Walter R. v. Saul, 1:18-cv-01042-DLP-SEB
| Decision Date | 12 August 2019 |
| Docket Number | No. 1:18-cv-01042-DLP-SEB,1:18-cv-01042-DLP-SEB |
| Parties | WALTER R., Plaintiff, v. ANDREW M. SAUL, Commissioner of the Social Security Administration, Defendant. |
| Court | U.S. District Court — Southern District of Indiana |
Plaintiff Walter R.1 seeks judicial review of the denial by the Commissioner of the Social Security Administration ("Commissioner") of his application for Social Security Disability Insurance Benefits ("DIB") under Title II of the Social Security Act ("the Act"). See 42 U.S.C. §§ 423(d), 405(g). For the reasons set forth below, this Court hereby REVERSES the ALJ's decision denying the Plaintiff benefits and REMANDS this matter for further consideration.
On October 8, 2014, Walter filed for disability and disability insurance benefits, alleging that his disability began on April 15, 2014. Walter asserts that his disability is caused by shoulder problems, gastroesophageal reflux disease (GERD)2,chronic venous insufficiency3, non-insulin dependent type II diabetes, recurrent cellulitis4 of the lower left leg, hypertension, headaches, insomnia, obesity, and depression. Walter's claim was denied initially and upon reconsideration. Walter then filed a written request for a hearing on August 12, 2015, which was granted.
On May 1, 2017, Administrative Law Judge ("ALJ") Albert J. Velasquez conducted the hearing, where Walter and a vocational expert testified. On August 29, 2017, ALJ Velasquez issued an unfavorable decision finding that Walter was not disabled as defined in the Act. On February 13, 2018, the Appeals Council denied Walter's request for review of this decision, making the ALJ's decision final. Walter now requests judicial review of the Commissioner's decision. See 42 U.S.C. § 1383(c)(3). On August 7, 2019, the Court held oral argument.
To prove disability, a claimant must show he 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 twelve months." 42 U.S.C. § 423(d)(1)(A). To meet this definition, a claimant's impairments must be of such severity that he is not able to perform the work he previously engaged in and,based on his age, education, and work experience, he cannot engage in any other kind of substantial gainful work that exists in significant numbers in the national economy. 42 U.S.C. § 423(d)(2)(A). The Social Security Administration ("SSA") has implemented these statutory standards by, in part, prescribing a five-step sequential evaluation process for determining disability. 20 C.F.R. § 404.1520. The ALJ must consider whether:
(1) the claimant is presently [un]employed; (2) the claimant has a severe impairment or combination of impairments; (3) the claimant's impairment meets or equals any impairment listed in the regulations as being so severe as to preclude substantial gainful activity; (4) the claimant's residual functional capacity leaves [him] unable to perform [his] past relevant work; and (5) the claimant is unable to perform any other work existing in significant numbers in the national economy.
Briscoe ex rel. Taylor v. Barnhart, 425 F.3d 345, 351-52 (7th Cir. 2005) (citation omitted). An affirmative answer to each step leads either to the next step or, at steps three and five, to a finding that the claimant is disabled. 20 C.F.R. § 404.1520; Briscoe, 425 F.3d at 352. A negative answer at any point, other than step three, terminates the inquiry and leads to a determination that the claimant is not disabled. 20 C.F.R. § 404.1520. The claimant bears the burden of proof through step four. Briscoe, 425 F.3d at 352. If the first four steps are met, the burden shifts to the Commissioner at step five. Id. The Commissioner must then establish that the claimant—in light of his age, education, job experience and residual functional capacity to work—is capable of performing other work and that such work exists in the national economy. 42 U.S.C. § 423(d)(2); 20 C.F.R. § 404.1520(f).
The Court reviews the Commissioner's denial of benefits to determine whether it was supported by substantial evidence or is the result of an error of law. Dixon v. Massanari, 270 F.3d 1171, 1176 (7th Cir. 2001). Evidence is substantial when it is sufficient for a reasonable person to conclude that the evidence supports the decision. Rice v. Barnhart, 384 F.3d 363, 369 (7th Cir. 2004). The standard demands more than a scintilla of evidentiary support but does not demand a preponderance of the evidence. Wood v. Thompson, 246 F.3d 1026, 1029 (7th Cir. 2001). Thus, the issue before the Court is not whether Walter is disabled, but, rather, whether the ALJ's findings were supported by substantial evidence. Diaz v. Chater, 55 F.3d 300, 306 (7th Cir. 1995).
In this substantial-evidence determination, the Court must consider the entire administrative record but not "reweigh evidence, resolve conflicts, decide questions of credibility, or substitute our own judgment for that of the Commissioner." Clifford v. Apfel, 227 F.3d 863, 869 (7th Cir. 2000). Nevertheless, the Court must conduct a critical review of the evidence before affirming the Commissioner's decision, and the decision cannot stand if it lacks evidentiary support or an adequate discussion of the issues, Lopez ex rel. Lopez v. Barnhart, 336 F.3d 535, 539 (7th Cir. 2003); see also Steele v. Barnhart, 290 F.3d 936, 940 (7th Cir. 2002).
When an ALJ denies benefits, he must build an "accurate and logical bridge from the evidence to his conclusion," Clifford, 227 F.3d at 872, articulating aminimal, but legitimate, justification for his decision to accept or reject specific evidence of a disability. Scheck v. Barnhart, 357 F.3d 697, 700 (7th Cir. 2004). The ALJ need not address every piece of evidence in his decision, but he cannot ignore a line of evidence that undermines the conclusions he made, and he must trace the path of his reasoning and connect the evidence to his findings and conclusions. Arnett v. Astrue, 676 F.3d 586, 592 (7th Cir. 2012); Clifford v. Apfel, 227 F.3d at 872.
Walter was 42 years old at the time of the alleged onset date in 2014. [Dkt. 5-3 at 2 (R. 54).]. He obtained his General Educational Development ("GED") in 2012 followed by eight months of college courses at Ivy Tech. [Dkt. 5-2 at 40-41 (R. 39-40).] The Plaintiff last engaged in substantial gainful activity in April 2014 when he worked as a mechanic for Pep Boys. [Dkt. 5-2 at 39 (R.38).].
On March 1, 2012, Walter went to the emergency department at St. Vincent hospital complaining of lower left leg cellulitis. While at the hospital, the medical staff performed an ultrasound of the legs, which revealed no evidence of deep vein thrombosis ("DVT")5 but some abnormality with a lymph node. The staffadministered an IV for Walter and his condition improved. Walter was released from St. Vincent the next day.6 [Dkt. 5-10 at 58-78 (R. 496-521).]
On April 17, 2013, Walter visited IU Health Methodist Hospital emergency room complaining of severe dental pain, including swelling, redness, and bleeding of the mouth. The medical staff noted Walter reported having a headaches and his history of hypertension. He was given over-the-counter pain medication and instructions to visit a dentist. [Dkt. 5-8 at 11-13 (R. 285-87).]
On May 6, 2013, Walter visited Dr. Mark Freije at Westfield Primary Care. Dr. Freije noted that Walter was not taking hypertension medication, that he reported issues with daily fatigue and sleeping, and that he was experiencing chronic joint pain in his shoulder. Dr. Freije also noted that Walter had developed a skin rash. At the conclusion of the visit, Dr. Freije placed Walter on hypertension medication and prescribed him testosterone for his fatigue and a topical cream for his rash. [Dkt. 5-7 at 27-29 (R. 238-40).]
On August 12, 2014, Walter presented to IU Health Methodist Hospital emergency department complaining of lower left extremity pain, erythema,7 and swelling. He stated that his pain was a 10 out of 10 and that he had a fever as high as 103 degrees. Medical personnel noted that at the time of his visit Walter did not have a fever and that his pain eventually subsided to a 3 or 4 out of 10. Walternotified staff that he had visited the emergency room about 20 times in the last 15 years for the same symptoms. He was diagnosed with recurrent cellulitis and the doctor noted a history of hypertension and GERD. [Dkt. 5-8 at 14-24 (R. 288-98).] The next day, Walter had a venous duplex scan performed on his legs, which indicated that there was no evidence of DVT in either leg. [Dkt. 5-8 at 41 (R. 315).] There were some issues with the lymph nodes in his left leg, but the scan was otherwise unremarkable and unchanged from scans performed in February 2012 and October 2011. [Id.] Walter was discharged the next day with antibiotics and a recommendation to follow up with his primary care physician. [Dkt. 5-8 at 14-24 (R. 288-98).]
On September 6, 2014, Walter presented to the IU Health Methodist Hospital emergency room complaining of shortness of breath and chest pain. His initial examination was normal and showed no signs of abnormalities. [Dkt. 5-8 at 46 (R. 320).] Dr. Jeffrey Mossler performed an electrocardiogram ("EKG"), which was normal, [Dkt. 5-8 at 42 (R. 316).] and Dr. Jessica Smith performed a chest x-ray, which was also normal. [Dkt. 5-7 at 14 (R. 225).] Walter was later discharged. [Id.]
On September 17, 2014, Walter visited Dr. Keith Banks at Infectious Disease of Indiana, P.S.C. because he was continuing to struggle with lower extremity cellulitis. Dr. Banks noted Walter's previous diagnoses of obesity, hypertension, hyperlipidemia,8 and borderline diabetes. Dr. Banks also noted that Walter sufferedfrom lower leg edema...
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