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Sarah Beth Lewis v. Michael J. Astrue

May 18, 2012


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

Memorandum Opinion and Order

Michael T. Mason, United States Magistrate Judge:

Claimant Sarah Beth Lewis ("Sarah" or "claimant") has a filed motion for summary judgment [17] 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, 42 U.S.C. §§ 416(i) and 423(d). The Commissioner has filed a cross-motion for summary judgment [19], in which he asks the Court to uphold the decision of the Administrative Law Judge. 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 for summary judgment is denied.


A. Procedural History

On March 13, 2008, Sarah filed applications for period of disability and disability insurance benefits ("DIB") alleging a June 5, 2006 onset of disability due to learning disabilities and hearing loss. (R. 62.) Her date last insured is March 31, 2008. (Id.) Sarah's applications were denied initially on May 22, 2008, and upon reconsideration on August 31, 2008. (R. 64-68, 72-75.) Sarah filed a timely request for a hearing on October 24, 2008. (R. 78-79.)

On March 18, 2010, Sarah appeared with counsel before Administrative Law Judge ("ALJ") Peter J. Caras. (R. 29-61.) On April 23, 2010, ALJ Caras issued a written decision denying Sarah's request for benefits. (R. 13-24.) Sarah filed a timely request for review of the ALJ's decision (R. 12), but the Appeals Council denied that request on April 14, 2011. (R. 1-4.) At that time, the ALJ's decision became the final decision of the Commissioner. Tumminaro v. Astrue, 671 F.3d 629, 632 (7th Cir. 2011). This action followed.

B. Medical Evidence

1. Treating Physicians and School Records

a. Ottawa Township High School and the LaSalle County Educational Alliance for Special Education

Records reveal that Sarah received a number of special education services during her time at Ottawa Township High School, as well as in elementary school. On November 10, 2001, Sarah, a freshmen at the time, underwent a "Social Development Study" with school social worker Debra R. Turner. (R. 247-49.) Turner reported that Sarah had received learning disability services since 1994. (R. 249.) According to Turner, Sarah presented with weak reading comprehension and math concept skills, difficulties with written expression, and problems remaining attentive and staying organized. (R. 248.) She described Sarah as a "very needy young lady" emotionally and noted that some of Sarah's behaviors were "immature for her age." (R. 248-49.) Turner recommended that someone work with Sarah to "discuss age appropriate behaviors in the school setting." (R. 249.)

Sarah underwent hearing testing at the LaSalle County Educational Alliance for Special Education Audiological Center on December 2, 2003 after failing two hearing screenings with the school nurse. (R. 230-31.) The tests revealed that Sarah had severe, low to high frequency, sensorineural hearing loss in the right ear. (R. 231.) Her "speech discrimination in soundfield was excellent (92%) in quiet and was reduced to fair (76%) with competing noise present." (Id.) The audiologist recommended an otologic examination, an audiologic re-evaluation following medical management, and "preferential seating such that speech is oriented toward the better left ear." (Id.)

School psychologist Paula Medema evaluated Sarah on December 12, 2003, at which time she was in the eleventh grade. (R. 245-46.) According to the Wechsler Adult Intelligence Scale-III, Sarah's verbal IQ was 85, her performance IQ was 76, and her full scale IQ was 79. (R. 246.) The Woodcock-Johnson Psychoeducational Battery revealed that Sarah's reading recognition skills were at a beginning fourth grade level, her comprehension skills were at the high fifth grade level, her math calculation skills were at the high fourth grade level, and her spelling skills were at the mid-fourth grade level. (Id.) According to Medema, Sarah's overall ability fell within the borderline range. (Id.) Medema did note that this might be a low estimate of Sarah's abilities because she entered the evaluation "somewhat hesitantly" and "full effort may not have been given when she was becoming frustrated." (R. 245-46.)

The record also includes two of Sarah's Individualized Education Plan ("IEP") Reports. The IEP Report dated March 4, 2004 includes comments on Sarah's recent hearing loss, her weak reading comprehension, abstract reasoning and organizational skills, and her tendency to become easily overwhelmed.(R. 232-44.)The IEP indicates that Sarah continues to benefit from "a program that can provide modified/adapted curriculum and instructions, services to help improve strategies to increase vocabulary and comprehension skills, and services to assist with distractibility and organizational skills and slow processing skills." (R. 236.) It was recommended that Sarah receive supplemental classroom notes from other students and that her seating assignment accommodate her hearing loss. (R. 239.)

The IEP Report from May 4, 2005 reveals that Sarah was on track to graduate high school and intended to attend "IVCC" (presumably Illinois Valley Community College) to study "interpreting for hearing impaired." (R. 222-29.) Post-secondary learning disability support was recommended upon graduation. (R. 228.)

On March 16, 2010, Dr. Karen J. Hoffman, Director of Special Needs at Ottawa Township High School, submitted a letter to the ALJ in support of Sarah's disability applications. (R. 186.) Dr. Hoffman reported that Sarah's school record reveals that she received special needs support services throughout high school for "significant deficits in the areas of visual abstract reasoning skills, weak organizational skills, distractibility, listening comprehension, reading comprehension, written expression, math calculations and math reasoning skills." (Id.) She further stated that Sarah's processing speed fell in the mild cognitive disability range, which "makes it extremely difficult for Sarah to grasp and retain new or difficult material." (Id.) Dr. Hoffman also explained that after high school, Sarah worked as a substitute teaching assistant, but was let go due to her level of performance. (Id.) In Dr. Hoffman's opinion, Sarah "will have extreme difficulty in finding and maintaining competitive employment." (Id.)

b. Ottawa Medical Center

On March 11, 2005, Sarah saw Dr. Brian Rosborough at the Ottawa Medical Center for "an examination for possible limited guardianship." (R. 192, 194.) In describing the history of Sarah's "present illness," Dr. Rosborough noted that she had "cognitive dysfunction with low average intelligence, not meeting the criteria for mental retardation." (R. 194.) Dr. Rosborough further noted that Sarah did not have a history of ADHD or depression, nor prior child psychiatric involvement or counseling. (Id.) Sarah's mother explained to Dr. Rosborough that she was concerned about guardianship because Sarah could not make decisions on her own or get a job handling money. (Id.) Dr. Rosborough also noted complaints of anxiety, low self esteem, and weak organizational skills. (Id.)

Dr. Rosborough's physical examination revealed unremarkable results. (R. 192.) He assessed a "mild cognitive impairment" and completed the medical report for the petition for appointment of guardianship. (Id.) He noted that the intent was for Sarah to live with her parents and continue basic education, with the goal of finding a suitable job and living situation. (Id.) On May 11, 2005, the Circuit Court of the Thirteenth Judicial Circuit of Illinois entered an order adjudicating Sarah disabled and appointed her parents her legal guardians. (R. 122-23.)

c. Dr. Amar Dave

On May 3, 2008, Dr. Amar Dave sent a letter to the Illinois Department of Human Services in support of Sarah's application for benefits. (R. 250.) Dr. Dave reported that he had reviewed Sarah's school records and examined her on May 2, 2008. (Id.) According to Dr. Dave, Sarah has a "significant cognitive deficit performing at 4-5 years of age." (Id.) He commented on the loss of hearing in Sarah's right ear, but noted there was no definitive determination as to the cause of that hearing loss. (Id.) Dr. Dave stated that Sarah's parents "take care of her life in every aspect." (Id.) Although Dr. Dave is described in the record as having treated Sarah on and off for her entire life, (R. 135), none of Dr. Dave's treatment records were a part of the record before the ALJ.*fn1

2. State Agency Consultants

On April 21, 2008, Dr. Joseph Mehr completed a psychiatric review technique for Sarah. (R. 201-14.) Dr. Mehr found that Sarah suffered from a organic mental disorder, specifically "borderline to low normal intellectual function." (R. 202.) He concluded that Sarah had mild restrictions of activities of daily living, mild difficulties in maintaining social ...

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