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Martinez v. Colvin

United States District Court, N.D. Illinois, Eastern Division

July 2, 2015

CAROLYN COLVIN, Acting Commissioner of the Social Security Administration, Defendant.


SIDNEY I. SCHENKIER, Magistrate Judge.

Plaintiff Teresa Martinez filed an application for supplemental security income benefits on April 12, 2011. After her application was denied by an Administrative Law Judge and her appeal was rejected by the Appeals Council, Ms. Martinez filed suit seeking review of the final decision rejecting her claim. Plaintiff has requested a remand (doc. #10), and defendant has filed a motion for summary judgment seeking affirmance (doc. #20). For the reasons set forth below, the Court denies the motion for summary judgment and grants the request for remand.


In late September 1991, when she was sixteen years old, Ms. Martinez suffered a sudden, severe headache (R. 173). Doctors at the University of Chicago discovered two major problems: a subarachnoid hemorrhage ( i.e., aneurysm) and coarctation ( i.e., narrowing) of the aorta (R. 159, 167, 173). Doctors surgically repaired the aneurysm within days (R. 167-168) and surgically repaired the aorta a few months later (R. 188-190). Plaintiff experienced memory problems after the surgery to repair the aneurysm. On October 10, 1991, for example, her doctor noted that plaintiff was unaware that she had had her sixteenth birthday (R. 165).

Given her memory problems, Ms. Martinez was unable to finish high school (R. 519). She got married and is raising a daughter (R. 519). During a brief period of time in the late 1990's, Ms. Martinez worked as a bill collector (R. 146, 152). She left that job either because she was laid off or because of her headaches (the record contains evidence of both reasons) (R. 45, 145, 459).


Years later, in April 2011, Ms. Martinez applied for supplemental security income on the basis of her purported disability (R. 127). In her application, Ms. Martinez stated that the onset date of her disability was January 31, 2009 (R. 127). She later amended her claimed onset date to April 12, 2011, the date of her application (R. 32). In connection with her application, Ms. Martinez filled out a function report (R. 248). In her function report, Ms. Martinez noted that her "extreme lack of short-term memory" prevents her from working, and that she also suffers "unpredictable chest pains" and migraines (R. 237, 239, 243). She also described how her medical issues affect her daily life. For example, Ms. Martinez stated that she writes on her calendar how often she washes her hair and when she needs to take her pills (R. 240). She does not handle cash, because she has trouble remembering how much money she has handed to a cashier (R. 241). She no longer uses the stove, because she forgets that she turned it on (R. 240). Instead, she prepares cold meals, such as cereal and sandwiches (R. 240). Notwithstanding her memory issues and her inability to follow verbal directions, Ms. Martinez said she can follow written directions very well, so long as she keeps them with her (R. 243). Ms. Martinez stated that her memory affects her ability to travel, because she cannot remember where she is going (R. 241). For that reason, and because she is afraid of experiencing the sudden onset of a migraine or chest pain, Ms. Martinez does not drive (R. 241).


In addition to Ms. Martinez's own descriptions of her medical issues, the record also contains evidence that Ms. Martinez has seen a variety of health-care providers in connection with her various complaints.

For chest pain, Ms. Martinez has been treated by Cesar Herrera, M.D. ("Dr. Herrera"). On September 22, 2008, Dr. Herrera noted that Ms. Martinez reported having experienced episodes of sharp chest pain that were not related to exertion (R. 436). Ms. Martinez returned to see Dr. Herrera on October 11, 2010, at which point Dr. Herrera noted that Ms. Martinez reported experiencing chest pains while moving in bed (R. 440). On January 17, 2011, Dr. Herrera conducted a stress test with Ms. Martinez (R. 424-425). Dr. Herrera noted that Ms. Martinez was able to exercise for nine minutes without chest pain (R. 425, 434). Dr. Herrera also noted that the repair of Ms. Martinez's coarctation was stable; but, because Ms. Martinez had experienced hypertension during her stress test, Dr. Herrera recommended that she begin taking 25 mg daily of metopolol (R. 425). Ms. Martinez again discussed her chest pain with Dr. Herrera at her appointment with him on May 24, 2011, at which time he prescribed Toprol (R. 539-540). On January 17, 2012, Ms. Martinez again told Dr. Herrera about her chest pain, but she noted that she had experienced some improvement since taking Toprol (R. 537).

For her memory problems and headaches, Ms. Martinez was treated by Serge Pierre-Louis, M.D. ("Dr. Pierre-Louis"), a neurologist. On March 8, 2011, Ms. Martinez attended her appointment with Dr. Pierre-Louis by herself (R. 448). Dr. Pierre-Louis prescribed Elavil (a/k/a amitriptyline) and referred Ms. Martinez to Dr. Stephen Clingerman, Ph.D. ("Dr. Clingerman") for a neuropsychological evaluation (R. 448). Ms. Martinez met with Dr. Pierre-Louis again on June 30, 2011. At that time, Ms. Martinez reported to Dr. Pierre-Louis that she was still experiencing migraine headaches (R. 452). Dr. Pierre-Louis noted that Ms. Martinez had stopped taking Elavil, because she felt it was not working (R. 452, 528). Dr. Pierre-Louis encouraged Ms. Martinez to continue taking the medication and referred her for a CT scan of her head (R. 528). The CT scan uncovered a 15 millimeter by 12 millimeter meningioma ( i.e., tumor), but, on March 29, 2012, Dr. Pierre-Louis concluded that the tumor was not causing Ms. Martinez's symptoms (R. 510, 515). Instead, Dr. Pierre-Louis opined that Ms. Martinez's memory problems were caused by her aneurysm (R. 515). He also opined that Ms. Martinez suffered from chronic headaches, which "may be a combination of migraine variant귦 headache痪歺쬨, " and that her symptoms may be due to depression ( Id. ).

During a July 12, 2012 visit with Dr. Pierre-Louis, Ms. Martinez continued to complain of headaches and noise in her ears (R. 512). Dr. Pierre-Louis noted that Ms. Martinez had again stopped taking Elavil because she thought it was not working, but he encouraged her to restart the medication (R. 512-513). Dr. Pierre-Louis also stated that he would order an EEG in connection with Ms. Martinez's intermittent tinnitus (R. 513).

As noted above, Dr. Pierre-Louis referred Ms. Martinez to Dr. Clingerman for a neuropsychological evaluation. In his report, Dr. Clingerman noted that Ms. Martinez had been an honors student at Lane Tech before her aneurysm, but had dropped out due to her inability to retain information (R. 519). Dr. Clingerman noted that Ms. Martinez had seen a psychologist once or twice after her surgeries, but stopped because she could not afford to continue (R. 519). Dr. Clingerman also noted the effects Ms. Martinez's memory problem had on her daily living (R. 518). He described how Ms. Martinez used post-it notes as reminders and repeated out loud the name of the object for which she was searching (R. 518).

Before issuing his report, Dr. Clingerman met with Ms. Martinez on several occasions (twice in August 2011 for a total of five hours; once in September 2011 for three hours; and once in October 2011) (R. 517-518). Dr. Clingerman conducted various tests, including intelligence and personality tests, and included the results of the various tests in his report (R. 517-518). Dr. Clingerman noted that Ms. Martinez was mildly to moderately impaired with respect to her ability to recall a list of words and was severely impaired with respect to her ability to recall items after twenty minutes had passed (R. 521). Dr. Clingerman explained that "[i]n a constellation of largely average and occasionally above average intellectual abilities, Ms. Martinez has numerous severe verbal memory and motor strength deficits... indicating Moderate Cognitive Disorder, " along with depression (R. 522). Dr. Clingerman further opined that "the onset and timing of symptoms strongly indicates sequelae from the subarachnoid hemorrhage" (R. 523). He concluded that "aggressive treatment" of Ms. Martinez's psychiatric symptoms "is vital" and that Ms. Martinez "is disabled from obtaining and maintaining competitive employment" (R. 523).

Ms. Martinez continued to see Dr. Clingerman after he completed his neuropsychological evaluation. On January 11, 2012, Ms. Martinez told Dr. Clingerman she had stopped taking Elavil (R. 508). During appointments on March 7, 2012, April 13, 2012 and May 21, 2012, Ms. Martinez and Dr. Clingerman discussed primarily Ms. Martinez's depression and her trouble sleeping (R. 500, 503, 505). Ms. Martinez's other ...

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