Foust v. Saul
5:19-cv-00977
N.D.N.Y.Sep 8, 2020Background
- Plaintiff (born 1993), previously found disabled with a 2013 onset, underwent a left total hip replacement and was found to have medical improvement; SSA terminated benefits effective September 14, 2017.
- Plaintiff is a transgender male (prefers "Jakob") with physical impairments (status-post hip replacement, obesity, PCOS/endometriosis, hypertension) and mental diagnoses (PTSD, depression/anxiety, gender dysphoria, dissociative disorder).
- At the administrative hearing plaintiff proceeded pro se; Appeals Council denied review after considering additional records.
- ALJ Hoffman found severe impairments post-2017 but concluded plaintiff did not meet listings and had an RFC for light work with the ability to perform simple, unskilled tasks and tolerate routine workplace interactions.
- ALJ relied primarily on consultative examiner Dr. Dennis Noia (psychological) and orthopedist Dr. Kalyani Ganesh; therapist letter stating claimant "unable to work" was from a non-acceptable medical source and not controlling.
- District court applied the substantial-evidence/deferential standard and affirmed the Commissioner, granting defendant's judgment on the pleadings.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Duty to develop the record (missing Planned Parenthood/Upstate records) | ALJ failed to obtain treatment records relevant to PCOS/endometriosis and other care | Record was sufficiently developed: claimant was asked about additional evidence, did not identify missing records, and relevant treatment notes are in the record | No duty to further develop; no obvious gaps; any error would be harmless |
| RFC nonexertional limits (social/ADL/self-management) | RFC should include express mild limitation interacting with others and moderate limitation in adapting/managing self | Consultative exam (Dr. Noia) supports only mild/moderate findings which do not preclude unskilled work; ALJ properly weighed opinions | Court gave Dr. Noia great weight; RFC supported by substantial evidence; limitations do not preclude basic unskilled work |
| Credibility of subjective symptoms | ALJ improperly discounted claimant's symptom reports and therapist's opinion | ALJ applied SSR 16-3p, relied on activities, objective findings, sparse treatment, and examiner reports | Credibility analysis upheld as reasonable and supported by substantial evidence |
| Step 5 / need for vocational expert vs. reliance on grids | Nonexertional limits require vocational expert testimony | Nonexertional limits here do not significantly erode the light-work occupational base; SSR 85-15 guidance on unskilled work applies | VE not required; reliance on the grids and SSR 85-15 was permissible |
Key Cases Cited
- Brault v. Social Security Admin., 683 F.3d 443 (2d Cir. 2012) (articulates deferential "substantial evidence" review standard)
- Bapp v. Bowen, 802 F.2d 601 (2d Cir. 1986) (mere existence of nonexertional limitations does not automatically require a vocational expert)
- Sibala v. Astrue, 595 F.3d 402 (2d Cir. 2010) (vocational expert necessary only where nonexertional limits significantly restrict job base)
- Carvey v. Astrue, [citation="380 F. App'x 50"] (2d Cir. 2010) (claimant activities can support adverse credibility finding)
- Morris v. Berryhill, [citation="721 F. App'x 25"] (2d Cir. 2018) (discusses ALJ duty to develop record, especially for unrepresented claimants)
- Diaz-Sanchez v. Berryhill, 295 F. Supp. 3d 302 (W.D.N.Y. 2018) (treatment patterns and lack of physical therapy/treatment relevant to credibility)