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Spaulding v. Astrue

March 22, 2010


The opinion of the court was delivered by: Hon. Michael T. Mason


Michael T. Mason, United States Magistrate Judge: Presently before this Court is plaintiff Corrinda Spaulding's ("Spaulding" or "claimant") motion for summary judgment seeking judicial review of the final decision of the Commissioner of Social Security (the "Commissioner") denying her claim for disability insurance benefits under the Social Security Act (the "Act"), 42 U.S.C. §§ 416(i) and 423. The Commissioner filed a cross motion for summary judgment asking this Court to uphold the decision of the Administrative Law Judge ("ALJ"). This Court has jurisdiction to hear this matter pursuant to 42 U.S.C. § 405(g). For the reasons set forth below, claimant's motion for summary judgment is granted and the Commissioner's motion is denied.


Spaulding filed her application for disability insurance benefits on or around September 25, 1996, alleging a disability that precluded employment as of December 16, 1993. (R. 39-41). In a related document, claimant identified her disabling conditions as hiatal hernia, gastric reflux, chronic dyspepsia and erosive gastritis. (R. 47). Claimant's date last insured was December 31, 1998. (R. 23). Accordingly, in order to receive benefits, claimant must be disabled under the Act as of that date. 42 U.S.C. § 423(c).

Claimant's application was denied administratively, and she filed a timely request for an administrative hearing. (R. 17-27). On March 3, 1998, claimant appeared with counsel for a hearing before ALJ James A. Horn ("ALJ Horn"). (R. 120-52). On June 26, 1998, ALJ Horn issued a decision denying Spaulding's claim for benefits. (R. 11-16). Claimant filed a timely request for review. (R.186). The Appeals Council denied that request, and ALJ Horn's decision became the final decision of the Commissioner. (R. 4).

Claimant then sought judicial review of ALJ Horn's decision. The District Court for the Northern District of Illinois affirmed the ALJ, and Spaulding appealed to the Seventh Circuit Court of Appeals. The Seventh Circuit reversed the lower court on March 28, 2001. Spaulding v. Halter, No. 00-3738, 2001 U.S. App. LEXIS 5613, (7th Cir. March 28, 2001) ("Spaulding I"). The Seventh Circuit found that reversal was warranted because the ALJ committed factual errors and did not consider all of the relevant evidence, and remanded the case to the Social Security Administration for a new hearing. Spaulding I, at **1, 9.

On November 4, 2002, claimant and her counsel again appeared before ALJ Horn. (R. 297-334). ALJ Horn issued a second decision denying Spaulding's request for benefits on April 25, 2003. (R. 157-166). Claimant again appealed. In a decision dated May 12, 2004, the District Court remanded on the grounds that ALJ Horn failed to determine the severity and frequency of Spaulding's symptoms and related functional limitations. Spaulding v. Barnhart, No. 03 C 4393, 2004 U.S. Dist. LEXIS 8637, (N.D. Ill. May 12, 2004) ("Spaulding II").

The Commissioner then vacated ALJ Horn's decision and appointed a new ALJ to hear Spaulding's case. (R. 416). On July 27, 2005, claimant appeared with counsel at a hearing before ALJ John K. Kraybill ("ALJ Kraybill"). (R. 357-92). At that time, ALJ Kraybill considered claimant's request for disability insurance benefits from December 16, 1993, her alleged onset date, through December 31, 1998, the date last insured, as well as an application for social security income ("SSI") benefits filed on April 27, 2004.

On September 16, 2005, ALJ Kraybill issued a decision denying Spaulding's claim for disability insurance benefits, and awarding her SSI as of April 27, 2004. (R. 339-47). The ALJ found that prior to April 2004, claimant could perform her past relevant work as a payroll clerk and film developer. (R. 345). Relying in part on the testimony of medical expert Dr. Carl Leigh ("ME Leigh"), ALJ Kraybill found that "from December 16, 1993, the date the claimant claims her disability began, until at least December 31, 1998, the claimant could do, at most, light work, or work involving lifting no more than 20 pounds at a time and 10 pounds occasionally, with the additional functional limitation of requiring 4 to 5 unscheduled bathroom breaks, during the workday." (R. 344). He found claimant's condition had "worsened" since April 2004 "such that she needed more numerous and longer restroom breaks." (Id.). Consistent with this finding, the ALJ determined that claimant was disabled under the Act since "at least April 27, 2004." (R. 347).

Spaulding appealed the denial of her claim for benefits from December 16, 1993 through December 31, 1998 to the District Court. At that time, the Commissioner conceded that the ALJ failed to resolve all material factual issues related to Spaulding's claim, but opposed outright reversal of the decision and an award of benefits. The District Court allowed plaintiff to decide if she wished to "push ahead" with summary judgment, or if she preferred to accept the proposed remand. Spaulding v. Astrue, No. 05 C 6311, 2006 U.S. Dist. LEXIS 63407, *3 (N.D. Ill. July 14, 2006) ("Spaulding III"). Plaintiff elected to proceed with summary judgment. Spaulding v. Astrue, No. 05 C 6311, 2007 U.S. Dist. LEXIS 42118, *1 (N.D. Ill. March 2, 2007) ("Spaulding IV"). The Honorable James B. Moran ("Judge Moran") granted claimant's motion for summary judgment in part and remanded with instructions that the ALJ "specifically articulate his reasons for believing or not believing Spaulding's testimony as to her need for additional, extended, and unscheduled bathroom breaks." Id. at ** 2, 23. Judge Moran observed that "the crux of this disability determination appears to hinge on the number and length of bathroom breaks [claimant] would have needed in 1998," and directed the ALJ to consider all relevant evidence in the record. Id. at *25. The District Court explained that this "means assessing the previous testimony of plaintiff and medical and vocational experts, all of the medical records, evidence of plaintiff's symptoms, her diagnoses, and evidence of plaintiff's headaches and weakness that ensued after her episodes of vomiting and diarrhea." Id. Judge Moran held that "if the ALJ is unable to articulate specific reasons, drawn from the medical records and expert testimony, for any disbelief of [claimant's] testimony, he must award Spaulding the relief she requests." Id. at *24. The District Court also determined that "if [claimant] needed 4 or 5 or more unscheduled bathroom breaks lasting up to an hour or required more than 2 or 3 sick days per month, she would have been unemployable." Id.

Claimant appeared with counsel for another hearing before ALJ Kraybill on October 30, 2007. (R. 604-37). On February 8, 2008, the ALJ issued a decision denying claimant's request for disability insurance benefits for the period of December 16, 1993 to December 31, 1998. (R. 544-50). ALJ Kraybill determined that Spaulding was not disabled under the Act because the gastrointestinal disorders did not preclude performance of her past relevant work. (R. 549). The Appeals Council declined to assume jurisdiction over the ALJ's decision, and it became the final decision of the Commissioner. Nelms v. Astrue, 553 F.3d 1093, 1097 (7th Cir. 2009). Claimant then commenced the present action.


A. Medical Evidence

On March 30, 1988, Dr. Michael Colligan ("Dr. Colligan") examined Spaulding and diagnosed duodenitis with possible erosions and irritable bowel syndrome ("IBS").

(R. 108). At that time, Spaulding reported a two-year history of "symptoms of hyperacidity manifested by burning epigastric pain and nausea that is usually worse on an empty stomach," and episodes of alternating constipation and diarrhea. (Id.). Dr. Colligan prescribed Zantac on a trial basis. (Id.)

Spaulding returned to Dr. Colligan on April 28, 1992, complaining of "recurrent symptoms of postprandial nausea and vomiting, and attacks of constipation followed by bouts of diarrhea" over the past year. (R. 109). Claimant reported "several diarrheal stools over a 24-hour period, after which she restarts the cycle of constipation." (Id.). Dr. Colligan noted that claimant had gained 50 to 60 pounds, and "certain foods such as cheese and meat seem to cause the most symptoms." (Id.). The doctor opined that Spaulding's "symptoms sound like a combination of IBS and gastroparesis," and recommended an upper gastrointestinal ("GI") exam. (Id.).

Spaulding returned for further treatment on July 21, 1992, complaining of recurrent nausea, vomiting, and dry heaves. (Id.). Claimant reported that her symptoms initially improved after starting Zantac and Reglan in May, but started flaring up again in the past week. (Id.). She had lost 18 pounds, part of which was "intentional" as claimant had been using Slim Fast for breakfast and lunch. (Id.).

The record includes the results of a "negative CT scan of [claimant's] abdomen" dated August 6, 1992. (R. 81). On August 7, 1992, and after reviewing the CT scan, Dr. Colligan performed an endoscopic examination. (R. 80). He observed a small hiatal hernia with increased secretions in the stomach, and again diagnosed erosive gastritis (Id.). Dr. Colligan continued Spaulding's medical therapy with H2 blockers, Reglan, Carafate and Zantac. (Id.). On September 2, 1992, Spaulding called the doctor's office to report that she was "feeling much better" and that the problem was "milk products."

(R. 110).

On July 27, 1993, Dr. Eugene B. Loftin ("Dr. Loftin") noted that claimant "is taking antiinflammatory and muscle relaxant medications that may cause her to be inaccurate in handling money." (R. 89). Claimant returned to Dr. Loftin on December 7, 1993 and reported nausea, vomiting, and stomach pain "worse in AM." (R. 85) Dr. Loftin narrowed his diagnosis to either gastroesophageal reflux disease ("GERD") or pancreatic inflammation, prescribed Pepcid and Reglan, and ordered more tests. (Id.). On December 15, 1993, Spaulding called the doctor's office and requested a note for work because "they do not believe she is really sick." (Id.). Dr. Loftin wrote a note stating that Spaulding was under his care for "severe stomach pain" but could "continue to work her usual job." (R. 86).

Spaulding missed her next two scheduled appointments with Dr. Loftin on December 21, 1993 and January 4, 1994. (R. 84). She received treatment from Dr. Loftin on May 16, 1995, at which time he prescribed Reglan and Zantac. (Id.). On June 4, 1996, Spaulding contacted Dr. Loftin's office to request a refill of her prescription. (Id.). When informed that she could not receive a refill without an examination, Spaulding became "very mad" and stated that she could not afford a visit because she and her husband were out of work. (Id.). The record does not show that Spaulding received a refill of her medication at that time, or that she received any further treatment from Dr. Loftin. (Id.).

Three months later, on July 17, 1996, Spaulding returned to Dr. Colligan. (R. 110). According to the doctor's notes, claimant stopped seeing him because of an unpaid balance owed to his office and a change of insurance coverage. (Id.). Dr. Colligan reviewed Spaulding's medical file and noted that her symptoms had "responded partially" to medications in the past, but they were not "completely effective because some of her symptomatology was due to non ulcer dyspepsia." (Id.). He also noted that "since [Spaulding] has been off work for the past three years she has felt as well as she ever has. She has lost 40 lbs. and kept it off. She is only having minimal dyspepsia, occasional episodes of nausea and dry heaves. Bowel pattern is normal." (Id.).

After Spaulding applied for disability insurance benefits, the Bureau of Disability Determination Services ("DDS") requested that Dr. Colligan complete a disability evaluation form. (R. 100). In a form dated October 28, 1996, Dr. Colligan noted claimant's current diagnoses of duodenitis and hiatal hernia. (R. 100-01). He indicated that Spaulding had not lost weight and had no other impairments or conditions. (Id.). When asked to describe claimant's ability to perform a variety of work-related activities, Dr. Colligan reported that "[e]mployment-related stress cause[d] G.I. symptoms to become intolerable according to patient. She should not bend over or lift objects greater than 20 pounds because of hiatal hernia." (R. 101).

On January 6, 1997, Dr. Colligan examined Spaulding and completed a general medical report form at the request of the Social Security Administration. (R. 96-99). In the physical findings section, Dr. Colligan reported a history of gastroesophageal reflux and hiatal hernia for which claimant was taking Zantac and Reglan. (R. 96-97). The doctor's physical exam revealed a "slight tenderness in the left costal margin area" of claimant's abdomen and no palpable masses. (Id.). He recommended that claimant "continue medical management of above conditions." (Id.). The record does not include any evidence of claimant's treatment, if any, from January 1997 through December 31, 1998, her date last insured.

On February 16, 1999, Spaulding received treatment from Dr. Loren B. White ("Dr. White") at Northwest Gastroenterologists. (R. 259-62). Dr. White diagnosed first trimester pregnancy. (R. 262). He also noted claimant's history of GERD, hiatal hernia and IBS. (Id.). Spaulding returned for further treatment on May 26, 1999 and reported she was "still having reflux." (R. 257). Dr. White noted "no Tums - prenatal visit." (Id.). Spaulding canceled two follow-up appointments in 1999. (R. 256).

On September 28, 2000, Dr. White diagnosed claimant with esophagitis and nausea with vomiting. (R. 255). He performed an esophagogastroduodenoscopy ("EGD") plus biopsy on October 2, 2000. (R. 267). During that exam, Dr. White noted a "mild degree of esophagitis with perhaps... several small erosions." (Id.). He determined that cardia of the stomach revealed granulation, induration and edema "consistent with a moderate esophagitis." (Id.). Dr. White opined that "these symptoms would be consistent with [claimant's] abdominal pain," and continued Spaulding's prescription for Zantac. (Id.).

On April 2, 2001, Spaulding complained to Dr. White of abdominal pain "lower abdominal in nature, usually preceding or related to a bowel movement." (R. 276). Claimant had been taking Prevacid which, according to the doctor, resulted in "significant improvement in her flux, though [it] has not entirely disappeared." (Id.). A November 21, 2001 upper gastrointestinal and small bowel study ordered by Dr. White did not reveal any abnormalities. (R. 287).

The record includes a July 8, 2002 note from Dr. White stating that claimant "is currently under [his] care... for [treatment] of gastritis and abdominal pain... [and] diarrhea which may require frequent trips to restroom." (R. 477). On August 5, 2002, Dr. White noted claimant's report of frequent bowel movements of five to eight per day, with occasional vomiting. (R. 476). ...

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