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Holliman v. Astrue

October 5, 2010


The opinion of the court was delivered by: Hon. P. Michael Mahoney Magistrate Judge


I. Introduction

Bonnie J. Holliman ("Claimant") seeks judicial review of the Social Security Administration Commissioner's decision to deny her claim for Disability Insurance Benefits ("DIB"), under Title II of the Social Security Act, and Supplemental Security Income ("SSI") benefits, under Title XVI of the Social Security Act. See 42 U.S.C. § 405(g). This matter is before the Magistrate Judge pursuant to the consent of both parties, filed on August 6, 2009. See 28 U.S.C. § 636(c); Fed. R. Civ. P. 73.

II. Administrative Proceedings

On January 21, 2005, Claimant applied for DIB and SSI alleging her disability onset date as June 15, 2004. (Tr. 110.) Claimant's application was initially denied on May 27, 2005, and then denied a second time upon reconsideration on September 23, 2005. (Tr. 99-101, 105-08.) Claimant then filed a timely request for a hearing before an Administrative Law Judge ("ALJ"). The hearing took place on December 11, 2007, via video teleconference between Evanston, Illinois and Rockford, Illinois, before ALJ Cynthia Bretthauer. The Claimant appeared pro se before the ALJ, but indicated that an attorney agreed to represent her if the hearing could be postponed. Relying on this information, the ALJ agreed to postpone the hearing. (Tr. 55-61.)

Claimant's attorney ultimately declined to take her case. (Tr. 64.) Claimant then sought legal representation from Prairie State Legal Clinic (PSLC). (Tr. 21-22, 65.) PSLC also declined to represent Claimant, because Claimant did not have supporting medical records and she "has a history of heavy drinking." (Tr. 21.) According to the declination letter, dated March 10, 2008, Claimant told PSLC that she had not been treated by a doctor for a year or more, and before that time (2007 and prior), she had only been treated "sporadically." (Tr. 21.) PSLC went on to communicate the importance of developing a current medical record, and recommended that Claimant contact Winnebago County Lawyer Referral to obtain counsel. (Tr. 21.) There is no evidence on record that Claimant made an effort to contact any other representative.

The rescheduled hearing was held on March 18, 2008. Claimant again appeared without an attorney present. (Tr. 62-86.) The ALJ reminded Claimant that the "last time [Claimant was in court] was in 2007, and [Claimant] was well aware of [her] rights[,] [a]nd [Claimant] had the list of attorneys and attorney referral agencies." (Tr. 64.) The ALJ then asked Claimant if she was ready to proceed without an attorney to represent her. (Tr. 65.) Claimant replied, "I guess so, ma'am. Yes, ma'am." (Tr. 65.) During the hearing, the ALJ heard testimony from both the Claimant and vocational expert ("VE") James J. Radke. (Tr. 62-86.)

On April 23, 2008, the ALJ found Claimant was not disabled and denied Claimant's applications for DIB and SSI. (Tr. 9-20.) On June 3, 2008, Claimant filed a Request for Review with the Social Security Administration's Office of Hearing and Appeals. (Tr. 7.) The Appeals Council denied Claimant's Request for Review on July 15, 2008. (Tr. 4-6.) As a result of the denial, the ALJ's decision is considered the final decision of the Commissioner. 20 C.F.R. §§ 404.981, 404.981, 416.1455, 416.1481. Claimant now files a complaint in Federal District Court seeking judicial review under 42. U.S.C. §§ 405(g), 1383(c)(3).

III. Background

Claimant was born on September 25, 1956, making her fifty-one years old at the time of the hearing. (Tr. 142.) She weighed approximately 190 pounds, and was five feet and two inches tall. (Tr. 178.) Claimant was not married and lived alone in an apartment in Rockford, Illinois. (Tr. 67-68.) Claimant speaks English fluently, and has completed her high school education. (Tr. 69.)

Claimant testified that her typical daily schedule consisted of waking up in the morning to attend rehabilitation treatment at Rosecrance, a substance abuse treatment facility in Rockford. (Tr. 85.) Since the Claimant does not drive, she rode the bus in order to get to the facility. Claimant further testified that she walked one city block to get to the bus stop from her apartment. (Tr. 85-86.) She normally received treatment at Rosecrance for approximately three hours. Afterwards, she walked to the nearest bus stop, and took the bus back home. (Tr. 85.) According to her testimony, once in her apartment, she often sat down, tried to clean, and made something to eat. (Tr. 85.) After eating, Claimant usually watched television until she went to bed. (Tr. 85.)

Claimant further stated that she generally did her own dusting and vacuuming. She washed her own dishes and cleaned her clothes by hand. She also testified that she was able to do her own grocery shopping. (Tr. 86.) She attended church two or three times a week, and maintained social relationships with her family and friends. She testified that she generally got along with other people. (Tr. 86a.) Occasionally, friends would drive her to run errands, or she rode the bus when she could afford it. (Tr. 69.) Around the time of the hearing, Claimant's brother and sister drove her to Iowa City, Iowa, in order to visit another sister in the hospital. (Tr. 86a.) Otherwise, Claimant tended to stay within the city limits. (Tr. 86a.)

Claimant regularly received $450 for her rent and $19 in additional assistance under Section 8. (Tr. 68.) See 24 C.F.R. § 5.601. She also was receiving a Link Card for the amount of $162 to pay for groceries. (Tr. 68.)

Although she was unemployed at the time of the hearing, Claimant has held several occupations over the past thirty years. (Tr. 70.) Most notably, she was employed as a cook, dietary aide, homemaker, machine operator, and factory assembler. (Tr. 159.) Claimant testified that she worked most recently as a babysitter for her grandchildren from 2005 to 2007. (Tr. 70.) She has not been employed since that time. (Tr. 70.) Claimant has alleged that she can no longer work due to asthma, high blood pressure, emphysema, depression, shortness of breath, stroke, and heart attack. (Tr. 142-45, 178.)

IV. Medical Evidence

On July 13, 1994, Claimant was brought to Rockford Memorial Hospital ("RMH") complaining of shortness of breath. (Tr. 354.) Claimant stated that she was taking medications for asthma, but could not relate what medications she was taking. (Tr. 354.) Dr. Dennis T. Uehara, M.D., diagnosed the Claimant with acute alcohol intoxication, and she was discharged. (Tr. 354.)

On March 24, 1997, Claimant was brought to RMH with chest pain. (Tr. 346.) Dr. Uehara noted that she had a "similar episode in 1992 which she thinks may have been a small 'heart attack.'" (Tr. 346.) At the time, Claimant stated that she had not experienced any chest pains since 1992. (Tr. 346.) Dr. Uehara discharged Claimant with a prescription for Toradol*fn1. (Tr. 346.)

On January 17, 1998, Claimant returned to RMH with pain in her right shoulder and neck. (Tr. 340.) Dr. Thomas S. Pannke, M.D., examined Claimant and diagnosed her with acute right shoulder strain. (Tr. 340.) She was given Toradol and Norflex*fn2 while at the hospital. (Tr. 340.) Dr. Pannke discharged Claimant and recommended that Claimant not work with her right hand for three days. (Tr. 340.)

On April 16, 1998, Claimant came to RMH complaining of hypertensive headaches, lightheadedness, and dizziness. (Tr. 337.) Dr. Robert W. Schwaner, M.D., noted that the symptoms started when Claimant ran out of her Procardia XL*fn3 prescription about three days prior. (Tr. 337.) Dr. Schwaner diagnosed Claimant with hypertension, recommended that she not work for the "next couple of days," and renewed Claimant's prescription for Procardia XL. (Tr. 337.)

On May 14, 1998, Claimant was treated at RMH after sustaining a fall. (Tr. 330.) Claimant complained of pain in her neck, buttocks, and a headache. (Tr. 330.) Dr. Craig H. Brown, M.D., diagnosed the Claimant with a severe headache ("acute cephalgia"), acute coccyx injury, and acute lumbosacral strain. (Tr. 330.) When examining Claimant's spine, Dr. Brown noted that there was "[f]ocal mild degenerative disc disease at L4-5, but [it was] advanced for [Claimant's] age." (Tr. 332.) Dr. Brown discharged Claimant after giving her Toradol. (Tr. 332.)

Claimant returned to RMH on May 20, 1998, complaining of more back pain related to her fall on May 13, 1998. (Tr. 326.) Dr. Brian N. Aldred, M.D., diagnosed Claimant with acute muscular back pain. (Tr. 326.) Claimant requested a "pain shot," and was given a shot of Toradol. (Tr. 326.). Dr. Aldred instructed Claimant to follow up with her doctor and to rest. Claimant was discharged in "good condition." (Tr. 326.)

On June 5, 1998, Claimant entered RMH for anxiety. She complained of a mild headache and was worried about her blood pressure. (Tr. 323.) Again, as on April 16, 1998, Claimant stated that she ran out of her Procardia XL medication approximately three days prior. (Tr. 323.) Dr. Pannke diagnosed Claimant with acute psychological stress, elevated blood pressure, and noted Claimant's "history of hypertension." (Tr. 323.) Claimant was given a single dose of Procardia XL and a few Xanax*fn4. She was asked to follow up with Dr. Ramchandani to recheck her blood pressure. (Tr. 323.) She was also given another prescription for Procardia XL. (Tr. 323.)

Five years later, on June 23, 2003, Claimant entered RMH complaining of a severe headache. (Tr. 315.) Dr. Jane L. Kotecki, M.D., noted that Claimant has had a history of "hypertension, medical noncompliance, and alcohol abuse." (Tr. 315.) Claimant's physical examination revealed that the Claimant was "grossly intoxicated" at the time of her admittance. (Tr. 315.) Dr. Kotecki diagnosed the Claimant with acute hypertensive urgency, acute alcohol intoxication, and "chronic and continuous" alcohol abuse. (Tr. 315.) Claimant was given Lopressor*fn5, Clonidine*fn6, and Dilaudid*fn7. Claimant was discharged and ordered to see her doctor at Crusader Clinic ("Crusader") in one to two days for a checkup. (Tr. 315.)

On March 11, 2004, Claimant entered Crusader with an asthmatic attack and signs of an upper respiratory tract infection. (Tr. 225.) Dr. Adekola Ashaye, M.D., gave Claimant nebulizer treatment. (Tr. 225.) After the treatment, Claimant showed signs of improvement. (Tr. 225.) Dr. Ashaye then referred Claimant to the emergency room ("ER") in order to manage her blood pressure. (Tr. 225.)

Claimant was then immediately taken to SwedishAmerican Hospital ("SAH"). (Tr. 206.) Claimant stated that she had not been taking her medication for approximately two years because she could not afford it. (Tr. 206.) Claimant also stated that she had been coughing up blood for a period of two months. (Tr. 206.) Dr. Michael P. Lehmann, M.D., prescribed Procardia XL, Albuterol*fn8, and Atrovent*fn9. (Tr. 206.) Dr. Lehmann diagnosed Claimant with hypertensive urgency and hemoptysis ("coughing blood"). (Tr. 206.) Dr. Lehmann agreed to discharge Claimant home, but advised her to get her blood pressure checked the next day at Crusader. (Tr. 206.)

On March 20, 2004, Claimant returned to Crusader with hypertension. (Tr. 224.) Dr. Ashaye noted that Claimant "[h]as been going up and down through [the] ER and [Crusader] and has not been collecting her medications." (Tr. 224.) Dr. Ashaye continued: "[Claimant] will be seen in the ER and given prescriptions[,] but until the last nine days since I [have seen] her, she has not picked up any of her prescriptions. She says she has no money." (Tr. 224.) Dr. Ashaye contacted the pharmacy and managed to get Claimant into a program to help her pay for her prescriptions. (Tr. 224.) Under the program, Claimant was able to receive her monthly Atacand prescription for five dollars. (Tr. 224.)

On April 8, 2004, Claimant returned to Crusader with hypertension. (Tr. 222.) Dr. Ashaye noted that Claimant was taking her medication, and increased her Toprol XL*fn10 prescription. (Tr. 222.) Claimant was also given a prescription for a Combivent*fn11 inhaler, and Lasix*fn12. (Tr. 222.)

On April 22, 2004, Claimant returned to Crusader. Dr. Ashaye stated that he has "had problems controlling [Claimant's] blood pressure, primarily because [Claimant] cannot afford the medications." (Tr. 221.) He continued: "I got [Claimant] into a free drug program... She did not take the Toprol as directed... I have explained to her that the problem [with] her blood pressure control has to do with [her not taking the] medications." (Tr. 221.)

On April 29, 2004, Claimant returned to Crusader to see Dr. Ashaye. (Tr. 220.) In her report, Dr. Ashye stated: "We have helped [Claimant] with her medications from the drug assistance program... Toprol XL at a maximum dose and Atacand*fn13 are not helping her blood pressure. She is supposed to be taking Lasix. She has not taken it." (Tr. 220.) After Claimant declined to be taken to the ER, Dr. Ashye explained the dangers inherent in not complying with her medications. (Tr. 220.)

On May 20, 2004, Claimant went to see Dr. Ashaye at Crusader again. (Tr. 219.) Dr. Ashaye reported that "[t]his is the first time during all of her visits that her blood pressure has come down to 110/60 sitting, 110/70 standing. She feels ...

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