Gregory B. v. Saul

• Decision Date: 02 March 2020
• Docket Number: CIVIL NO. 2:19cv184
• Parties: GREGORY B., Plaintiff, v. ANDREW SAUL, Commissioner of Social Security, Defendant.
• Court: U.S. District Court — Northern District of Indiana

GREGORY B.¹, Plaintiff, v. ANDREW SAUL, Commissioner of Social Security, Defendant.

CIVIL NO. 2:19cv184

UNITED STATES DISTRICT COURT NORTHERN DISTRICT OF INDIANA

March 2, 2020

OPINION AND ORDER

This matter is before the court for judicial review of a final decision of the defendant Commissioner of Social Security Administration denying Plaintiff's application for Disability Insurance Benefits (DIB), as provided for in the Social Security Act. 42 U.S.C. § 423(a), § 1382c(a)(3). Section 405(g) of the Act provides, inter alia, "[a]s part of his answer, the [Commissioner] shall file a certified copy of the transcript of the record including the evidence upon which the findings and decision complained of are based. The court shall have the power to enter, upon the pleadings and transcript of the record, a judgment affirming, modifying, or reversing the decision of the [Commissioner], with or without remanding the case for a rehearing." It also provides, "[t]he findings of the [Commissioner] as to any fact, if supported by substantial evidence, shall be conclusive. . . ." 42 U.S.C. §405(g).

The law provides that an applicant for disability insurance benefits must establish an "inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to last for a continuous period of not less than 12 months. . . ." 42 U.S.C. §416(i)(1); 42 U.S.C. §423(d)(1)(A). A physical or mentalimpairment is "an impairment that results from anatomical, physiological, or psychological abnormalities which are demonstrable by medically acceptable clinical and laboratory diagnostic techniques." 42 U.S.C. §423(d)(3). It is not enough for a plaintiff to establish that an impairment exists. It must be shown that the impairment is severe enough to preclude the plaintiff from engaging in substantial gainful activity. Gotshaw v. Ribicoff, 307 F.2d 840 (7th Cir. 1962), cert. denied, 372 U.S. 945 (1963); Garcia v. Califano, 463 F.Supp. 1098 (N.D.Ill. 1979). It is well established that the burden of proving entitlement to disability insurance benefits is on the plaintiff. See Jeralds v. Richardson, 445 F.2d 36 (7th Cir. 1971); Kutchman v. Cohen, 425 F.2d 20 (7th Cir. 1970).

Given the foregoing framework, "[t]he question before [this court] is whether the record as a whole contains substantial evidence to support the [Commissioner's] findings." Garfield v. Schweiker, 732 F.2d 605, 607 (7th Cir. 1984) citing Whitney v. Schweiker, 695 F.2d 784, 786 (7th Cir. 1982); 42 U.S.C. §405(g). "Substantial evidence is defined as 'more than a mere scintilla. It means such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.'" Rhoderick v. Heckler, 737 F.2d 714, 715 (7th Cir. 1984) quoting Richardson v. Perales, 402 U.S. 389, 401, 91 S.Ct. 1410, 1427 (1971); see Allen v. Weinberger, 552 F.2d 781, 784 (7th Cir. 1977). "If the record contains such support [it] must [be] affirmed, 42 U.S.C. §405(g), unless there has been an error of law." Garfield, supra at 607; see also Schnoll v. Harris, 636 F.2d 1146, 1150 (7th Cir. 1980).

In the present matter, after consideration of the entire record, the Administrative Law Judge ("ALJ") made the following findings:

1. The claimant meets the insured status requirements of the Social Security Actthrough June 30, 2019.

2. The claimant has not engaged in substantial gainful activity since July 1, 2015, the alleged onset date (20 CFR 404.1571 et seq.).

3. The claimant has the following severe impairments: hypertension, obesity, degenerative disc disease of the lumbar spine, migraine headaches, osteoarthritis of the lower extremities, degenerative joint disease of the bilateral knees, carpal tunnel syndrome of the right upper extremity, fibromyalgia, sleep apnea, neuropathy of the upper extremities, and polymyositis (20 CFR 404.1520(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), 404.1525 and 404.1526).

5. After careful consideration of the entire record, the undersigned finds that the claimant has the residual functional capacity to perform light work as defined in 20 CFR 404.1567(b) except the claimant can never climb ladders, ropes and scaffolds and must avoid concentrated exposure of noise, vibration, fumes, odors, dusts, gases, poor ventilation, and hazards. The claimant cannot operate foot controls bilaterally or perform any overhead reaching bilaterally and is limited to frequent handling and fingering bilaterally.

6. The claimant is unable to perform any past relevant work (20 CFR 404.1565).

7. The claimant was born on September 10, 1968 and was 46 years old, which is defined as a younger individual age 18-49, on the alleged disability onset date (20 CFR 404.1563).

8. The claimant has a limited education and is able to communicate in English (20 CFR 404.1564).

9. Transferability of job skills is not material to the determination of disability because using the Medical-Vocational Rules as a framework supports a finding that the claimant is "not disabled," whether or not the claimant has transferable job skills (See SSR 82-41 and 20 CFR Part 404, Subpart P, Appendix 2).

10. Considering the claimant's age, education, work experience, and residual functional capacity, there are jobs that exist in significant numbers in the national economy that the claimant can perform (20 CFR 404.1569 and 404.1569(a)).

11. The claimant has not been under a disability, as defined in the Social Security Act, from July 1, 2015, through the date of this decision (20 CFR 404.1520(g)).

(Tr. 20 - 28).

Based upon these findings, the ALJ determined that Plaintiff was not entitled to disability benefits. The ALJ's decision became the final agency decision when the Appeals Council denied review. This appeal followed.

Plaintiff filed his opening brief on October 29, 2019. On January 7, 2020, the defendant filed a memorandum in support of the Commissioner's decision, to which Plaintiff replied on January 21, 2020. Upon full review of the record in this cause, this court is of the view that the ALJ's decision must be remanded.

A five-step test has been established to determine whether a claimant is disabled. See Singleton v. Bowen, 841 F.2d 710, 711 (7th Cir. 1988); Bowen v. Yuckert, 107 S.Ct. 2287, 2290-91 (1987). The United States Court of Appeals for the Seventh Circuit has summarized that test as follows:

The following steps are addressed in order: (1) Is the claimant presently unemployed? (2) Is the claimant's impairment "severe"? (3) Does the impairment meet or exceed one of a list of specific impairments? (4) Is the claimant unable to perform his or her former occupation? (5) Is the claimant unable to perform any other work within the economy? An affirmative answer leads either to the next step or, on steps 3 and 5, to a finding that the claimant is disabled. A negative answer at any point, other than step 3, stops the inquiry and leads to a determination that the claimant is not disabled.

Nelson v. Bowen, 855 F.2d 503, 504 n.2 (7th Cir. 1988); Zalewski v. Heckler, 760 F.2d 160, 162 n.2 (7th Cir. 1985); accord Halvorsen v. Heckler, 743 F.2d 1221 (7th Cir. 1984). From the nature of the ALJ's decision to deny benefits, it is clear that step five was the determinative inquiry.

Plaintiff was born on September 10, 1968 and was 50 years-old on the date last insured. Plaintiff was five-feet, nine-inches tall; weighed as much as 236 pounds; and had a resulting bodymass index (BMI) of 34.8. (AR 623.)

In November 2015, Plaintiff presented at the emergency department with throbbing left lateral thigh pain. (AR 912.) Examination revealed tenderness to palpation over the left lateral thigh to the left greater troch muscle. (AR 913.) In December 2015, examination confirmed decreased range of motion, bony tenderness, swelling, pain, crepitus, spasm, and decreased strength in the right shoulder; tenderness in the wrists; positive Tinel's sign and positive Phalen's sign; swelling, effusion, deformity, tenderness, and lateral collateral ligament tenderness in the left knee; and pain and tenderness in the lumbar back. (AR 237-38.)

In February 2016, Plaintiff presented at the emergency department after waking with pain in the right arm and right leg. (AR 864.) Plaintiff demonstrated decreased lumbar range of motion, positive straight leg raise test, and positive Stinchfield test in March 2016. (AR 545.) He sought emergency medical care in April 2016 after he developed right-sided headache, blurred vision, neck pain, and right arm numbness and tingling. (AR 837.)

Plaintiff presented at the emergency department in May 2016 with right-sided weakness, tingling, and numbness. (AR 318.) Doctors noted that Plaintiff's medical history included multiple transient ischemic attacks (TIA), glucose-6-phosphate dehydrogenase (G6PD) deficiency, hypertension, sleep apnea, and cervical disc herniations. Id. Doctors suspected that the most likely diagnosis was a TIA. (AR 320.) Plaintiff returned to the emergency department days later after chest palpitations awakened him from sleep. (AR 326.) En route to the hospital via ambulance, he developed radiating chest pain and dyspnea. Id. His symptoms resolved and doctors diagnosed vasculopathy. (AR 330.)

In July 2016, Plaintiff developed neck pain and tingling on the sides of the lips. (AR 592.)Doctors attributed the facial tingling to a potential TIA. (AR 594.) Doctors admitted Plaintiff to the hospital with right-sided weakness and limping in September 2016. (AR 1352.) A CT scan of the brain confirmed small vessel ischemic changes in the periventricular white matter. (AR 1385.) During a neurology consultation that occurred during this hospitalization, Plaintiff averred that he had suffered migraine headaches for several years and that he suffered headaches that lasted up...