Perez-Maldonado v. Commissioner of Social Security

CourtDistrict Court, D. Puerto Rico
DecidedJuly 24, 2024
Docket3:23-cv-01147
StatusUnknown

This text of Perez-Maldonado v. Commissioner of Social Security (Perez-Maldonado v. Commissioner of Social Security) is published on Counsel Stack Legal Research, covering District Court, D. Puerto Rico primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Perez-Maldonado v. Commissioner of Social Security, (prd 2024).

Opinion

WALESCA I. PÉREZ-MALDONADO, Petitioner,

v. Civil No. 23-1147 (BJM)

COMMISSIONER OF SOCIAL SECURITY, Defendant.

OPINION AND ORDER Walesca I. Pérez-Maldonado (“Pérez”) moves to reverse the Commissioner of the Social Security Administration’s (the “SSA’s”) decision to terminate her Social Security Disability Insurance benefits (“SSDI”). Docket No. (“Dkt.”) 1. Such termination followed a rehearing held after this court found that the SSA’s initial redetermination procedure violated Pérez’s constitutional due process rights. Dkt. 12 (“Transcript” or “Tr.”) at 1263-75. The SSA opposes the appeal. Dkt. 18. The case is before me on consent of the parties. Dkts. 4, 6. For the following reasons, the SSA’s decision is REVERSED and REMANDED for further proceedings consistent with this opinion. STANDARD OF REVIEW The court’s review of SSDI cases is limited to determining whether the SSA committed legal or factual error in evaluating a claim. Manso-Pizarro v. Sec’y of Health & Human Servs., 76 F.3d 15, 16 (1st Cir. 1996). The SSA’s findings of fact are conclusive when supported by substantial evidence. 42 U.S.C. § 405(g). Questions of law are reviewed de novo. Coskery v. Berryhill, 892 F.3d 1, 3 (1st Cir. 2018). After reviewing the pleadings and record transcript, the court has “the power to enter 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). An SSDI claimant is considered disabled if she is unable “to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months.” 42 U.S.C. § 423(d)(1)(A). Under the statute, a claimant is unable to engage in any substantial gainful activity when she “is not only unable to do [her] previous work but cannot, considering [her] age, education, and work experience, engage in any other kind of substantial gainful work which exists in the national economy.” 42 U.S.C. § 423(d)(2)(A). In determining whether a claimant is disabled, the adjudicator must consider all evidence in the record. 20 C.F.R. § 404.1520(a)(3). Rather than requesting review of an initial determination, Pérez appeals a redetermination. “The Commissioner of Social Security shall immediately redetermine the entitlement of individuals to monthly insurance benefits under this subchapter if there is reason to believe that fraud or similar fault was involved in the application of the individual for such benefits.” 42 U.S.C. § 405(u)(1)(A). The SSA may have reason to believe fraud or similar fault occurred through its own investigations, upon referral of an investigation by the Office of the Inspector General (“OIG”), or following a law enforcement investigation or criminal conviction. U.S. Soc. Sec. Admin., Hearings, Appeals, and Litigation Law Manual I-1-3-25(C)(4)(A) (updated June 7, 2022) (“HALLEX”).1 “When redetermining the entitlement, or making an initial determination of entitlement, of an individual under this subchapter, the Commissioner of Social Security shall disregard any evidence if there is reason to believe that fraud or similar fault was involved in the providing of such evidence.” 42 U.S.C. § 405(u)(1)(B). According to HALLEX, a redetermination “based on fraud or similar fault is a re- adjudication of the individual’s application for benefits.” HALLEX I-1-3-25(A). The administrative law judge (“ALJ”) charged with redetermining a claim may consider evidence initially submitted as well as new, material evidence that does not involve fraud or similar fault and that is related to the time period at issue. Id. at I-1-3-25(A), (C)(4)(c). The period at issue runs from the disability onset date through the date of the final benefits determination. Id. at I-1-3-

1 HALLEX can be located online at https://www.ssa.gov/OP_Home/hallex/hallex.html. 25(C)(3). After reviewing the eligible evidence, the ALJ decides whether the beneficiary was entitled to benefits at the time of the original determination. On redetermination, should the SSA determine “that there is insufficient evidence to support such entitlement, the Commissioner of Social Security may terminate such entitlement and may treat benefits paid on the basis of such insufficient evidence as overpayments.” 42 U.S.C. § 405(u)(3). The Commissioner may “require such overpaid person or his estate to refund the amount in excess of the correct amount.” Id. § 404(a)(1)(A). Beneficiaries may seek a waiver to avoid repayment of benefits later categorized as overpayments. Id. § 404(b)(1) (“[T]here shall be no adjustment of payments to, or recovery by the United States from, any person who is without fault if such adjustment or recovery . . . would be against equity and good conscience.”). BACKGROUND The following is a summary of Pérez’s medical history and records, as well as the case history before the SSA and this court. Pérez was born on February 17, 1970. Tr. 1134. She spent roughly twenty years working in quality control in the pharmaceutical industry. Tr. 1136-37. During such time, Pérez developed several ailments, including degenerative disc disease, bilateral carpal tunnel syndrome, left knee degenerative joint disease, and depressive disorder. Tr. 1107. On August 25, 2011, she applied for SSDI, claiming a disability onset date of October 12, 2010. Tr. 1130. Samuel Torres Crespo (“Torres”), a non-attorney representative, represented Pérez in her initial SSDI claim. Tr. 269. In support of her claim, Pérez submitted various forms of medical evidence, including records provided by her treating physician, Dr. Jose R. Hernández-González (“Dr. Hernández”). Tr. 271-72. The evidence from Dr. Hernández included nerve conduction studies, functional testing results, and neurological reports in which he opined that, based on Pérez’s several medical conditions, she was unable to work. Tr. 759-61, 793-98, 1063-68. After an initial denial, the SSA informed Pérez that she had been found disabled and would begin receiving disability benefits. Tr. 282, 349. Roughly seventeen months later, the Agency sent Pérez a letter informing her that it would be suspending her benefits because it believed fraud or similar fault was involved in her claim. Tr. 395. Given the suspected fraud, the SSA would redetermine Pérez’s SSDI eligibility. Id. The letter had its origins in an investigation into social security claims in Puerto Rico that began in 2009. Declaration of Francis X. Barry, Pérez-Maldonado v. Commissioner of Social Security, No. 18-cv-1725 (D.P.R. May 28, 2019), Dkt. 16-1 (“Barry Decl.”). Employees of the Puerto Rico Disability Determination Service suspected that certain doctors were submitting fraudulent medical evidence in support of SSDI claims. Id.

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