Nunez v. Berryhill

CourtDistrict Court, D. Connecticut
DecidedFebruary 28, 2020
Docket3:18-cv-01952
StatusUnknown

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

Bluebook
Nunez v. Berryhill, (D. Conn. 2020).

Opinion

UNITED STATES DISTRICT COURT DISTRICT OF CONNECTICUT

RUTH NUNEZ : Plaintiff : No. 3:18-cv-1952 (VLB) : v. : : ANDREW SAUL, : February 28, 2020 COMMISSIONER OF SOCIAL : SECURITY : Defendant. : :

MEMORANDUM OF DECISION AFFIRMING DECISION OF COMMISSIONER AND DENYING MOTION TO REVERSE AND REMAND Ruth Nunez (“Ms. Nunez” or “Plaintiff” or “Claimant”) challenges the Commissioner of Social Security now Andrew Saul’s1, final decision to deny Ms. Nunez’s application for disability benefits pursuant to 42 U.S.C. § 405(g). Ms. Nunez moves pro se to reverse and remand Administrative Law Judge Eskunder Boyd’s (the “ALJ”) decision as not supported by substantial evidence in the record and/or not rendered in accordance with law. [Dkt. 15 (Pl. Mot. to Rev.)]. Defendant Andrew Saul (“Defendant” or “Commissioner”) moves to affirm the Commissioner’s final decision, as expressed by the ALJ decision. [Dkt. 16 (Def. Mot. to Affirm)]. For the reasons stated below, the Court GRANTS Defendant’s motion to affirm [Dkt. 16] and DENIES Claimant’s motion to reverse and remand [Dkt. 15].2

1 Andrew Saul is automatically substituted as a party pursuant to Fed. R. Civ. P. 25(d).

2 A second motion to reverse and remand appears on the docket. [Dkt. 17]. That motion is unaccompanied by a memorandum of law as required by D. Conn. L. R. Civ. P. 7(a). Moreover, the motion is signed by Ms. Evelyn Rosa, who is neither a party to this case nor entered an appearance as an attorney of record for Ms. Background

I. Procedural Background Ms. Nunez was born in 1962 and previously worked as an office clerk. [Dkt. 15 (Pl. Mot. to Reverse) at 2]; [Dkt. 12 (Record) at 28].3 She filed an application for Title II benefits on November 10, 2015, alleging a disability onset date of April 10, 2014. [R. 17]. The claim was initially denied on February 2, 2016 and again on

reconsideration on May 3, 2016. Ibid. Ms. Nunez moved for a hearing, which was held before ALJ Boyd on October 5, 2017. Ibid. She testified at the hearing with the assistance of a Spanish language interpreter and was represented by counsel. Ibid. The ALJ issued his decision on October 19, 2017, denying Ms. Nunez’s claim for benefits because he found that Ms. Nunez’s Residual Functional Capacity (“RFC”) rendered her able to perform relevant past work as an office clerk. [R. 28]. The Social Security Appeals Council declined to hear her appeal on October 4, 2018. [R. 5-10]. A timely petition for judicial review followed. [Dkt. 1 (Compl.)].

II. Relevant Medical History The medical record begins roughly two and a half years before the October 2017 hearing and reflects various physical maladies and mental health conditions.

Nunez. Pursuant to Fed R. Civ. P. 11(a) every written motion be signed by either a party appearing pro se or an attorney of record. Accordingly, [Dkt. 17] is also DENIED.

3 Citations to the record, [Dkt. 12], are identified as [R. __]. The ALJ’s opinion comprises [R. 17-29]. In May 2014, Ms. Nunez was seen by her primary care physician, Dr. Cynthia Gentes, for anxiety that increased after her father died and she was laid off from her job, and for headaches. [R. 407]. Dr. Gentes observed normal demonstrated behavior, mood, and affect during the examination. [R. 408]. She was also seen in

May 2014 for anemia and treated with an intravenous iron infusion. [R. 369-70]. Ms. Nunez was seen by Dr. Gentes again in August 2014 for headaches and anxiety. [R. 416-20]. Ms. Nunez reported that her anxiety was improving with the new medication regiment and that she had no loss of interest in activities. [R. 416]. Her neurological and psychiatric assessments were normal. [R. 417-18]. Ms. Nunez continued to treat with hematologist Dr. Sandhya Dhanjal for anemia. [R. 363-76].

In October 2015, Ms. Nunez experienced sudden deafness in her left ear and underwent an MRI with contrast, but the findings were unremarkable. [R. 289]. The radiologist found that her brain was stable when compared to 2011 imaging. Ibid. Her audiologist’s report reflects that Ms. Nunez has 100% hearing in her right ear and 90% hearing in her left ear on word recognition testing. [R. 397].

The notes from Plaintiff’s October 2015 physical exam with her primary care physician, Dr. Gentes, indicate that she had an annular tear in the lumbar region of her back that she was scheduled to treat with physical therapy. [R. 302]. In addition to physical therapy, Dr. Gentes recommended regular exercise and increased weight bearing activity. [R. 306]. The exam also reiterates that her depression worsened after her father died, her son went to jail, and she lost her job. [R. 306]. Dr. Gentes changed her antidepressant and referred her to psychiatrist Dr. Javier Lopez. Ibid.

During her November 2015 office visit with Dr. Gentes, her mood and affect were normal, but she had decreased sensation in her right foot and no sensation in her hands. [R.298]. Dr. Gentes noted that her neurological exam was “confusing” and referred her to a neurologist. Ibid.

Ms. Nunez was examined by neurologist Dr. Yaniv Chen in November 2015 and January 2016 after her back pain did not improve with physical therapy. [R. 332- 38]. All of her mental status and neurological exams were normal. Ibid. Dr. Chen concurred on the diagnosis for the lumbar pain, citing the earlier MRI findings, and also diagnosed her with fibromyalgia. [R. 337]. Thereafter, she continued physical therapy until March 2016. [R. 339-362]

Ms. Nunez treated with Dr. Javier Lopez for anxiety and depression beginning in April 2016 and was seen on a monthly or bi-monthly basis thereafter. [R. 534]; [R. 677]. In her initial assessment, Dr. Lopez noted that Ms. Nunez had a history of suicidal ideation, but no intent or prior attempts. [R. 677]; [R. 683]. On June 28, 2016, Ms. Nunez was seen in the emergency room for dizziness.

[694-98]. Her neurological and psychiatric exam was normal; her strength was rated 5/5, equal in all extremities; and she had a normal mood and affect. [R. 697]. At her next appointment with Dr. Lopez a month later, her depression and anxiety were moderate and improving. [R. 699-703]. She improved further the following month. [R.703]; [R.545]. But her mental health condition worsened in October 2016. [R. 559-61]. She then stated that the June 2016 emergency room visit was actually caused by taking extra Klonopin as a suicide gesture.4 Ibid. Her depression and anxiety continued to worsen in January and February 2017. [R. 564-68].

On March 31, 2017, her new primary care physician, Dr. Veronica Plasencia, completed a full physical exam. [R. 569-577]. The physical examination showed scoliosis and decreased range of motion of the left arm, with tenderness on palpation on the back of the left shoulder (R. 574). Her neurological exam was also positive for weakness and headaches. [R. 570]. After her physical examination, Ms. Nunez was transferred to Bridgeport Hospital because of severe depression with

suicidal ideation with plans. [R. 575]. At the time, she had intrusive thoughts about suicide methods, but was not experiencing psychosis. [R. 582]. She was discharged ten days later. [R. 597]. She was improving at her next appointment with Dr. Lopez, three days later. [R. 597-601]. The following month, Ms. Nunez reported her depression lessening, but anxiety

increased. [R. 605]. In her next visit with Dr. Plasencia, no neurological symptoms presented. [R. 609-10]. Dr. Plasencia recommended regular exercise. [R. 612]. In June 2017, Dr. Lopez recommended “finding things to do during the day so that she has a reason to get up in the morning-volunteering, exercise, walking.” [R. 613].

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