Guillen v. Berryhill, 697 F. App'x 107

Karen Guillen appealed denial of her applications for Supplemental Security Income; district court affirmed the Commissioner and denied remand.
ALJ decision relied on medical records and noted no physician had opined claimant disabled; no treating-source medical-source statement was in file.
Guillen proceeded pro se before the ALJ.
The record contained medical entries referencing lupus and other conditions but lacked assessments of functional limitations or RFC from treating providers.
The ALJ did not obtain or explicitly solicit a medical-source statement clarifying work-related limitations or confirming the lupus diagnosis.
Second Circuit vacated the district court judgment and remanded for further administrative development and consideration.

Issue	Plaintiff's Argument	Defendant's Argument	Held
Whether ALJ failed to develop the record	ALJ had an affirmative duty, heightened for pro se claimants, to obtain treating-source opinions and to clarify diagnoses	Commissioner says requests were made for treating opinions and remand not always required if record otherwise sufficient	Court held ALJ failed to develop the record and remand required
Whether ALJ improperly rejected treating physician’s lupus diagnosis	Guillen argued records show treating physician diagnosed lupus and ALJ erred in treating it as merely possible	Commissioner maintained no formal diagnosis or disabling opinion in record	Court found ALJ’s rejection inconsistent with treating records and required further inquiry
Whether existing medical evidence supported RFC findings without additional opinion	Guillen argued records contain no basis to assess RFC; needed treating-source functional assessment	Commissioner cited Tankisi and argued ALJ can assess RFC from existing medical evidence	Court distinguished Tankisi and found existing records did not permit reliable RFC assessment; requested treating opinion required
Remedy to correct errors	Guillen sought reversal or remand for further proceedings	Commissioner opposed broad remand or directed findings	Court vacated and remanded to Commissioner with instructions to obtain treating medical-source statement, clarify lupus diagnosis, allow supplementation, reassess credibility and RFC, and obtain vocational expert if warranted

Brault v. Soc. Sec. Admin., Comm’r, 683 F.3d 443 (2d Cir. 2012) (standard of review for SSA decisions and focus on administrative record)
Moran v. Astrue, 569 F.3d 108 (2d Cir. 2009) (heightened duty to develop record for pro se claimants)
Rosa v. Callahan, 168 F.3d 72 (2d Cir. 1999) (ALJ’s affirmative obligation to develop medical history; remand when record deficient)
Pratts v. Chater, 94 F.3d 34 (2d Cir. 1996) (non-adversarial nature of benefits proceedings)
Burgess v. Astrue, 537 F.3d 117 (2d Cir. 2008) (treating physician rule and requirement to weigh treating opinions when supported and consistent)