Beaver v. Colvin
| Decision Date | 26 September 2014 |
| Docket Number | CAUSE NO.: 2:13-cv-269-JEM |
| Parties | DONNA BEAVER, Plaintiff, v. CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant. |
| Court | U.S. District Court — Northern District of Indiana |
This matter is before the Court on a Complaint [DE 1], filed by Plaintiff Donna Beaver on August 2, 2013, and an Opening Brief of Plaintiff in Social Security Appeal Pursuant to L.R. 7.3 [DE 15], filed by Plaintiff on January 2, 2014. Plaintiff requests that the decision of the Administrative Law Judge denying her benefits on March 23, 2012, be remanded. For the reasons set forth below, the Court grants Plaintiff's request for reversal and remands this case for further proceedings.
On July 2, 2010, Plaintiff filed an application for disability insurance benefits (DIB) and Supplemental Security Income (SSI) with the U.S. Social Security Administration (SSA) alleging that she became disabled on July 28, 2008, due to chronic obstructive pulmonary disease (COPD), lupus, Sjögrens syndrome, asthma, chronic muscle/joint pain, fatigue, pleural effusion in her left lung, depression, and anxiety. Plaintiff's application was denied initially and upon reconsideration. On February 21, 2012, Administrative Law Judge (ALJ) Henry Kramzyk held a hearing at which Plaintiff, with an attorney representative, and a vocational expert (VE) testified. Following the hearing, the ALJ concluded that Plaintiff was not disabled. The ALJ made the following findings under the required five-step analysis:
3. The claimant has the following severe impairments: chronic obstructive pulmonary disease (COPD), lupus, and obesity (20 CFR 404.1520(c) and 416.920(c)).
4. The claimant does not have an impairment or combination of impairments that meets or medically equals the severity of one of the listed impairments in 20 CFR Part 404, Subpart P, Appendix 1 (20 CFR 404.1520(d), 404.1526, 416.920(d), 416.925 and 416.926).
5. After careful consideration of the entire record, the undersigned finds that the claimant has the residual functioning capacity to perform light work as defined in 20 CFR 404.1567(b) and 416.967(b) in that she can lift, carry, push, and pull up 20 pounds occasionally and 10 pounds frequently. She can sit for a total of up to 6 hours per workday. The claimant would have to avoid concentrated exposure to extreme cold and extreme heat, and also avoid concentrated exposure to fumes, odors, gasses, and poor ventilation.
6. The claimant is capable of performing past relevant work as a manager. This work does not require the performance of work-related activities precluded by the claimant's residual functioning capacity. (20 CFR 404.1565 and 416.965).
7. The claimant has not been under a disability, as defined in the Social Security Act, from July 28, 2008, through the date of this decision (20 CFR 404.1520(f) and 416.920(f)).
On June 19, 2013, the Appeals Council denied Plaintiff's request for review, making the ALJ's decision the final decision of the Commissioner. On August 2, 2013, Plaintiff filed a civil complaint with this Court.
The parties filed forms of consent to have this case assigned to a United States Magistrate Judge to conduct all further proceedings and to order the entry of a final judgment in this case. Therefore, this Court has jurisdiction to decide this case pursuant to 28 U.S.C. § 636(c) and 42 U.S.C. § 405(g).
Plaintiff was 48 years old at the time of her alleged onset date and 50 on the date of the hearing. She has completed her high school education. She worked in the past as a manager.
Plaintiff's medical records begin in January 2007 with a check-up performed by her primary care physician, Dr. Kameswari Kalluri. Dr. Kalluri noted that Plaintiff complained of muscle weakness and fatigue. Dr. Kalluri's notes from various check-ups through June 2009 contain continued complaints of muscle weakness and aches, fatigue, and tiredness. After a July 25, 2007, check-up, Dr. Kalluri also noted that Plaintiff had a rash on her scalp related to lupus.
On May 21, 2007, Dr. Kalluri referred Plaintiff to rheumatologist Dr. Vinay Reddy to assess her generalized weakness and muscle aches. On June 12, 2007, Dr. Reddy wrote to Dr. Kalluri, indicating that he did not believe Plaintiff had lupus based on a preliminary examination but that he would have tests run. Those tests revealed positive ANA, positive SSA and SSB antibodies, but negative ENA and rheumatoid factors. Dr. Reddy concluded that Plaintiff had Sjögrens syndrome and prescribed her hydroxychloroquine. Lab results from July 21, 2007, include a statement that "antibodies to SSA and SSB are observed with the highest frequency in Sjögrens syndrome, although these antibodies are also found in significant percentage of patients with [systemic lupus erythematosus]." AR 410. Plaintiff testified at the hearing that she stopped seeing Dr. Reddy after she lost her insurance. Records indicate that her last visit was on September 21, 2009.
In March 2008, Dr. Kalluri first noted that Plaintiff had a left pleural effusion. When it did not clear up on its own, Plaintiff was referred to Dr. Asaad Jandali at Chest Physician Consultants. On June 30, 2008, Dr. Jandali noted Plaintiff's history of lupus and Sjögrens but wrote that thepleural effusion was not likely related to Plaintiff's lupus because her lupus was stable. On July 28, 2008, Dr. Jandali noted that Plaintiff's lupus was in remission.
Plaintiff's lupus is mentioned frequently throughout later records. On February 2, 2010, Dr. Deanna Porte-Keene noted that Plaintiff had had lupus with Sjögrens for two and a half years. She also noted that Plaintiff had problems with becoming easily fatigued and questioned whether it was related to her lupus. On March 16, 2010, a cardiologist to whom Dr. Porte-Keene referred Plaintiff noted Plaintiff's fatigue and stated that Plaintiff "is known to have lupus for which she is under treatment by Dr. Reddy." AR 558. On August 10, 2010, Dr. Porte-Keene noted that Plaintiff had filed for disability because her lupus was affecting her left lung. On September 10, 2010, a consultative examiner noted that Plaintiff had a history of lupus erythematosus "five or six years ago" and that she had erythema on her face on that date. AR 612.
In February 2011, Plaintiff began going to the East Chicago Community Health Center ("ECCHC"). She saw Dr. Gerri Browning in February, April, May, July, and September of 2011 for general check-ups, evaluation for COPD, evaluation of various muscle and joint pains, coughing, and for evaluation of a mass suspected to be cancer. She testified that she went to the ECCHC because it accepted payment on a sliding scale. On February 2, 2011, Dr. Browning noted joint and muscle pain related to Plaintiff's lupus diagnosis.
Plaintiff's records also contain diagnoses and/or treatment for anxiety, depression, minor degenerative changes of the lumbar spine, mild degenerative changes of the right hip, arthritis, vertigo, and high blood pressure. Weight gain was reported after Plaintiff quit smoking.
On September 8, 2010, state agency physician Fernando Montoya prepared a Physical Residual Functional Capacity Assessment based on his examination of Plaintiff's medical records.He concluded that Plaintiff was capable of light work with no postural, manipulative, or visual limits, but that she should avoid concentrated exposure to extreme heat, extreme cold, fumes, odors, gases, dusts, and poor ventilation. He also noted that Plaintiff had a "[history of] pleural effusion from lupus," but wrote that it was "resolved." AR 616. On October 4, 2010, state agency psychologist William Shipley completed a Psychiatric Review Technique form based on his examination of Plaintiff's medical records. He concluded that Plaintiff's mental impairments were non-severe, diagnosed her with adjustment disorder, and found mild restrictions in activities of daily living, maintaining social functioning, and maintaining concentration, persistence, or pace.
On February 12, 2012, Gerri Browning, M.D., a treating physician, filled out a medical source statement. Dr. Browning first addressed Plaintiff's lupus and noted that she had constitutional symptoms of severe fatigue and malaise. Dr. Browning indicated that Plaintiff's lupus at least moderately involved three major organ or body systems: her respiratory system, her mental health, and her immune system. He elaborated that her mental health involvement included anxiety and fluctuating cognition, or "lupus fog," and her immune system involvement included inflammatory arthritis and Sjögren's syndrome. AR 821.
Dr. Browning also offered an opinion on the effects of Plaintiff's impairments on her functional ability. He opined that Plaintiff's symptoms were likely to be severe enough to interfere with her attention and concentration, resulting in her likely being off task twenty-five percent of the time or more. However, Dr. Browning opined that Plaintiff had few limitations with social functioning, concentration, persistence, and pace. Dr. Browning indicated that Plaintiff could walk half a block without rest, sit 20 minutes at one time, stand 45 minutes at one time, sit and stand less than two hours in an eight hour day, needed to be able to shift position at will, and would sometimes need to take unscheduled breaks every two hours for 15 minutes, during which she would need tolie down or sit quietly. Dr. Browning further opined that Plaintiff could rarely lift and carry less than 10 pounds and could never carry more; could occasionally twist, never stoop, crouch, or climb ladders; could rarely climb stairs;...
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