United States District Court, N.D. Illinois, Eastern Division
MEMORANDUM OPINION AND ORDER
SHEILA FINNEGAN, Magistrate Judge.
Plaintiff Tonya James seeks to overturn the final decision of the Commissioner of Social Security ("Commissioner" or "Defendant") denying her applications for Disability Insurance Benefits ("DIB") and Supplemental Security Income ("SSI") under Titles II and XVI of the Social Security Act. 42 U.S.C. §§ 416, 423(d), 1381a. The parties consented to the jurisdiction of the United States Magistrate Judge pursuant to 28 U.S.C. § 636(c), and filed cross-motions for summary judgment. After careful review of the record, the Court now grants Plaintiff's motion, denies Defendant's motion, and remands the case for further proceedings.
Plaintiff applied for DIB and SSI on March 29, 2010, alleging in both applications that she became disabled on March 24, 2010 due to a hearing impairment and hepatitis C. (R. 142, 149, 177). The Social Security Administration denied the applications initially on July 20, 2010, and again upon reconsideration on September 22, 2010. (R. 70-86). Plaintiff filed a timely request for hearing and appeared before Administrative Law Judge Jose Anglada (the "ALJ") on February 1, 2012. (R. 38). The ALJ heard testimony from Plaintiff, who was represented by counsel, as well as from vocational expert Glee Ann L. Kehr (the "VE"). Shortly thereafter, on March 15, 2012, the ALJ found that Plaintiff is not disabled because there are a significant number of light jobs she can perform. (R. 18-30). The Appeals Council denied Plaintiff's request for review, (R. 1-3), and Plaintiff now seeks judicial review of the ALJ's decision, which stands as the final decision of the Commissioner.
Plaintiff raises numerous arguments in support of her request for remand, including that the ALJ: (1) did not provide an evidentiary basis for the residual functional capacity ("RFC") assessment that she is capable of light work; (2) failed to explain why she can work despite significant hearing loss; (3) provided no rationale for finding that she would be off-task for 4% of an 8-hour workday; (4) afforded improper weight to the opinion from Dr. Huhn; and (5) made a flawed credibility determination. As discussed below, the Court agrees that remand is appropriate because the RFC assessment is not supported by substantial evidence.
Plaintiff was born on September 11, 1960 and lives with her boyfriend, her daughter and her grandson, who was four years old at the time of the hearing. (R. 41, 142). She completed high school and has worked at various times as an instructor for Goodwill and an encoding machine operator instructor. (R. 41, 170, 179). Most recently, Plaintiff spent seven years doing data entry at a bank until she was laid off in May 2009. (R. 178-79). She now takes care of her grandson part-time while her daughter is at work. (R. 42-43).
A. Medical History
Plaintiff has been wearing hearing aids since childhood and was diagnosed with HIV in 2004. (R. 312, 314). The first available medical note is from January 2009, when Plaintiff went to see Gregory Huhn, M.D., at the Core Center for treatment of HIV, hepatitis C ("HCV") and hypertension. The handwritten notes are difficult to decipher, but it appears that Plaintiff was fully compliant with her medications at that time. (R. 312). Nearly a year later, on December 3, 2009, Plaintiff returned to Dr. Huhn with "no complaints." (R. 310). She similarly expressed "no complaints" at a December 30, 2009 follow-up exam. (R. 309).
Plaintiff continued to have regular visits with Dr. Huhn throughout 2010. On March 10, 2010, he changed her HAART (highly active antiretroviral therapy) regimen for HIV, (R. 308), and at the next appointment on March 24, 2010, she complained of "profound dizziness" that persisted throughout the day and made her head feel "somewhat disconnected." (R. 307). Dr. Huhn readjusted the medication and by April 7, 2010, the dizziness had "fully resolved" and Plaintiff once again had "no complaints." (R. 306). When Plaintiff returned to Dr. Huhn on May 5, 2010, she asked him to complete some disability forms in connection with the application for benefits she had filed in late March. (R. 305). A week later, on May 12, 2010, Plaintiff told Dr. Huhn that she was "overall feeling well though easily fatigued." The rest of the notes are largely illegible. (R. 345).
On June 4, 2010, M.S. Patil, M.D., performed an Internal Medicine Consultative Examination of Plaintiff for the Bureau of Disability Determination Services ("DDS"). (R. 314-16). Plaintiff told Dr. Patil about her many years of HCV treatment but said she had no related complaints at that time. She also discussed her hearing loss, noting that though her right hearing aid had broken five months earlier and the left one kept "buzzing all the time, " she did not have insurance to replace the devices. (R. 314). Plaintiff's physical examination was largely unremarkable, as she exhibited full motor strength of 5/5 in the arms and legs, normal gait, normal ability to perform fine and gross manipulative movements of the hands and fingers, and full range of motion in all joints. (R. 315-16). Dr. Patil diagnosed HCV and moderate to severe hearing loss at a distance of six feet "even with the left hearing aid, " possibly due to malfunction. (R. 316). There is no evidence that Dr. Patil was aware of Plaintiff's HIV status.
Later that month, on June 24, 2010, Plaintiff had a hearing test with clinical audiologist Natalia Rubin, M.S. (R. 324, 389). Ms. Rubin indicated that Plaintiff "will experience significant difficulties hearing speech, " with "limited benefit from the use of amplification." She recommended new hearing aids for both ears. ( Id. ). Plaintiff gave Dr. Huhn the hearing aid paperwork on July 7, 2010, but it is not clear that she was ever able to obtain the new devices. Dr. Huhn's notes reflect that Plaintiff was fully compliant with her medications and "feeling much better." (R. 343).
On July 19, 2010, Towfig Arjmand, M.D., completed a Physical Residual Functional Capacity Assessment of Plaintiff for DDS. (R. 328-35). He found that she has no exertional, postural, manipulative or visual limitations, but she must avoid concentrated exposure to noise because of her hearing loss. (R. 329-32, 335). Charles Kenney, M.D., affirmed this RFC assessment on September 22, 2010. (R. 349-50).
In the meantime, Plaintiff continued to "feel well" at a follow-up visit with Dr. Huhn on August 18, 2010, and remained fully compliant with her medication. (R. 341). She likewise had no complaints during an October 13, 2010 ...