DePaulo v. Saul

CourtDistrict Court, E.D. New York
DecidedMarch 30, 2021
Docket1:19-cv-04804
StatusUnknown

This text of DePaulo v. Saul (DePaulo v. Saul) is published on Counsel Stack Legal Research, covering District Court, E.D. New York primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
DePaulo v. Saul, (E.D.N.Y. 2021).

Opinion

UNITED STATES DISTRICT COURT EASTERN DISTRICT OF NEW YORK --------------------------------------------------------------- X : PETER DePAULO, : Plaintiff, : MEMORANDUM

DECISION AND ORDER - against - : : 19-CV-4804 (AMD) ANDREW SAUL, :

Defendant. : : --------------------------------------------------------------- X

ANN M. DONNELLY, United States District Judge:

The plaintiff challenges the Social Security C ommissioner’s decision that the claimant, his sister,1 was not disabled for the purposes of receivi ng Social Security Disability Insurance

(“SSDI”) under Title II of the Social Security Act. On March 9, 2020, the plaintiff moved for

judgment on the pleadings. (ECF No. 10.) On June 8 , 2020, the defendant filed a cross-motion for judgment on the pleadings. (ECF No. 14.) For the reasons explained below, I grant the

plaintiff’s motion in part, deny the defendant’s motion and remand the case for further

proceedings. BACKGROUND 1. Statutory and Regulatory Framework The Social Security Act directs that the Commissioner “immediately redetermine” a claimant’s eligibility for benefits “if there is reason to believe that fraud or similar fault was involved in the application.” 42 U.S.C. § 405(u)(1)(A). The statute further instructs the Commissioner that “[w]hen redetermining the entitlement,” she “shall disregard any evidence if

1 The claimant passed away on June 15, 2015, while a redetermination of her benefits was pending. (Tr. 17.) Her brother substituted for her in this proceeding. (Tr. 17, 100.) there is reason to believe that fraud or similar fault was involved in the providing of such evidence.” § 405(u)(1)(B). If, pursuant to a redetermination, the Commissioner concludes there is insufficient evidence of the claimant’s entitlement to benefits, the Commissioner “may terminate such entitlement and may treat benefits paid on the basis of such insufficient evidence

as overpayments.” § 405(u)(3). The SSA promulgated regulations to implement § 405(u)’s mandate. Those regulations, which are outlined in the Hearings, Appeals, and Litigation Law Manual (“HALLEX”), contemplate that the SSA may be required to redetermine a claimant’s benefits under three circumstances: (i) when it receives information “from the Office of Inspector General” (“OIG”), (ii) when it receives information “from a federal or state prosecutor,” or (iii) when it “uncover[s] information in the course of processing or reviewing a case(s) that provides a reason to believe that fraud or similar fault was involved in the application for benefits.” HALLEX I-1-3-25(A). According to the HALLEX procedures, “adjudicators do not have discretion to reconsider the issue of whether the identified evidence should be disregarded when based on an OIG referral or

information or a referral based on information obtained during a criminal or other law enforcement investigation.” HALLEX I-1-3-25(C)(4)(a). By contrast, “when the redetermination is based solely on an SSA finding of fraud or similar fault, an adjudicator can consider a beneficiary’s or recipient’s objection to the disregarding of certain evidence.” Id. 2. Factual and Procedural Background On May 6, 1997, Frances DePaulo applied for disability insurance, citing disability beginning March 13, 1996 due to depression and hearing loss in her left ear. (Tr. 166.) Attorney Raymond Lavallee helped the claimant submit her application (see Tr. 37-38), which also included treating records and forms completed by Dr. Raymond Pierre-Paul, a psychiatrist (see, e.g., Tr. 186, 289-90). The SSA granted Ms. DePaulo’s application on July 10, 1997. (Tr. 30.) In a letter dated February 25, 2014, an assistant district attorney from the New York County District Attorney’s office (“DA”) updated the Commissioner on an ongoing fraud

investigation, and included the following description: Raymond Lavallee, working together with [others], referred SSDI applicants to psychiatrists Dr. Edward Sodaro and Dr. Raymond Pierre-Paul . . . in order to fabricate a psychiatric disability prior to their applying for SSDI. Lavallee and his co-conspirators further assisted applicants with completing paperwork that contained false statements regarding their activities of daily living, and coached applicants about how to behave during Consultative Examinations, ALJ hearings, and treatment sessions with pre-designated doctors. . . . [A]pplicants paid cash kick-backs to Lavallee and his co-conspirators over and above the authorized representative fee. (Tr. 53.) The letter also listed applicants whose applications, according to the DA’s investigation, “follow[ed] some of the patterns described and consequently may have obtained SSDI benefits under fraudulent pretenses.” (Tr. 54.) The claimant was included in this list. (ECF No. 15-1 ¶¶ 3-5.) In a May 6, 2014 letter, the Commissioner notified the claimant that the SSA was suspending her disability insurance “while we redetermine whether you were entitled to benefits on 07/10/97, the date we initially allowed your claim,” “because we believe that fraud or similar fault was involved in providing evidence that we used to find you disabled.” (Tr. 73.) The Commissioner further explained that criminal charges had been filed against Raymond Lavallee and others, and that “[o]ne or more of these sources provided evidence in your case that we used to find you disabled.” (Id.) The claimant submitted a request for reconsideration (Tr. 79), which the disability examiner denied in a determination dated July 1, 2015 (Tr. 84-97). In that determination, the disability examiner disregarded medical evidence that Dr. Pierre-Paul submitted, as well as medical evidence from Mr. Lavallee. (Tr. 92.) The examiner also disregarded the claimant’s activities of daily living because they were “based on a mental condition in part or in whole on the claimant’s allegations.” (Id.) On redetermination, the disability examiner invoked the

findings of consulting physicians, and concluded that the claimant’s hearing loss formed a “moderate impairment” that “precludes work in high ambient noise environments or where good hearing is essential to job performance or safety.” (Tr. 97.) The examiner also concluded that without the excluded evidence, there was “insufficient evidence to rate the mental impairment severity,” and that “a finding of not disabled” was appropriate given the claimant’s “age, education, and PRFC.” (Id.) The plaintiff requested a hearing (Tr. 102), which took place before ALJ Black- Pennington on September 18, 2018 (Tr. 151). Before the hearing, the plaintiff submitted additional evidence—the claimant’s “complete medical record[s],” to support the application. (Tr. 275.)2 The ALJ denied the plaintiff’s application in a decision dated October 18, 2018. (Tr.

14-26.) The ALJ excluded “evidence regarding a mental impairment, submitted by [Mr. Lavallee],” as well as medical evidence from Dr. Pierre-Paul, in accordance with § 405(u) and the corresponding SSA regulations. (Tr. 17.) The plaintiff was not given an opportunity to challenge the exclusion of this evidence. The ALJ “considered all remaining evidence that relates to the period on or before the original allowance date”—July 10, 1997—including hearing testimony from the claimant’s brother and a vocational expert. (Tr. 17-18.) The ALJ made the following conclusions:

2 In addition to what had been submitted in support of the claimant’s initial application, and before the initial redetermination decision, these records included treatment notes, including 2004 notes from Dr. Frederic Vagnini, a cardiologist. (Tr. 1134-35.) First: the claimant did not engage in substantial gainful activity between March 13, 1996 (the alleged date of onset) and July 10, 1997. (Tr.

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Bluebook (online)
DePaulo v. Saul, Counsel Stack Legal Research, https://law.counselstack.com/opinion/depaulo-v-saul-nyed-2021.