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Angelina Jimenez v. Michael J. Astrue

July 5, 2011


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


Michael T. Mason, United States Magistrate Judge:

Plaintiff Angelina Jimenez ("Jimenez" or "claimant") filed this action seeking judicial review of the final decision of the Commissioner of Social Security (the "Commissioner") that denied her claim for Supplemental Security Income benefits. The Commissioner argues this Court should affirm its decision. We have jurisdiction to hear this matter pursuant to 42 U.S.C. § 405(g). For the reasons set forth below, Jimenez's motion for summary judgment [15] is granted.


A. Procedural History

Jimenez began receiving Supplemental Security Income ("SSI") disability benefits as a minor in 1998. (See R. 37, 186-88.) Claimant reached age 18 on August 13, 2005, at which point her eligibility for benefits was subject to reevaluation. (R. 110, 113-22.) The Bureau of Disability Determination Services determined the claimant to no longer be disabled as of January 1, 2006. (Mem. at 1 [16]; R. at 24; see also R. 128.) Claimant appealed that decision. (R. 129-43.) Following a disability hearing, Disability Hearing Officer Mike Finley upheld that determination upon reconsideration. (R. 82-90.) Thereafter, Jimenez requested a hearing, which was held on June 23, 2008, before Administrative Law Judge Michael G. Logan ("ALJ Logan" or the "ALJ"). On February 4, 2009, ALJ Logan issued a written decision denying Jimenez's request for benefits. (R. 22-32.) Claimant appealed the ALJ's denial to the Appeals Council, which denied her request for review and adopted the ALJ's decision as the final decision of the Commissioner. (R. 7-10.) Jimenez subsequently filed this action.

B. Medical History

As a minor, claimant previously received disability benefits. Claimant's medical records reflect that claimant has been diagnosed with attention deficit hyperactivity disorder ("ADHD") and behavior disorder, learning disability, and depressive disorder. For example, Walter Pedemonte, a psychiatrist at Saint Mary of Nazareth Hospital Center ("St. Mary's") in Chicago, Illinois, treated claimant with individual outpatient psychotherapy sessions and managed her medications for ADHD and conduct disorder from January 12, 1998 until November 2, 2000. (See R. 189-219.) In April 1998, Carl Hermsmeyer, Ph.D., reviewed Jimenez's records on behalf of the Social Security Administration ("SSA"), and determined she was eligible for disability benefits for ADHD, "predominantly Hyperactive-Impulsive Type; [and a] Learning Disability." (R. 186-88.)

The SSA periodically reviews all SSI disability cases to determine if an individual receiving benefits remains disabled. See 42 U.S.C. § 1383 (a)(2)(G)(i). Here, that reevaluation process began in April 2001. On April 13, 2001, Jorge Fernald, M.D., a consultative examiner, examined claimant and prepared a "Psychiatric Evaluation" report for the Bureau of Disability Determination Services (the "Bureau"). (R. 292-97.)

He found that Jimenez had signs and symptoms of inattention, hyperactivity, and impulsivity. (R. 296.) Additionally, Dr. Fernald's report states "There is no history of auditory, visual, or tactile hallucinations. She admits though she may have some tactile hallucinations .... She admits to, in the past, hearing voices but no longer." (R. 293.) Dr. Fernald found Jimenez did not have psychotic or mood symptoms during the interview, but had "significant depressive symptoms including suicidal ideation and sadness most days" (R. 296.) Dr. Fernald diagnosed claimant with ADHD, "Combined Depressive Disorder," and "Learning Disability." (R. 297.) In May 2001, Jerrold Heinrich, Ph.D., used Dr. Fernald's report, along with claimant's medical records from St. Mary's, in reevaluating claimant on behalf of the Bureau. (R. 298-303.) He concluded claimant remained disabled and had impairments of ADHD, "Depressive Disorder, Learning Disability [and a] history of conduct disorder." (R. 298.)

As noted above, claimant reached age 18 on August 12, 2005. In advance of that birthday, on August 2, 2005, claimant participated in a "Continuing Disability Interview" with a representative of the SSA whose name is illegible in the record. (R. 113-122.) According to that representative's report, claimant stated she was receiving disability benefits for ADHD, there was no change in her condition, and she did not have any new injuries or illnesses. (R. 113.) Claimant also reported that she is "going to start seeing" a "Dr. Chain/St. Elizabeth." (R. 114.) Given the subsequent history, we assume claimant was referring to Dr. Chung K. Chen, and mentioned St. Elizabeth due to its affiliation with St. Mary's as part of Resurrection Health Care. (See R. 437.) The record does not indicate how claimant was originally put in contact with Dr. Chen.

On September 2, 2005, claimant had her first meeting with Dr. Chung K. Chen, a psychiatrist at St. Mary's.*fn1 (R. 384.) Dr. Chen's notes on this date are largely illegible. Claimant had her second meeting with Dr. Chen on December 21, 2005. (R. 383.) Dr. Chen's notes from this meeting are also largely illegible. (Id.)

On December 13, 2005, claimant completed an "Activities of Daily Living Questionnaire" for the Bureau. (R. 123-27.) Among other things, she reported that she watches her children and plays with them, but that her mother-in-law does all the chores, cooking, and cleaning. (R. 123, 126.) Claimant reported that she "wash[es] up and dr[ies] off" but that her mother-in-law does her hair and chooses the claimant's clothing. (R. 124.) She also reported she heard voices of people who were not around, but that they did not interfere with her activities. (R. 124.) Those voices told her not to go outside, and when she went outside, she reported being afraid that people were looking at her, talking about her, or would call her names. (R. 124-125.) She wrote she does not like to be around people she does not know because she thinks they are trying to hurt her. (R. 125.) She also reported leaving her home "when necessary [sic]" to visit family and keep appointments, and that her condition had not changed this. (Id.)

On January 5, 2006, Richard S. Abrams, M.D., performed a psychiatric examination of claimant on behalf of the Illinois Bureau. (R. 304-05.) According to Dr. Abrams' report, claimant told him, among other things, that her hobbies are "watching cartoons" and "playing with her children." (R. 304.) She stated that she cooks, cleans, and goes to church every two weeks. (Id.) She also reported that she has no female friends, lives with her boyfriend, and talks to her sister once a week. (Id.) Claimant said that she was afraid of going out alone and so she does not take public transportation. (Id.) Dr. Abrams wrote that claimant has had three psychiatric hospitalizations and sees a psychiatrist monthly for medication. (Id.) Claimant evidently reported that she used to have "talking sessions years ago, but not now," and that "she takes no medications currently" and "has not used street drugs or alcohol." (Id.) Dr. Abrams also wrote that claimant reported "[s]he hears voices to kill herself since age 11 [sic]," and that she "has not made suicidal attempts, but has had the thoughts." (Id.) She also told him that three years earlier, she had worked in a fast food restaurant for one week. (Id.)

Dr. Abrams also wrote that, during his examination, claimant's voice was soft and depressed, she did not slur her speech, and she was rational and coherent but superficial. (R. 304.) He found "no gross sign of thought disorder or psychosis." (Id.) He also found "no insights into the nature of her problems and little motivation for such." (Id.) Dr. Abrams found her memory and attention span "were only fair," and her IQ was "at best borderline" from the clinical exam. (Id.) He opined that claimant "appeared very anxious," related with shyness and insecurity, her memory and attention span were "only fair," and she "showed clearly a very low IQ." (R. 304, 305.) He wrote "I did not think she was malingering." (R. 305.) Dr. Abrams concluded by diagnosing claimant with "schizoaffective disorder, 295.70 with depressive features, in partial remission." (R. 305.) He also wrote that claimant had a "[history] of ADHD, but not evident now," found "Borderline intellectual functioning," and noted that if declared disabled, "she would not be able to handle her own funds due to her poor ability to calculate." (Id.)

On January 17, 2006, Kirk Boyenga, Ph.D., a non-examining medical consultant for the Bureau, completed a mental residual functional capacity ("RFC") assessment of claimant. (R. 34, 323-26.) He concluded, among other things, that claimant was moderately limited in her abilities to: carry out detailed instructions, maintain attention and concentration for extended periods; complete a normal workday and workweek without interruptions from psychologically based symptoms; and perform at a consistent pace without an unreasonable number and length of rest periods. (R. 323-24.) He found that claimant "experiences an affective disorder, a history of learning problems, and a history of substance addiction." (R. 325.) He noted that there was no documentation to corroborate Jimenez's statement that she has received mental health care. (Id.) He also wrote that "[s]he denies the current use of psychotropic medication, which raises a question about treatment and severity." (Id.) He noted that her "[c]redibility is also suspect, in light of some inconsistent reports in the record." (Id.) Dr. Boyenga also found Jimenez was "acceptably oriented and free of thought disorder." (Id.) He noted that although her "sustained concentration is impaired," claimant is "able to care for three children, prepare meals, do cleaning and play games." (Id.) He also wrote that she was able to retain family relationships but her social skills were impaired, and that she was able to perform simple tasks in settings with reduced interpersonal contact. (Id.) Finally, he noted that "Reports of travel are inconsistent" and "[f]ield office information and SSA form 454 indicates the capacity for independent travel." (Id.)

Dr. Boyenga separately completed a "Psychiatric Review Technique" report regarding claimant. (R. 327-340.) He noted a history of learning problems and possible schizoaffective disorder. (R. 328, 330.) He also found moderate restrictions in Jimenez's activities of daily living, moderate difficulties in maintaining social functioning, moderate difficulties in maintaining concentration, persistence or pace, and no episodes of decompensation. (R. 337.)

Phyllis Coon, a representative of the Bureau, met with the claimant on January 18, 2006 and filled out a "Report of Contact" that day. (R. 128.) Ms. Coon reviewed the results of Dr. Boyenga's mental RFC assessment. (Id.) On behalf of the Bureau, Ms. Coon determined that claimant was not disabled and that she could work in an occupation not requiring close supervision or close cooperation with co-workers. (Id.)

On February 6, 2006, claimant saw Dr. Chen for the third time. (R. 383.) Although Dr. Chen's notes from this meeting are illegible to this Court, the ALJ stated in his opinion that Dr. Chen noted the claimant complained of depression. (R. 28.)

On February 12, 2006, claimant completed a form entitled "Disability Report -Appeal." (R. 129-36.) On that form, she wrote, among other things, that since she last completed a disability report, there had been a change in her condition, specifically, "Since she's been talking diphentycramine, Zoloft, Geodon the Anxiety worsen and her Behavior change. She's angry a lot, has a hard time sleeping, has angry feelings, she's very hyper talking, she's anxiety throught social activitys and doesn't want to eat [sic]."

(R. 129.) She also wrote she had experienced new limitations in "mental health, antidepression, paranoid, nervous behavior and unstable [sic]." (Id.)

The next day, February 13, 2006, claimant admitted herself to St. Mary's at approximately 4:30 pm, where she stayed until February 15, 2006. (R. 341-71.) During her stay, claimant complained of depression and auditory hallucinations, and indicated she had been non-compliant with her medication. (R. 350-52, 422.) Her drug screen tested positive for cannabinoids. (R. 349.) While admitted, claimant attended group, occupational, activity, and one-on-one therapy. (R. 351.) Hisham S. Sadek, M.D., was the claimant's attending physician, and he conducted a mental status examination. (R. 354-55.) In a report entitled "Psychiatric Evaluation," Dr. Sadek stated that claimant was "alert and oriented times three and appears to be of an average intelligence." (R. 355.) She reported "commanding hallucinatory experiences telling her that life is not worth living," but "denied any visual hallucination" or "delusional thoughts of any nature." (Id.) She also reported using marijuana prior to admission. (R. 354.) Dr. Sadek gave her a Global Assessment of Functioning ("GAF") score of 30. (R. 355.) His discharge report indicated that claimant had a good attention span with no impairment for recent, remote, or immediate recall. (R. 350-352.) He diagnosed claimant with "Major depression recurrent with psychotic features" and a history of cannabis abuse. (R. 350, 355.) Dr. Sadek noted claimant's "disposition" on discharge to be "fully stabilized," and that she was "discharged with prescriptions for Zoloft, trazodone and Risperdal [sic]."

(R. 351.) He also advised claimant "to see Dr. Chen for follow-up care on 2-20-06," and referred claimant to Dr. Chen's office "at St. Elizabeth Hospital." (Id.)

While being discharged from St. Mary's, claimant also met with Sheila Soto, a social worker. (R. 413-14.) According to Ms. Soto's discharge notes, claimant told Ms. Soto that she came to the hospital for depression and hearing voices, "male, female voice telling me that my kids do not love me and nobody love me and to leave. I try to fight them back." (R. 413.) Ms. Soto wrote that claimant "said that now that she is taking medication she is not depressed any more and is not hearing voices." (Id.) Ms. Soto also wrote that claimant "is preoccupied with discharge." (Id.) Claimant evidently also told Ms. Soto that she does not smoke marijuana but "she has been around people who use; her girlfriend gave her a roll-up but she was not aware it had marihuana." (Id.) With respect to claimant's mother, claimant reported to Ms. Soto: "I used to have a good relationship with her but not anymore, I just say Hi and bye to her." (R. 414.) Ms. Soto recommended "activity therapy, occupational therapy, 1:1, educational groups, and medication management under the care of Hisham Sadek, MD." (Id.)

At this same time in February 2006, claimant completed a second form entitled "Disability Report - Appeal." (R. 137-43.) Beneath the question asking whether there has been any change in illnesses, injuries, or conditions, claimant checked the box for "yes" and the word "depression" is typed as her description of that change. (R. 137.) Claimant stated that change occurred on February 13, 2006. (Id.) Claimant listed Dr. Chen of "St. Elizabeth" as a doctor she visited for "depression." (R. 138.) Where the form asked "How do your illnesses, injuries or conditions affect your ability to care for your personal needs," the word "NONE" is typed. (R. 141.) Where asked "[w]hat changes have occurred in your daily activities since you last completed a disability report?", "I SOMETIME HEAR VOICES [sic]" is written. (Id.)

On September 19, 2006, L.M. Hudspeth, Psy.D., completed a "Psychiatric Review Technique" form regarding claimant for the Bureau. (R. 310-22.)*fn2 Dr. Hudspeth did not examine claimant, but relied on her "updated medical records," specifically listing Dr. Abrams' report from January 2006 and claimant's February 2006 hospitalization at St. Mary's. (R. 322.) He indicated that the categories on which his medical disposition was based were 12.04, Affective Disorders, and 12.09, Substance Addiction Disorders.

(R. 310.) Dr. Hudspeth noted claimant's complaints of auditory hallucinations and some suicidal ideation, as well as her reports that she was afraid of being around people and needed to be instructed to care for her children. (R. 322.) Following that description, Dr. Hudspeth wrote: "This is not supported by the medical evidence in the file." (Id.) He also wrote: "It is established that the client would be capable of performing a wide range of unskilled tasks." (Id.) Finally, he concluded the evidence did not establish the presence of required criterion for the Affective Disorder listing.*fn3 (R. 321.)

That same day, September 19, 2006, Dr. Hudspeth also completed a mental RFC assessment of claimant. (R. 306-09.)*fn4 Based on unspecified "enclosed medical information," he found that claimant had a moderate limitation in her ability to understand, remember and carry out detailed instructions. (R. 308; see also R. 322.) He also concluded claimant had moderate limitations in her ability to maintain concentration, persistence and pace for an extended period of time. (Id.) Dr. Hudspeth found claimant had no limitations in her ability to understand, remember and carry out very short and simple instructions. (Id.) He determined she was capable of performing a wide range of unskilled tasks and substantial gainful work activity. (Id.)

Despite having been advised during her February 15 discharge from St. Mary's to follow up with Dr. Chen on February 20, the record indicates that claimant did not see Dr. Chen for over eight months following her discharge. (R. 351, 383.) On November 1, November 29, 2006, and December 20, 2006, claimant saw Dr. Chen for the fourth, fifth, and sixth times. (R. 383.) Although the notes from those meetings are largely illegible to this Court, the ALJ stated in his opinion that claimant complained of hallucinations during her November 1st meeting with Dr. Chen. (R. 30.)

On January 3, 2007, claimant had a hearing with Disability Hearing Officer ("DHO") Mike Finley, to determine whether claimant remained disabled under the Social Security Act. (R. 144-55, 82-90.) Among other things, claimant told the DHO she spent her days playing with dolls and her children, and that her mother provided childcare (R. 82, 148.) She also told the DHO that she is afraid of people but that her medications help because they calm her. (R. 82-83.) Claimant also indicated that she left her home when she has had her medication, and her mother would make sure she returned before her medications wore off. (Id.) The DHO observed claimant to be "very childlike," reported that she "frequently asked if candy would be made available to her" and if there was a television in the hearing office, and that "she stated over and over that she really liked cartoons." (R. 83.)

On May 1, 2007, DHO Finley rendered a decision based on claimant's school and medical records and testimony. (R. 82-90.) He found that the claimant was not disabled, and that a cessation of disability benefits, effective January 2006, was appropriate. (R. 86.) In reaching his decision, DHO Finley explained:

The claimant has history of depression however, the claimant clearly exaggerated her condition to the point that her testimony is not believable. The claimant has irregular treatment with her physician and was hospitalized the month that she received her cessation notice. This seems to be convenient hospitalization. The claimant acted in a very child-like manner, claimed to receive Special Education Services when in fact testing from school indicates claimant functions in the low-average range of intellectual ability. Therefore the severity of the claimant's condition is not determinable due to claimant faking her condition in a very poor manner [sic].

(R. 87.)

Between February 7, 2007 and October 3, 2007, claimant met with Dr. Chen on ten occasions. (R. 385-87.) On February 14, 2007, Dr. Chen completed a "Psychiatric Report" for submission to the Bureau. (R. 372-75.) In this report, he noted that he had met with claimant that day and the frequency of her visits was "irregular." (R. 372.) Dr. Chen reported that the claimant was "sad and worried," "soft spoken but coherent and relevant in general," had "fair" orientation, and had "auditory and visual hallucinations and some paranoia." ...

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