United States District Court, N.D. Illinois, Eastern Division
GORDON D. SOTO, Plaintiff,
CAROLYN W. COLVIN, Acting Commissioner of Social Security,  Defendant.
MEMORANDUM OPINION AND ORDER
SIDNEY I. SCHENKIER, Magistrate Judge.
Plaintiff Gordon D. Soto seeks reversal and remand of the final determination by the Commissioner of Social Security ("Commissioner"), denying his application for Supplemental Security Income ("SSI") and Medicare Qualified Government Employee benefits ("MQGE") (doc. #23). The Commissioner has responded, seeking affirmance of the decision denying benefits (doc. #27). For the following reasons, the Court grants Mr. Soto's motion and denies the Commissioner's motion.
On May 18, 2010, Mr. Soto applied for MQGE and SSI, alleging a disability onset date of December 10, 2008 (R. 165-68, 171, 185). His last-insured date was December 31, 2008 (R. 185). Mr. Soto was thus obligated to show that he was disabled between December 10 and December 31, 2008 in order to qualify for MQGE. See 20 C.F.R. §§ 404.130, 404.131, 404.315(a)(1), 404.320(b). To qualify for SSI, Mr. Soto must show that he was both disabled and financially eligible at any time after the filing of his May 18, 2010 application and prior to the March 20, 2012 Administrative Law Judge ("ALJ") decision. See 20 C.F.R. §§ 416.200, 416.202, 416.203, 416.305, 416.335.
At the administrative level, Mr. Soto claimed an inability to work due to "injuries after a fall of 15 feet off of a ladder" while working at a construction site, specifically because of arm and shoulder pain and weakness, as well as increased stress and depression beginning in May 2010, worsening hand inflammation and arthritis, digestive problems, and gum disease (R. 189, 196, 202, 217). Mr. Soto's claims were denied initially, and upon reconsideration (R. 89-93, 95-97). He requested a hearing before an ALJ, which was held on November 11, 2011 (R. 102-104, 41-79). In a written opinion issued on March 20, 2012, the ALJ concluded that Mr. Soto was not disabled through the date of the opinion (R. 20-30). The Appeals Council denied Mr. Soto's request for review of the ALJ's decision (R. 1-6), making the ALJ's decision the final decision of the Commissioner. See 20 C.F.R. § 404.981; Shauger v. Astrue, 675 F.3d 690, 695 (7th Cir. 2012).
We begin with a summary of the administrative record. We review Mr. Soto's general background and medical record in Part A; the hearing testimony and post-hearing medical consultation in Part B; and the ALJ's written opinion in Part C.
Mr. Soto was born on August 30, 1951, and was 60 years old at the time of the hearing (R. 48, 80, 185). Mr. Soto is a college graduate with a degree in music education (R. 49, 189); he worked as an elementary school music teacher from 1996 through 2006 (R. 190). Mr. Soto's most recent work experience was self-employment in drywall construction from 2006 until December 10, 2008, when he fell from a ladder while working (R. 46, 59, 190). Mr. Soto asserts that as a result of the fall he became unable to work, but he did not seek medical attention for his injuries until later, stating that he could not afford the medical expenses because he was uninsured (R. 59, 207). Mr. Soto explained that he is "broke" and has "tried to file bankruptcy" (R. 205). He also wrote that he could not "afford to go to a doctor because [he had] no medical insurance" and was afraid the financial strain would cause more stress (R. 207). Mr. Soto instead has tried alternative treatments, such as massage and paraffin wax therapy, which have provided little relief (R. 65, 66).
Because Mr. Soto rarely sought medical treatment, the bulk of his medical record consists of documents from doctors who examined him or reviewed his medical records in connection with his social security applications. On May 24, 2010, shortly after Mr. Soto filed his disability applications, state agency consulting physician Norma Villanueva, M.D. examined him (R. 275-77). Dr. Villanueva determined that Mr. Soto could not lift more than ten pounds at a time and that he had a 20 percent reduced capacity to push and pull and to perform gross manipulation ( Id. ). Dr. Villanueva reported tenderness and a reduced range of motion in Mr. Soto's right shoulder (R. 276). She also observed that he had a normal gait with full capacity to walk and full grip strength in both hands ( Id. ). She diagnosed Mr. Soto with "possible posttraumatic arthritis" in the right shoulder, and noted that he "didn't go to see a doctor or go to any hospital due to not having insurance" (R. 277).
On July 14, 2010, Mr. Soto met with Corpia Smith, M.D., to establish primary care and have a full physical examination (R. 343-46). Dr. Smith noted that Mr. Soto "ha[d] not seen a physician since 2004 and currently uses alternative herbs for illnesses as well as acupuncture if he endures any pain" (R. 343). Dr. Smith observed that Mr. Soto had "reflexes 2" and "muscle strength 5 throughout upper and lower extremities, " with "[n]o swelling or tenderness appreciated in upper or lower extremity joints [bilaterally]" (R. 344). Dr. Smith reported that ten years earlier Mr. Soto's brother had killed his wife and children and then committed suicide, and as a result of that tragedy Mr. Soto suffered guilt and depression (R. 343). During the examination, Mr. Soto expressed "concerning thoughts about suicidal ideation, " leading Dr. Smith to recommend that Mr. Soto follow up with a social worker, which he did on that same day (R. 345-47). The social worker with whom he met, Diane Ativie, reported that Mr. Soto had no current suicidal or homicidal intent ("SI/HI") and had no history of psychiatric treatment for SI/HI (R. 347). Ms. Ativie concluded that she would offer Mr. Soto support as needed ( Id. ).
On July 15, 2010, state agency medical consultant Ernst Bone, M.D., reviewed Dr. Villanueva's May 2010 report and completed a physical residual functional capacity ("RFC") assessment for Mr. Soto (R. 282-89). Dr. Bone found that Mr. Soto could lift, carry, push or pull up to twenty pounds occasionally and up to ten pounds frequently; stand or walk for about six hours in a normal eight-hour work day; sit about six hours in a normal eight-hour work day; and occasionally climb ladders and scaffolds (R. 283-86). In addition, Mr. Soto had a limited ability to push or pull or reach in all directions with his upper extremities, and should avoid exposure to certain hazards, such as certain machinery and heights ( Id. ). Dr. Bone assessed Mr. Soto's fingering ability as unlimited in both hands (R. 285). On October 19, 2010, state agency medical consultant James Madison, M.D., affirmed Dr. Bone's RFC assessment (R. 327-32).
On September 27, 2010, state agency consulting physician Roopa K. Karri, M.D., examined Mr. Soto (R. 294-97). Dr. Karri noted that Mr. Soto had borderline high blood pressure, a reduced range of motion in both shoulders, a history of arthritis in his hands with decreased grip strength of 3/5, and was obese (R. 295-97). Dr. Karri observed Mr. Soto was "able to get on and off the exam table" and "could walk 50 feet without support" (R. 296). He had "moderate difficulty squeezing the blood pressure pump, " "mild difficulty with buttoning, zipping, and tying shoelaces, " and could "make fists and oppose fingers" ( Id. ). She also reported that he had "tenderness in [his] fingers with small nodules" ( Id. ).
On January 4, 2011, Mr. Soto visited rheumatologist Amir Patel, M.D., to evaluate joint pain and swelling his hands (R. 341-43). Dr. Patel noted that Mr. Soto's prior arthritis had resolved in 2004 but had returned in 2010, and that although Mr. Soto did not take any over-the-counter pain relievers, he did use yoga and acupuncture for relaxation ( Id. ). That same day, x-rays were taken of Mr. Soto's hands and showed a "mild narrowing" and "mild sclerosis" of the finger joints, with "no soft tissue swelling or calcification" (R. 338). Dr. Patel diagnosed Mr. Soto with oligoarthropathy (multiple joint disease), most likely due to osteoarthritis (R. 342). Dr. Patel recommended Voltaren gel for the hand pain and advised Mr. Soto to follow up with his primary care physician (R. 343).
On October 19, 2011, Mr. Soto visited Zachary Smith, D.O., complaining of urinary difficulty (R. 351-58). Dr. Smith took Mr. Soto's medical history, including the fall from the ladder (R. 351). Dr. Smith noted that Mr. Soto "had difficulty rehabilitating" from the fall, "still thinks he has weakness today[, and] tries to do pushups daily in an effort to maintain his strength" ( Id. ). Dr. Smith diagnosed Mr. Soto with polyuria, shoulder pain (for which he ordered x-rays), and a need for a flu vaccination (R. 354). Mr. Soto was to return to Dr. Smith in six months ( Id. ). ...