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Dias v. Colvin

United States District Court, D. Massachusetts

February 20, 2018

CAROLYN COLVIN, Commissioner of Social Security, Defendant.



         Plaintiff Liliana Maria Dias (“Ms. Dias” or “Claimant”) brings this action pursuant to section 205(g) of the Social Security Act, 42 U.S.C. § 405(g), challenging the final decision of the Commissioner of the Social Security Administration (the “Commissioner”) denying her claim for Social Security Disability Insurance (“SSDI”). Currently pending are Claimant's motion to reverse the Commissioner's decision denying her disability benefits [ECF No. 25], and the Commissioner's cross-motion for an order affirming the decision. [ECF No. 32]. For the reasons described herein, the Court finds that the ALJ's decision is supported by substantial evidence and therefore DENIES Claimant's motion to reverse and remand and ALLOWS the Commissioner's motion to affirm.

         I. BACKGROUND

         A. Statutory and Regulatory Framework: Five-Step Process to Evaluate Disability Claims

          “The Social Security Administration is the federal agency charged with administering both the Social Security disability benefits program, which provides disability insurance for covered workers, and the Supplemental Security Income program, which provides assistance for the indigent aged and disabled.” Seavey v. Barnhart, 276 F.3d 1, 5 (1st Cir. 2001) (citing 42 U.S.C. §§ 423, 1381a).

         The Social Security Act (the “Act”) provides that an individual shall be considered to be “disabled” if he or 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 that has lasted or can be expected to last for a continuous period of not less than twelve months.

42 U.S.C. § 1382c(a)(3)(A); see also 42 U.S.C. § 423(d)(1)(A). The disability must be severe, such that the claimant is unable to do his or her previous work or any other substantial gainful activity that exists in the national economy. See 42 U.S.C. § 1382c(a)(3)(B); 20 C.F.R. § 416.905. The claimant must also establish that he or she was disabled under the Act during the relevant time period between the alleged onset date and the date when the claimant last met the earning requirements for disability benefits under the Act. Rodriguez-Gonzalez v. Astrue, 854 F.Supp. 2d. 176, 179 (D.P.R. 2012) (citing Evangelista v. Sec'y Health & Human Servs., 826 F.3d 136, 140 n.3 (1st Cir. 1987)).

         When evaluating a disability claim under the Act, the Commissioner uses a five-step process, which the First Circuit has explained as follows:

All five steps are not applied to every applicant, as the determination may be concluded at any step along the process. The steps are: 1) if the applicant is engaged in substantial gainful work activity, the application is denied; 2) if the applicant does not have, or has not had within the relevant time period, a severe impairment or combination of impairments, the application is denied; 3) if the impairment meets the conditions for one of the “listed” impairments in the Social Security regulations, then the application is granted; 4) if the applicant's “residual functional capacity” is such that he or she can still perform past relevant work, then the application is denied; 5) if the applicant, given his or her residual functional capacity, education, work experience, and age, is unable to do any other work, the application is granted.

Seavey, 276 F.3d at 5 (citing 20 C.F.R. § 416.920).

         B. Procedural Background

         Ms. Dias filed her application for SSDI benefits on April 18, 2008. [R. 90].[1] She alleged that she became disabled on January 2, 2004, due to fibromyalgia, depression, anxiety, and post-traumatic stress disorder (“PTSD”). [R. 12, 14-15, 90]. Her date last insured was December 31, 2007. [R. 99].

         The Social Security Administration (the “SSA”) denied Ms. Dias's applications for SSDI benefits on July 16, 2008, and again upon reconsideration.[2] [R. 48-53]. Thereafter, Ms. Dias requested an administrative hearing [R. 56-57], and a hearing took place before Administrative Law Judge (“ALJ”) James H. Packer on September 14, 2010. [R. 6]. Ms. Dias, who was represented by counsel, appeared and testified at the hearing. [R. 6-32]. On October 1, 2010, the ALJ issued a decision finding that Ms. Dias was not disabled. [R. 35-44]. The SSA Decision Review Board declined to review Ms. Dias's claim within the prescribed timeframe, and the ALJ's decision became final on January 24, 2011. [R. 45-47].

         On June 6, 2011, Plaintiff filed a timely complaint with this Court[3] seeking review of the Commissioner's decision pursuant to section 205(g) of the Act. See [R. 812]. The government filed an assented-to motion to remand the case to the SSA on March 14, 2012, requesting further development of the record, which the court granted on March 15, 2012. [R. 809-12]. On April 9, 2012, the SSA Appeals Council subsequently remanded the case to the ALJ for additional proceedings on the grounds that the original decision did not 1) contain an evaluation of the opinions submitted by Claimant's treating sources, 2) contain a detailed analysis of Claimant's credibility, or 3) contain an assessment of Claimant's ability to do work-related mental activities. [R. 813-17]. The ALJ held a second hearing on September 30, 2013 [R. 783-808] and subsequently issued a second decision on November 22, 2013 finding that Ms. Dias was not disabled as of her date last insured. [R. 761-74]. Ms. Dias's counsel filed timely written exceptions to the Appeals Council on November 25, 2013. [R. 755-60]. On May 20, 2015, the Appeals Council declined to assume jurisdiction and the ALJ's second decision became final. [R. 744-46]. On July 23, 2015, Ms. Dias filed a timely complaint with this Court, seeking review of the Commissioner's decision pursuant to section 205(g) of the Act. [ECF No. 1].

         C. Factual Background

         Ms. Dias was born May 2, 1968 [R. 201-04] in Portugal and lived there until the age of 18. [R. 9]. She described a traumatic upbringing and childhood due to her father's alcoholism. [R.15]. In 1986, Ms. Dias immigrated to the United States and graduated from Stoughton High School a year and a half later. [R. 10]. She is currently 49 years old.

         From approximately 1989 to 2002, Ms. Dias worked as a customer service representative for an insurance agency. [R. 10-11]. She worked primarily face-to-face with customers at a service counter, and estimated that she spent about half the day seated behind a desk and half the day standing behind the counter. [R. 11]. She stopped working in 2002. [R. 10-11]. Additional facts are included below as applicable.

         D. Medical Evidence

         In 1994, Ms. Dias was involved in a car accident which resulted in, inter alia, a concussion and back pain. [R. 344-54]. She went to the emergency room in 1995 with post- concussion syndrome and complaints of migraines due to the car accident. [R. 358-59]. Medical records indicate that her treating physicians believed that Ms. Dias was suffering from PTSD as a result of her difficult upbringing, which was exacerbated by the car accident. [R. 698, 700].

         Ms. Dias was first diagnosed with fibromyalgia in January 2002. [R. 422]. In 2004, she visited Raphael Bueno, M.D. for extremity pain and weakness. [R. 276]. Dr. Bueno noted that although attempts at therapy resulted in limited improvement, MRIs and an EMG showed no abnormalities. Id. Dr. Bueno also wrote that during the physical exam Ms. Dias appeared “quite well.” Id. In 2005, Ms. Dias suffered a post-partum hemorrhage following a Cesarean section during the birth of her twins and was transported via an emergency medical flight to Brigham and Women's Hospital, where she underwent a total hysterectomy. [R. 501-504]. After this, Ms. Dias began seeing doctors for complaints of headaches, blurred vision, depression, back pain, and fatigue. See, e.g., [R. 180-83, 204, 207, 209, 267, 269-71, 273-75, 493-94]. In 2005, Ms. Dias began seeing treating physician Lucia Dias-Hoff, M.D., M.S.[4] and treating rheumatologist Michael Hait, M.D. See, e.g., [R. 188-241, 264]. Both doctors reported fibromyalgia with varied pain, and some difficulty sleeping, but that she was tolerating medications well and was functional. See, e.g., [R. 264].

         In 2006, a chest X-ray came back normal and a CAT scan showed no abnormalities. [R. 234, 236]. In the same year, Ms. Dias had several pelvic exams in relation to her hysterectomy and other physical exams which revealed appendicitis. See, e.g., [R. 229-32]. In 2007, Ms. Dias went to Gregg Angell, M.D., complaining of abdominal pain, however, the physical exam showed appropriate appearance and orientation and a normal abdomen. [R. 571-98]. In 2008, Barbara Stelle, M.D., a consultative psychiatrist, examined Ms. Dias. [R. 333-34]. Dr. Stelle noted Ms. Dias's history of fibromyalgia, subjective complaints of depression and fatigue as well as subjective feelings of panic and anxiety related to traumatic events in her life. Id. Dr. Stelle also noted at the time Ms. Dias was well groomed, made good eye contact, had good rapport, and was cooperative although her affect showed depressed mood. Id.[5]

         Also in 2008, Drs. Dias-Hoff and Hait examined Ms. Dias and reported her general appearance as active, alert, hydrated, and in no distress. See, e.g., [R. 180, 185, 292, 297, 305, 600]. Her abdomen was normal, and musculoskeletal exams showed full range of motion and strength in all joints and muscle groups. Id. At this time there were also no signs of inflammation or trigger points. Id. Physical exams remained unchanged throughout 2008. [R. 600-01]. Between 2008 and 2009, several state-agency medical consultants evaluated Ms. Dias. See, e.g., [R. 256-63, 284-91, 335-37]. These consultants determined that she retained the residual functional capacity (“RFC”)[6] to perform light work in spite of her subjective complaints of pain. Id. One consultant concluded that she could lift and/or carry twenty pounds occasionally and ten pounds frequently, stand and/or walk with normal breaks for a total of six hours in an eight-hour workday, and sit with normal breaks for a total of six hours in an eight-hour workday. [R. 285]. This report also concluded there were no physical abnormalities, and no identified or counted trigger points, but noted that she had nonetheless been treated by a rheumatologist for fibromyalgia. Id.

         Dr. Dias-Hoff examined Ms. Dias again in 2009 and referenced a surgery scheduled for abdominal pain. [R. 711-12]. Despite Ms. Dias's subjective complaints of pain, physical exams that day appeared normal. Id. Dr. Dias-Hoff recorded her impression of Ms. Dias's conditions as chronic ...

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