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Leona Jean Stephenson v. Michael J. Astrue

November 8, 2012


The opinion of the court was delivered by: Jeffrey T. Gilbert Magistrate Judge


Claimant Leona Jean Stephenson ("Claimant") brings this action under 42 U.S.C. § 405(g), seeking reversal and remand of the decision by Defendant Michael J. Astrue, Commissioner of Social Security ("Commissioner"), in which the Commissioner denied Claimant's application for disability insurance benefits. This matter is before the Court on Claimant's motion for summary judgment [Dkt.#20]. Claimant argues that the Administrative Law Judge's ("ALJ") decision denying her application for disability insurance benefits should be reversed and remanded because the ALJ improperly credited the opinions of consulting, non-treating physicians over her treating physicians. For the reasons set forth below, Claimant's motion for summary judgment [Dkt.#20] is granted in part and denied in part. The decision of the Commissioner of Social Security is reversed with respect to the determination as to Claimant's mental impairments and affirmed with respect to the determination as to Claimant's physical impairments. This matter is remanded to the Social Security Administration for further proceedings consistent with the Court's Memorandum Opinion and Order.

I. Background

A. Procedural History

Claimant filed an application for Social Security disability insurance benefits and supplemental security income on July 10, 2010, alleging a disability onset date of February 1, 2007. R.52-53. Claimant's date last insured was December 31, 2011.*fn1 R.51. The Social Security Administration ("SSA") denied her application on September 25, 2007. R.54. Claimant then filed a request for reconsideration on October 16, 2007, which was denied on May 12, 2008. R.60, 62. Claimant filed a timely written request for a hearing on September 10, 2008. R.69. A hearing was held before the ALJ on March 11, 2010, at which both Claimant and Vocational Expert Leanne L. Caird testified. R.29. On May 11, 2010, the ALJ issued a decision denying the claims for benefits. R.9-28. Claimant filed a timely request on May 24, 2010, for review of the ALJ's decision with the SSA's Appeals Council. R.8. On April 29, 2011, the Appeals Council denied her request for review, thus rendering the ALJ's decision a final administrative decision by the Commissioner. R.1-4. Claimant timely filed a complaint in this court pursuant to 42 U.S.C. § 405(g) on July 15, 2011 [Dkt.#7].

B. Personal History

Claimant was born on June 27, 1959, and was forty-seven years old at the time of the alleged onset of her disability on February 1, 2007. R.51. She has an 8th grade education. R.34, 140. Her past relevant work was as a personal assistant for individuals with disabilities from 2000 to 2007. R.35, 142. Claimant claims she was forced to stop working on February 1, 2007, due to her physical and mental impairments. R.36, 135.

C. Medical Evidence

1. Claimant's Physical Impairments

Claimant suffers from multiple physical impairments including HIV, hypertension, asthma, obesity, and osteoarthritis. R.14. She was first diagnosed with HIV in February of 2007. R.220. However, Claimant is asymptomatic, does not take any anti-retroviral medications, and has not had any problem with opportunistic infections. R.301.

Claimant also suffers from hypertension for which she has been taking medication off and on for the last twenty years. R.301. Dr. Regina Kim, Claimant's primary treating physician, performed an exercise stress/resting test on April 21, 2009, indicating no ST-T changes to suggest ischemia or any arrhythmia. R.524. Claimant also was noted to consistently struggle with obesity which has become more severe over time. R.266, 377, 508. As of December 17, 2007, Claimant had a BMI of 40.75, but on January 12, 2010, she was noted to have a BMI of 48. R.366, 521. Claimant's trouble with asthma also was noted to cause shortness of breath. R.37.

Claimant also has a history of osteoarthritis causing pain in her knees, shoulders, and fingers. R.301. X-rays were taken of the claimant's shoulder on April 14, 2009, due to pain, but all results were normal. R.525. However, a MRI was taken a week later which revealed moderate tendinosis and moderate degenerative arthropathy of the joint at the top of the shoulder. R.532. On October 12, 2009, Dr. Kim noted Claimant complaining of pain in her legs, which is worse with activity and limits her to walking three blocks. R.508. This pain was noted to improve with medication. R.508. X-rays of Claimant's lumbar spine on January 12, 2010, showed a moderate loss of disc space height at the L5/S1 level. R.536.

On January 15, 2010, Dr. Kim completed an assessment regarding Claimant's capacity for work related activities. R.501-507. Dr. Kim noted an ability to lift 20 pounds occasionally and 10 pounds frequently and to sit for two hours, stand for two hours, and walk for one hour out of an eight hour work day. R.501-502. Somewhat inconsistently or confusingly, Dr. Kim also indicated that the Claimant could sit for two hours, stand for two hours, and walk for one hour at one time. R.501-502 (emphasis supplied). Dr. Kim further noted limitations in Claimant's ability to climb stairs, stoop, crouch or crawl, and an inability to climb ladders and kneel. R.504. However, Dr. Kim also noted Claimant maintains the ability to shop, travel without assistance, ambulate without assistance, prepare meals, take care of her personal hygiene, and sort, handle, and use paper/files. R.506.

On March 26, 2008, Dr. Barry Fischer performed a consultative evaluation ("CE") of Claimant for Disability Determination Services. R.302. Claimant complained of bilateral knee pain with swelling and Dr. Fischer noted a limited range of motion of both knees. R.302-303. Claimant had difficulty squatting and rising and was unable to walk on her toes or heals. R.304. Dr. Fischer also noted Claimant had some difficulty with ambulation, but her lower extremity muscle strength was normal and she was still able to stand and walk with no difficulty. R.304-305. Claimant also displayed no limitations in her upper extremities or spinal segments. R.303-304. Dr. Fischer diagnosed her with HIV, hypertension, obesity, asthma, and osteoarthritis of both knees. R.305.

Dr. Charles Wabner, a state agency consultant, performed a physical residual functional capacity ("RFC") evaluation on May 6, 2008.*fn2 R.331. That evaluation indicated that Claimant is capable of light work as she could lift 20 pounds occasionally and stand for six hours out of an eight hour work day. R.331.

2. Claimant's Mental Impairments

Claimant reported worsening symptoms of depression and anxiety during a visit with Dr. Roger Trinh at Howard Brown Health Center on December 17, 2007. R.283. Claimant stated that the basis for her problems is her difficult relationship with her ex-boyfriend who infected her with HIV. R.283. Claimant also stated she continues to care for her children without any problem. R. 283. Dr. Trinh noted during a follow-up visit on December 28, 2007, that Claimant felt a lot less depressed and anxious and that she believed her medication was helping. R.285.

Claimant also received weekly psychiatric treatment from Dr. Nancy Luna from October 2, 2007 through August 11, 2009. R.476-495. Dr. Luna diagnosed Claimant with major depressive disorder, recurrent severe without psychotic features and a Global Assessment of Functioning ("GAF") score of 40.*fn3 R.21. Dr. Luna noted Claimant was tearful during most sessions and that she suffers from major depression which is exacerbated by her family history and environmental stress. R.476-495. Claimant also was reported to grieve the loss of custody for three of her children and the difficulties she has raising her remaining three children, two of whom have autism. R.476-479.

After almost a year of treatment, Dr. Luna noted that Claimant's depression limits her ability to meet her basic activities of daily living. R.481. Dr. Luna wrote a letter on the Claimant's behalf on April 24, 2008, stating that she suffers from major depression and, despite her cooperation and commitment to therapy and her medication, she would struggle to work in any capacity. R.299. Claimant also requires assistance from her son's homemaker, her son's father, and her aunt to perform many common daily activities such as grocery shopping, cleaning, and cooking. R.299. Dr. Luna also stated that there was no concern for a thought disorder or for harm to Claimant's self or others.


Dr. Luna later provided a mental RFC on August 11, 2009. R.495. Dr. Luna

indicated a diagnosis of major depression with a GAF score of 40. R.496. Dr. Luna noted extreme limitations in five categories including maintaining attention and concentration for extended periods and maintaining socially appropriate behavior, and marked limitations in eight categories including carrying out short and simple instructions and sustaining an ordinary routine without supervision, indicating an overall prognosis of poor. R.497-500.

After funding for treatment with Dr. Luna ran out, Claimant began going to the Community Counseling Center of Chicago. R.547. There, Claimant was initially diagnosed with dysthymic disorder/neurotic depression and later with major depression.

R.550, 572. Plans were made in January 2010 for Claimant to receive monthly counseling and attend weekly group therapy sessions. R.20.

On May 2, 2008, Dr. Michael J. Schneider, a state agency consultant, performed a psychiatric review and diagnosed Claimant with depression but stated that her depression is insufficient to meet the listing requirements. R.319. Dr. Schneider noted that Claimant's medical providers varied greatly in their assessments of her mental status and stated that a mental RFC would be necessary to evaluate her. R.328. Dr. Schneider then performed a mental RFC and noted moderate limitations in Claimant's ability to maintain attention and concentration for extended periods and her ability to complete a normal ...

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