United States District Court, N.D. Illinois, Western Division
SHANIE M. RUDDER, Plaintiff,
CAROLYN W. COLVIN,  Acting Commissioner of the Social Security Administration, Defendant.
MEMORANDUM OPINION AND ORDER
IAIN D. JOHNSTON, Magistrate Judge.
Plaintiff Shanie Rudder ("Claimant") brings this action under 42 U.S.C. § 405(g), seeking a reversal, or, in the alternative, remand of the decision by Defendant, Carolyn Colvin, Commissioner of Social Security ("Commissioner"), denying her application for Disability Insurance Benefits under Title II of the Social Security Act ("SSA"). This matter is before the Court on cross-motions for summary judgment. Dkt. ##18, 24.
Claimant argues that the Commissioner's decision to deny her application for benefits should be reversed or remanded because her claim and the evidence supporting it were not fully considered by the Administrative Law Judge ("ALJ"). The Commissioner argues that the ALJ's determination that Claimant was not as functionally impaired as alleged is supported by the record, he did not ignore material evidence, and should be affirmed. For the reasons set forth below, Claimant's motion for summary judgment (Dkt. #18) is granted, and the Commissioner's motion (Dkt. #24) is denied. The Court declines to award benefits, and the matter is remanded for additional proceedings consistent with this Memorandum Opinion and Order.
A. Procedural History
Claimant filed her application for benefits on April 13, 2007, alleging a disability onset of multiple sclerosis as of December 1, 2003. R. 21. Claimant's date last insured ("DLI") was December 31, 2003. R. 167. Claimant's initial application was denied on August 3, 2007, and upon reconsideration on August 31, 2007. R. 21. Three hearings were held before the ALJ, Robert Karmgard, in May 2008, November 2008, and February 2009. R. 33-166. Claimant was represented by counsel and appeared before the ALJ at each hearing. Claimant testified at the May 2008 and February 2009 hearings. R. 103-112, 40-62. The medical expert ("ME"), Dr. Roland Manfredi, M.D. appeared and testified at the November 2008 and February 2009 hearings. R. 149-166, 62-91. The Vocational Expert ("VE") appeared and testified at the February 2009 hearing. R. 91-102. The ALJ determined that Claimant was not disabled through the DLI and denied her benefits on April 29, 2009. R 32. The Appeals Council denied Claimant's request for review, making the ALJ's decision the final decision of the Commissioner. R. 4. This Court has jurisdiction pursuant to 42 U.S.C. § 405(g).
B. Hearing Testimony
Claimant testified that she was 39 years old and married with three children. R. 120. She completed high school and two years of college. R. 120. Claimant testified that she was 5'4" and weighed approximately 125-130 pounds since as far back as 2003. R. 121.
Claimant worked in sales for a publishing company for nine years. R. 43. In 1998, she ended that employment and became a stay at home caregiver to her two children because the combination of working and taking care of her children left her fatigued. R. 43-45. She also worked as a grocery bagger on a part-time basis for one week in January 2007. R. 126. She left her job as a bagger when she began to feel numbness and tingling on the left side of her body. R. 127.
At the hearing, Claimant testified that she began having difficulties swallowing food in 2002 or 2003. R. 59. She first sought medical care in 2002 because she was stumbling, dizzy, and had become "very klutzy." R. 123, 134. She experienced continued severe fatigue, dizziness, and difficulty swallowing in December 2003. R. 42. Her dizzy episodes were "off and on, " lasting a few minutes at time, and stopping if she sat down. R. 42. Also in December 2003, Claimant experienced trouble focusing and concentrating after reading for approximately ten minutes. R. 50, 60. Claimant testified that she first began experiencing left side numbness sometime in 2003. R. 45.
Claimant testified that from 2002 to 2005, she sought treatment for a combination of dizziness, severe fatigue, problems swallowing, ear problems, and loss of balance. R. 42-43, 45, 50, 60, 123, 134-35. She testified that during that time, her doctors misdiagnosed her disease and told her "it was all in [her] head for a long time." R. 134, 143. Claimant testified that she lost health insurance coverage for a period in 2006. R. 31-32; 35. She testified that she sought care from Dr. Ferley for fatigue, dizziness, slurred speech, and problems swallowing in March 2007. R. 134. She indicated that other people noticed her slurred speech before she noticed it. R. 134. Claimant stumbled every day. R. 135. Her doctor placed her on prescription medication, Rebif, to address her multiple sclerosis symptoms in 2007. R. 148.
Claimant testified that her daily activities included taking care of her kids, doing laundry, and cooking. R. 129. She usually spent her days staying around her house, she napped, and sometimes cooked dinner. R. 132. She described these daily activities as "a little trying." R. 129. Claimant testified that in total, she spent approximately one hour per day doing chores. R. 133. When asked if her activity level had changed since 2003, Claimant indicated that it had not. R. 133. Starting in 2002 or 2003, Claimant began taking about a half hour nap per day, which increased in duration over the years. R. 144. She also testified that she experienced Bell's palsy a few months before her hearing testimony. R. 141.
2. State Medical Expert
The non-treating ME, Dr. Manfredi, opined that Claimant had early stages of multiple sclerosis in 2003 that continued to the present. R. 77, 85-86. The ALJ prompted Dr. Manfredi to opine as to Claimant's level of disability over the years. R. 88-89. Dr. Manfredi could not opine with any degree of medical certainty whether the level of limitation present in 2007 was present in 2003. R. 89. He made this assessment based on the medical records that he had received from Claimant's medical providers. Id. Dr. Manfredi testified that an interval neurological evaluation before her DLI was needed to assess her neurological system during that time period. R. 89. Dr. Manfredi did not attach any significance to the gap in Claimant's medical records when she was not under the care of a physician between October 2005 and March 2007. R. 75. Dr. Manfredi also opined that Claimant possibly met a motor dysfunction listing during the five-year period when she experienced motor dysfunction. R. 89. Dr. Manfredi explained that by nature, multiple sclerosis is a progressive condition that "goes up and down." R. 88. Dr. Manfredi also testified that it was possible for Claimant to have "recurrents" where she would have been temporarily disabled and then improve, as early as 2003. R. 88-89.
Dr. Manfredi testified that from December 1, 2003 through the February 19, 2009 hearing, Claimant's symptoms included gait abnormalities, weakness, ataxia, occasional difficulty speaking, and difficulty walking. R. 70-71. As to the extent of her neurological impairment, Dr. Manfredi opined that in 2003, Claimant's impairment were likely in the early stages and were not disabling at that time. R. 85-86.
3. Vocational Expert
The VE, Frank Mendrick, also testified at the February 2009 hearing. During his testimony, the ALJ posed three hypotheticals involving a female with a job and educational background identical to that of Claimant, but with varying degrees of limitations. R. 95-96. The first hypothetical female could lift and carry up to a maximum of 20 pounds on an occasional basis and 10 pounds frequently; may sit, stand, and walk with normal breaks for up to six hours each within an eight-hour day. R. 96. The person could not climb ladders, ropes, or scaffolds, but may otherwise climb ramps or stairs, balance, stoops, kneel crouch and crawl on no more than an occasional basis; must avoid exposure to hazards such as exposed unprotected heights and excavations and exposed, unprotected, dangerous, moving machinery. R. 95-96. The VE opined that these limitations would not affect the person's ability to do past work. R. 96.
The ALJ's second hypothetical female had additional limitations, including: lifting only up to 10 pounds on occasion and lighter items such as small hand tools or case files on a frequent basis, and standing and walking with normal breaks up to two hours per day with not more than fifteen minutes continuously at a time. Id. The VE opined that this person could still do data entry processing work. Id. The VE opined that there are roughly 8, 500 jobs in the region at this sedentary, unskilled labor level. Id. He also opined that there were approximately 2, 500 unskilled jobs (such as a hand laborer) in the region. R. 97.
The ALJ's final hypothetical included the following limitations: the individual could not lift up to 10 pounds on occasion; could sit for no more than a combined total of one hour; could stand and walk for less than an hour in an eight-hour workday; could occasionally use her hands; and could not operate foot controls. R. 99. The VE opined that such limitations resulted in less than sedentary work foreclosing all competitive full-time employment in any variety. R. 100.
C. Medical Evidence
1. Symptoms and Treatment Before Multiple Sclerosis Diagnosis
In May 2002, Claimant visited Dr. Christy Benton, F.N.P., on two separate occasions due to dizziness with exertion, back pain, and stiffness. R. 331, 336. Specifically, Claimant reported that she lost her balance when dizzy but regained it after several minutes. R. 336. Dr. Benton diagnosed Claimant with a lumbosacral sprain/strain and benign vertigo. R. 331. In October 2002, Claimant visited Dr. Benton again because her ear felt clogged. R. 328. Dr. Benton diagnosed Claimant with Chronic Serous Otitis Media and prescribed Rhinocort and Clarinex medications. R. 328-29, 343.
On May 22, 2003, Claimant visited Dr. Michael Lesser, M.D., for ear, chest, and stomach pain lasting two weeks. R. 325-27. Claimant reported no fatigue or malaise. R. 325. Dr. Lesser diagnosed Claimant with Eustachian Tube Dysfunction. R. 327. The following month, Claimant returned to Dr. Lesser because she had pain in her right chest. R. 322. She again denied experiencing fatigue or malaise, and reported that her ear pain had improved. Id. Dr. Lasser diagnosed Claimant with a viral infection, likely strep throat. R. 323.
Claimant next sought treatment with Dr. O'Connel on August 9, 2004 because she had experienced episodes of dizziness with headaches and problems swallowing over the last year. R. 355. Dr. O'Connel diagnosed Claimant ...