OPINION AND ORDER
Plaintiff Roy W. Rogers (“Plaintiff’) brings this action against the Commissioner of Social Security (“Defendant”) pursuant to 42 U.S.C. § 405(g), seeking reversal of a decision of an Administrative Law Judge (“ALJ”) denying him Social Security Disability Insurance (“SSDI”) benefits. Defendant and Plaintiff both move for judgment on the pleadings pursuant to Fed.R.Civ.P. 12(c). The case was referred to Magistrate Judge Lisa M. Smith, who issued a thorough Report and Recommendation (“R & R”), in response to which Plaintiff filed timely objections. For the reasons stated herein, Defendant’s Motions for Judgment on the Pleadings is denied, Plaintiffs Motion for Judgment on the Pleadings is granted in part and denied in part, and the matter is remanded to the ALJ for further proceedings.
I. Background
A. Factual Background
Plaintiff is a Vietnam War veteran who is seeking SSDI benefits for the relevant time period of June 1, 1984 to December 31, 1989. ®. 16-17.) Although the Court adopts the thorough recitation of facts set forth in the R & R (R & R 1-11), and assumes the Parties’ familiarity with the facts, the Court briefly notes those facts most relevant to Plaintiffs objections.
1. Plaintiffs Hearing Testimony
Plaintiff testified that he gets “flashbacks from Vietnam,” goes “into cold sweats,” and cannot concentrate. (Id. at 1013-14.) Plaintiff testified that he had a nervous breakdown five months after returning from Vietnam, that he was discharged from the army due to medical reasons, and that he tried to recover from his illness but had frequent relapses. (Id. at 1014-15.) When the ALJ asked Plaintiff if he drank alcohol during the relevant time period, Plaintiff testified that the Veterans Administration (“VA”) did not “really recognize PTSD until 1987” and that he drank alcohol to “drown[ ] his sorrow” because he did not “know how to handle his condition.” (Id. at 1015.) Plaintiff stated that during his time in Vietnam, his friend died in his arms and he saw other friends with shrapnel in them. (Id.) Plaintiff also testified that for many years he “lived in cardboard boxes ... eating out of dumpsters behind McDonalds.” (Id.) Plaintiff further testified that during this time he would get “odd jobs sweeping up bars,
2. Medical Evidence
On May 12, 1970, after Plaintiff had gone to the emergency room for “intense agitation” and had stated that “he couldn’t take it anymore,” Major Gordon Preston, Chief of the Air Force Mental Health Services, diagnosed Plaintiff as having “one of the most classic character disorders [he] had seen to date” with “mild to moderate depression with marked agitation” that was “secondary to frustration from not being able to get what he wanted.” (Id. at 934-935.)
On April 20, 1977, the United States Postal Service removed Plaintiff from his employment because of excessive absences. (Id. at 937-40.) Plaintiff wrote a letter appealing the decision, stating that he was being treated by a Veterans hospital in East Orange, New Jersey for a “nervous condition.” (Id. at 954.) A referral card states that Plaintiff was being treated for a nervous condition on January 1, 1978 (id. at 947), but no other medical records were available from the East Orange Veterans Affairs Medical Center, (id. at 857).
There is almost no medical evidence in the record from during the relevant time period of June 1, 1984 to December 31, 1989. Records from Bayonne Hospital show that Plaintiff had surgery on July 20, 1987 for a laceration on his leg and was discharged after one night’s stay in the hospital. (Id. at 968-1000.) After the relevant period, the record shows that Plaintiff was in and out of several hospitals for alcohol detoxification treatment. (Id. at 770-777 (Plaintiff was hospitalized for one month in 1991 at Muhlenberg Regional Medical Center for detoxification); id. at 858-909 (Plaintiff was hospitalized for one month in 1994 at the Lyons VA Medical Center); id. at 780-807 (Plaintiff was admitted to Bayonne Hospital for several weeks after suffering from a seizure and being diagnosed with delirium tremens). During Plaintiffs 1994 hospitalization at Lyons VA Medical Center, he was transferred to the psychiatry unit due to depression and was diagnosed with, inter alia, alcohol abuse, dysthymia, and borderline personality disorder. (Id. at 858-62.)
On February 17, 1996, Plaintiff was admitted to Bayonne Hospital after he called the police and stated that he was suicidal. (Id. at 814.) Plaintiff was discharged a few days later on February 25,1997 with a discharge diagnosis of depression and alcohol abuse. (Id. at 809, 817-18.) The next day, Plaintiff was admitted to the New York VA Medical Center, where he was diagnosed with PTSD, major depression, and alcohol dependence. (Id. at 588-592.) While at the New York VA hospital, Plaintiff reported seeing “death everywhere,” seeing “faces of people of Vietnam,” hearing voices “of the devil telling him he was a baby killer in Vietnam,” and seeing a “Viet Cong soldier [ ] coming toward him with a gun.” (Id.) Plaintiff was transferred to Montrose VA Hospital (which is also referred to as the Hudson Valley VA hospital) and treated there for PTSD, depression, and alcohol dependence until March 2000. (Id. at 101-667.)
On March 30, 2000, Plaintiff was transferred to a group home facility. (Id. at 102.) Plaintiff was readmitted to the Montrose VA hospital from July 10, 2001 until August 8, 2001, after reporting that his “symptoms of PTSD had become more frequent and severe,” including flashbacks and nightmares. (Id. at 912.) Plaintiff was diagnosed with, inter alia, PTSD, schizoaffective disorder, and alcohol dependence in remission. . (Id. at 910-913.) On July 17, 2001, Dr. Kathleen Fortner, who was still a staff psychologist at the Mont-rose VA hospital, wrote a letter regarding Plaintiffs condition, which appears to have been sent to the VA as part of Plaintiffs application for veterans benefits. (Id. at 910, 915.) The letter, which Plaintiff argues is a retrospective diagnosis, states:
[Plaintiff] is a Vietnam combat veteran. He served in the U.S. Air Force from 6/28/67 to 6/4/70. He was in Vietnam in 1969.
[Plaintiff] has a long history of severe, chronic PTSD directly related to his experiences in the service during the Vietnam War. He had many traumatic experiences which he remembers in nightmares and in flashbacks. However, the one which distresses him the most is of his buddy’s head being blown off and of him holding the body.... The vet reacted to the trauma of the War with a sense of horror and helplessness. He reportedly received a medical discharge from the Air Force.
When [Plaintiff] returned from Vietnam, he was not the same person, per his family and his report. He isolated from everybody to the extent that he lived in a box near a dumpster on the streets of Bayonne, N.J. for years. He would not leave his box despite his family’s urging. He had auditory hallucinations for years, isolated from everyone, was unable to recall some of the traumas until very recently and had suicidal ideation. In 1997, he informed the local police that he was suicidal and then he was hospitalized in a local hospital in Bayonne for a week. From there, he was sent to the VA Hudson Valley, first to the Dual Diagnosis Rehabilitation Unit and then for long term psychiatric care. He had serious symptoms. He heard voices chronically, sometimes screams and gunfire. At times, the voices would tell him to kill himself. He required various medications which only partially relieved his symptoms.
On this admission, he described disabling flashbacks and nightmares. He has constant intrusive thoughts and continues to hear the voices. He tends to become depressed, helpless and unable to function. At the present time, heremains in the High Intensity General Psychiatry Unit.
[Plaintiffs] symptoms of PTSD were caused by the War. They are a direct result of the trauma that he experienced and his helplessness in dealing with what he saw. He is 100% disabled for any type of work due to PTSD. Any assistance that can be provided this worthy veteran will be greatly appreciated.
(Id. at 910-11.)
3. Applications for Veterans and Social Security Insurance Benefits
Plaintiff applied to the VA for veterans benefits in 1987, but his application was denied for failure to establish a service connection to his claimed PTSD. (Id. at 960-64.) The VA stated that Plaintiffs medical conditions were due to “habitual excess drinking.” (Id. at 963.) Plaintiff claims that he applied again in 1993 and 1997, and that each time his application was denied because he was unable to provide sufficient documentation. (Id. at 915.) Plaintiff appears to have again applied for veterans benefits in 2000, and on August 12, 2002, the VA sent Plaintiff a letter stating that it had determined that he was 100% disabled due to PTSD as of March 9, 2000. (Id. at 918-23.) On August 21, 2002, the VA sent Plaintiff a letter stating that it was correcting its previous decision and that Plaintiff was determined to have been disabled by PTSD effective March 11,1997. (Id. at 924.)
Plaintiff also applied for Social Security Insurance (“SSI”) benefits in May 1999. (Id. at 15.) Although the Social Security Administration (“SSA”) deemed Plaintiff disabled, he did not receive benefits at that time because he was in a VA hospital. (Id.) In March 2000, Plaintiff again applied for SSI benefits, was again determined to be disabled, and received those benefits because he was in a congregate care facility. (Id.) Plaintiff stopped receiving SSI benefits in September 2002 because his veterans benefits increased to more than $2,000. (Id. at 16.)
B. Procedural Background
Plaintiff applied for SSDI benefits on March 24, 2001, claiming an inability to work since June 1, 1984. (Id. at 73-75.) The SSA denied Plaintiffs claim on November 13, 2001, and Plaintiff requested a hearing before an ALJ. (Id. at 40-49.) The ALJ held a hearing on October 26, 2004, which consisted solely of Plaintiffs testimony. (Id. at 1005-24.) On December 1, 2004, the ALJ issued a decision denying Plaintiffs claim, finding that Plaintiff was not disabled during the relevant period of June 1, 1984 to December 31, 1989. (Id. at 15-19.) The ALJ noted the lack of evidence from the relevant time period, except for one medical record regarding Plaintiffs treatment for a leg laceration, and that the earliest medical evidence discusses Plaintiffs alcohol abuse. (Id. at 18.) The ALJ noted that the “VA has had all [of Plaintiffs] medical records [], yet found him disabled only as of March 1997.” (Id.) In sum, the ALJ found that, although “ample evidence” existed in the record of Plaintiffs “mental health problems after” the last insured date, he “would be speculating to fix an earlier onset date, as there [was] no specific medical evidence to establish a disability” prior to that date. (Id. at 18-19.) (emphasis in original) On June 24, 2005, the Appeals Council denied Plaintiffs request to review the ALJ’s decision. (Id. at 3-5.)
On August 24, 2005, Plaintiff filed the instant action in federal court. (Dkt. No. 1.) The Honorable Colleen McMahon, who was originally assigned to this case, referred the case to Magistrate Judge Smith. (Dkt. No. 3.)
II. Discussion
A. Standard of Review
A district court reviewing a report and recommendation addressing a dispositive motion “may accept, reject, or modify, in whole or in part, the findings or recommendations made by the magistrate judge.” 28 U.S.C. § 636(b)(1); see also Donahue v. Global Home Loans & Fin., Inc., No. 05-CV-8362,
Where a party submits timely objections to a report and recommendation, as Plaintiff has here, the district court reviews de novo the parts of the report and recommendation to which the party objected. See 28 U.S.C. § 636(b)(1); Fed. R.Civ.P. 72(b)(3); Donahue,
When a claimant seeks review of a Social Security hearing regarding disability benefits, the court’s function is not to determine whether the appellant is disabled. See Schaal v. Apfel,
“To be eligible to receive [SSDI] benefits, “an applicant must be insured for disability insurance benefits.” Kohler v. Astrue,
To determine whether a claimant is entitled to disability benefits, the ALJ must follow the familiar five-step sequential analysis. See 20 C.F.R. § 404.1520(a); Williams v. Apfel,
B. Treating Physician Rule & Retrospective Diagnosis
Plaintiff objects to Magistrate Judge Smith’s conclusion that the ALJ did not err in failing to give Dr. Fortner’s July 17, 2001 letter controlling weight under the “treating physician rule” or significant weight as a retrospective diagnosis. (Obj. 2-7.) Plaintiff argues that the ALJ failed to consider Dr. Fortner’s letter, which showed “he was 100% disabled as a result of’ PTSD. (Id. at 4.) Plaintiff also argues that his testimony and the evidence from the Montrose VA hospital show that he was disabled during the relevant time period. (Id. at 7-8.)
Pursuant to the treating physician rule, an ALJ is required to give “controlling weight” to the medical opinion of an applicant’s treating physician if the opinion is “well supported by medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with the other substantial evidence” in the record. 20 C.F.R. § 404.1527(c)(2); see also Green-Younger v. Barnhart,
Relatedly, the ALJ “cannot reject the treating physician’s diagnosis without first attempting to fill any clear gaps in the administrative record.” Rosa,
Although Plaintiff argues that Dr. Fortner’s opinion is entitled to controlling weight under the treating physician rule, Magistrate Judge Smith correctly noted that the treating physician rule should not be applied here because Dr. Fortner was not Plaintiffs treating physician during the relevant time period. See Monette,
Unfortunately, as Magistrate Judge Smith noted, Dr. Fortner’s 2001 letter is less than clear. Although Dr. Fortner states that Plaintiff “has a long history of severe, chronic PTSD directly related to his experiences” in Vietnam, that he “was not the same person” when he returned from Vietnam, and that his “symptoms of PTSD were caused by” Vietnam, her letter does not explicitly indicate that the PTSD diagnosis dates back to the relevant time period. ®. 910.) Thus, it is difficult to tell if her opinion was meant to be a retrospective diagnosis or if she believed that she could not make such a diagnosis. Adding to the confusion, the ALJ did not specifically address Dr. Fortner’s letter at all. As a result, it is unclear whether the ALJ believed the letter was a retrospective diagnosis that was not entitled to significant weight because it was contradicted by substantial evidence, whether the ALJ did not believe the letter was a retrospective diagnosis, or whether the letter was simply overlooked.
In this situation, the case of Martinez v. Massanari, is instructive. In Martinez, the plaintiffs physician, who treated her
Here, like in Martinez, the ALJ concluded that Plaintiff was not disabled during the relevant time period primarily because “there [was] no specific medical evidence to establish a ‘disability’ ” during the time period, other than Plaintiffs “own evaluation that he was ‘disabled’ since 1984.” ®. 18-19.) The ALJ also stressed that Plaintiff did not submit any mental health treatment records from 1987-1994, despite acknowledging that Plaintiff was homeless during this period. (Id. at 18.)
C. Inferring Onset Date Pursuant to Social Security Ruling 83-20
Although neither Party has addressed this issue, the Court notes that the ALJ also committed legal error by failing to determine the onset date of Plaintiffs PTSD in accordance with Social Security Ruling 83-20 (“SSR 83-20”) or to request the help of a medical advisor in inferring the onset date. See generally SSR 83-20,
SSR 83-20 provides that for disabilities without a “traumatic origin,” the Commissioner should consider “the applicant’s allegations, work history, if any, and the medical and other evidence concerning impairment severity,” and that “[w]ith slowly progressive impairments, it is sometimes impossible to obtain medical evidence establishing the precise date an impairment became disabling.” SSR 83-20,
Here, the ALJ decided that it would be speculation to try and infer an onset date prior to 1997 because of the lack of contemporaneous medical records during the relevant time period and because of the VA’s prior determination. ®. 18-19.) However, many of the medical reports from Plaintiffs treating physicians and the medical histories during his hospitalizations describe Plaintiff as having a long history of PTSD symptoms and mental health problems, creating at least an ambiguity regarding Plaintiffs onset date. (Id. at 588-91 (transfer record of Manhattan VA hospital, summarizing Plaintiffs hospitalization in 1997 and stating that Plaintiff reported flashbacks from Vietnam and reported seeing death everywhere and seeing faces of people of Vietnam); id. at 268 (hospital record of Dr. Michael Hwang, dated August 25, 1998, diagnosing Plaintiff with chronic PTSD and stating that Plaintiff reported twenty-year history of PTSD including flashbacks, vivid dreams, and hallucinations related to his battle experience in Vietnam); id. at 104 (hospital record of Dr. Hwang, dated June 28, 1999, noting history of PTSD and “long history of psychotic disorder); id. at 512 (hospital record of Dr. Arnold Mitchell, dated August 29, 2000, stating that Plaintiff had PTSD symptoms for over thirty years, had severe flashbacks sparked by stimuli such as airplanes or fireworks, and heard Vietnam combat sounds). Thus, although the ALJ noted the existence of this evidence, it was error for him to not even consider that these hospitalization records could aid in inferring Plaintiffs onset date as a date prior to the hospitalizations. See Plumley,
D. Disposition
Pursuant to sentence four of 42 U.S.C. § 405(g), a district court may “enter, upon the pleadings and transcript of the record, a judgment affirming, modifying, or reversing the decision of the Commissioner of Social Security, with or without remanding the cause for a rehearing.” 42 U.S.C. § 405(g); see also LoRusso v. Astrue, No. 08-CV-3467,
III. Conclusion
For the reasons stated herein, Defendant’s Motion for Judgment on the Pleadings is denied and Plaintiffs Motion for Judgment on the Pleadings is granted in part and denied in part. The final decision of the Commissioner is reversed and the Court remands the matter for further proceedings in accordance with this ruling. The Clerk of Court is respectively requested to close this case.
SO ORDERED.
Notes
. On several occasions Plaintiff was transferred out of the Montrose VA hospital to other hospitals for treatments unrelated to his mental health condition. Each time, he was transferred back to the Montrose VA hospital, where he stayed until March 30, 2000. (R. at 101-06; R & R 5-6.)
. Fed.R.Civ.P. 72(b)(2) was recently amended to extend the time for objections to fourteen days, but this amendment does not affect Plaintiff's objections. See Fed.R.Civ.P. 72(b)(2).
. The case was reassigned to the undersigned on August 6, 2007. (Dkt. No. 10.)
. The ALJ also concluded that the only medical record from the relevant time period, which related to a one-day hospitalization for a leg laceration in July 1997, contradicted Plaintiff's accounts of suffering from PTSD because this record did not mention any mental health symptoms, and that Plaintiff's testimony was contradicted by records from 1994 diagnosing Plaintiff with alcohol problems. (Id. at 18, 983-1000.) First, the Court notes that the records from 1994 also mention potential PTSD problems (id. at 858-62 (diagnosing Plaintiff with, inter alia, alcohol dependence and borderline personality disorder, and noting Plaintiff's possible history of PTSD); id. at 878-88 (diagnosing Plaintiff with alcohol dependence and noting that Plaintiff reported PTSD issues such as screaming out at night). Furthermore, Plaintiff reported abusing alcohol to self-medicate his PTSD symptoms because the VA did not recognize PTSD. (Id. at 1015.) In any event, the Court cannot evaluate whether the decision is based on substantial evidence when the record has not been fully developed to address Dr. Fortner's potential retrospective diagnosis. See Martinez,
. The record contains two documents titled “Request for Medical Advice,” both of which are dated over a year prior to Plaintiff's request for a hearing before the ALJ. ®. 766 (request for medical advice dated July 17, 2001); id. at 838 (request for medical advice dated February 14, 2002; id. at 40 (request for hearing by ALJ filed on March 23, 2003)).
. Because the Court remands this case to the ALJ pursuant to sentence four of 42 U.S.C. § 405(g), the Court need not address Plaintiff's request for this Court to consider new evidence that was not put before the ALJ or Magistrate Judge Smith. Specifically, Plaintiff proffers a medical record from the Lyons VA Medical Center showing that he was hospitalized there during the relevant period from October 19, 1987 until November 12, 1987, which diagnosed him with, inter alia, “Alcohol Dependence” and "Post Traumatic Stress Disorder, Delayed, Mild.” (Obj. 3; id. at unnumbered page 11-13.) The report provides that Plaintiff had a thirteen-year drinking problem, had “some flashback experiences” related to Vietnam, and complained during therapy that his Vietnam experiences were related to past suicidal intentions. (Id. at unnumbered page 12.) Additionally, the report states that Plaintiff was upset when he was turned down for a PTSD inpatient program and that, at discharge, he was considered fully employable. (Id. at unnumbered page 13.) Pursuant to sentence six of 42 U.S.C. § 405(g), a court "may at any time order additional evidence to be taken before the Secretary, but only upon a showing that there is new evidence which is material and that there is good cause for the failure to incorporate such evidence into the record in a prior proceeding.” 42 U.S.C. § 405(g); see also Tomatore,