Dipaolo Koehler v. Commissioner of Social Security
7:20-cv-07707
| S.D.N.Y. | Mar 24, 2022Background
- Plaintiff Ginamarie Dipaolo Koehler applied for disability insurance benefits alleging onset August 25, 2015, based primarily on fibromyalgia (application filed April 27, 2018). ALJ John Carlton denied benefits on September 24, 2019; Appeals Council declined review.
- Treating physician Dr. Mark Thomas (since 2008) submitted a Fibromyalgia Impairment Questionnaire and two medical source statements (2018, 2019) describing severe, work‑preclusive limitations: limited standing/walking, need to switch sit/stand every ~15 minutes, supine resting breaks totaling hours, and absences >3/month.
- State agency reviewer Dr. S. Ahmed concluded RFC at the light exertional level (sit/stand ~6 hours each, lift 20/10 lbs) and found fibromyalgia severe but overall functional capacity greater than Dr. Thomas’s opinions.
- At hearing Plaintiff testified to daily severe pain, frequent need to alternate positions, medication side effects, and reliance on others for childcare; a vocational expert testified that with the ALJ’s RFC the claimant could perform her past relevant work.
- ALJ found fibromyalgia and obesity severe, discounted Dr. Thomas’s opinions as not persuasive (citing internal inconsistencies and inconsistency with treatment notes and work history), deemed Dr. Ahmed persuasive, adopted a light‑work RFC with nonexertional limits, and concluded Plaintiff could perform past work — denying benefits.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether ALJ failed to develop the record (recontact treating physician or order consultative exam) | ALJ should have recontacted Dr. Thomas to resolve inconsistencies and/or ordered a consultative exam before rejecting his opinions | Record was complete, no obvious gaps, counsel said no missing records; recontact or consult exam unnecessary absent ambiguity preventing an RFC finding | ALJ satisfied development duty; no remand required for recontact or consultative exam |
| Whether ALJ properly evaluated treating‑physician opinions under the 2017 rules | Dr. Thomas’s opinions should have been credited; ALJ erred in rejecting treating opinions and relying on non‑examining reviewer | ALJ reasonably found Dr. Thomas’s opinions unsupported/inconsistent with his own treatment notes and the record; non‑examining opinion may be persuasive under revised rules | ALJ permissibly found Dr. Thomas’s opinions not persuasive and reasonably relied on Dr. Ahmed’s opinion |
| Whether ALJ adequately considered obesity per SSR 19‑2p | ALJ failed to explain how obesity affected RFC and its combined effects with other impairments | ALJ considered obesity (found it severe), record shows treating/examining sources did not link obesity to functional limits, and BMI was noted without evidence it caused limitations | No remand; the record lacks medical opinion tying obesity to work limitations and ALJ’s consideration was adequate |
| Whether ALJ erred in failing to account for frequent absences and in discounting subjective pain testimony | ALJ should have accounted for Dr. Thomas’s opinion that claimant would miss >3 days/month and should have credited claimant’s pain reports | ALJ reasonably discounted Dr. Thomas’s absence estimate as part of rejecting his overall opinion; claimant’s testimony conflicted with treatment records and activities | No error: ALJ permissibly found absence estimate unsupported and reasonably evaluated claimant’s subjective statements |
Key Cases Cited
- Cichocki v. Astrue, 729 F.3d 172 (2d Cir. 2013) (defines statutory framework for disability determination)
- McIntyre v. Colvin, 758 F.3d 146 (2d Cir. 2014) (summarizes five‑step sequential analysis)
- Selian v. Astrue, 708 F.3d 409 (2d Cir. 2013) (substantial evidence standard and deference to ALJ credibility findings)
- Rosa v. Callahan, 168 F.3d 72 (2d Cir. 1999) (remand appropriate where record gaps require further development)
- Perez v. Chater, 77 F.3d 41 (2d Cir. 1996) (ALJ has affirmative duty to develop the record in non‑adversarial proceedings)
- Pollard v. Halter, 377 F.3d 183 (2d Cir. 2004) (court must independently review legal standards applied by ALJ)
- Burgess v. Astrue, 537 F.3d 117 (2d Cir. 2008) (claimant bears burden at steps one through four)
- Brault v. Soc. Sec. Admin. Comm’r, 683 F.3d 443 (2d Cir. 2012) (burden shifts to Commissioner at step five)