for DIB and SSI in 2012 after a 2010 motor-vehicle accident and was denied by an ALJ; Appeals Council denied review, prompting this suit.
- Medical record documents cervical and lumbar disc bulges, cervical instability/subluxations, limited ROM, positive provocative tests, left shoulder pathology, and right wrist surgery.
- Multiple treating and consultative providers (chiropractor Dr. Cardamone; pain specialist Dr. Beaupin; orthopedists Drs. Tetro, Huckell, Newman, Hamill; consultative examiners Drs. Miller and Ryan) found objective findings and variously opined limitations or disability.
- Plaintiff repeatedly reported recurrent, treatment‑requiring headaches (treated with occipital nerve blocks and Fioricet) and testified medication induced significant sedation.
- After the ALJ found plaintiff capable of a limited range of light work, Coulter appealed, submitting a post‑ALJ chiropractor RFC opining inability to perform sedentary or light work; the Magistrate Judge recommends remand for further proceedings.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether ALJ erred by not finding headaches a severe impairment at step 2 | Headaches are recurrent, treated, and cause sedation from medication, so they are at least severe | Plaintiff failed to meet burden to show headaches are severe; record lacks objective tests | Magistrate: ALJ erred by failing to evaluate headaches at step 2 and their functional impact; remand required to assess severity and work‑related effects |
| Whether Appeals Council adequately considered chiropractor Dr. Cardamone’s RFC submitted on appeal | Cardamone’s RFC (submitted to Appeals Council) contradicts ALJ RFC and would require a disability finding; it must be considered | Appeals Council stated it considered the evidence and declined to change ALJ decision | Magistrate: New evidence must be considered in the whole record; Cardamone’s opinion could affect outcome and ALJ decision is not supported by substantial evidence when that evidence is included — remand for fuller consideration |
| Whether ALJ properly considered obesity in assessing RFC | Obesity (BMI/weight up to 210 lb at 5'1") can compound functional limits and was not addressed | ALJ referenced weight only to dispute appetite claims, implying no limiting effect | Magistrate: ALJ failed to account for obesity’s possible limiting effects; on remand obesity should be considered |
| Whether ALJ RFC finding (limited light work) is supported by substantial evidence | RFC underweights treating/other‑source opinions and post‑decision chiropractor RFC | Commissioner argues substantial evidence supports ALJ RFC | Magistrate: Considering the full record including new chiropractor opinion and unaddressed headaches/obesity, ALJ's RFC is not supported — remand for further development |
Key Cases Cited
- Shaw v. Chater, 221 F.3d 126 (2d Cir.) (standard for reviewing Commissioner factual findings)
- Consolidated Edison Co. of N.Y., Inc. v. NLRB, 305 U.S. 197 (Supreme Court) (definition of substantial evidence)
- Talavera v. Astrue, 697 F.3d 145 (2d Cir.) (allocation of burdens in five‑step disability analysis)
- Gold v. Secretary, 463 F.2d 38 (2d Cir.) (ALJ's duty to develop the record)
- Lesterhuis v. Colvin, 805 F.3d 83 (2d Cir.) (Appeals Council must consider new evidence and court reviews the whole record including that evidence)