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Kakoczki v. Colvin

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

August 25, 2016

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



         Claimant Michael Kakoczki (“Claimant”) seeks judicial review under 42 U.S.C. § 405(g) of a final decision of Defendant Commissioner of the Social Security Administration (“SSA”) denying his claim for Social Security Supplemental Security Income (“SSI”) benefits under Title XVI of the Social Security Act (“the Act”). The parties have consented to the jurisdiction of a United States Magistrate Judge pursuant to 28 U.S.C. § 636(c). Before the court is Claimant's motion to reverse the decision of the Commissioner's (Dkt. 20) and the Commissioner's motion for summary judgment (Dkt. 30). For the reasons that follow, Claimant's motion is granted and the Commissioner's motion is denied. This case is remanded to the SSA for further proceedings consistent with this opinion.

         I. BACKGROUND

         A. Procedural History

         On May 23, 2011, at the age of eighteen, Claimant filed a Title XVI SSI application alleging a disability due to bipolar disorder, obsessive compulsive disorder (“OCD”), seizure disorder, anxiety, memory deficit, and learning disability beginning May 1, 2011. (R. 177, 180-88.) The application was denied initially on October 18, 2011 and upon reconsideration on January 26, 2012. (R. 68-69.) After both denials, Claimant filed a timely request for a hearing, which was initially scheduled for June 15, 2012 before an Administrative Law Judge (“ALJ”). (R. 27-37, 85-86.) Claimant appeared for the hearing without a representative. (R. 27-37.) After being informed of his rights to representation, the hearing was rescheduled to provide time for Claimant to seek counsel. (Id.) On March 6, 2013 Claimant appeared for the rescheduled hearing along with his representative and his mother. (R. 38-67.) A Vocational Expert (“VE”) was also present to offer her testimony. (Id.) On April 26, 2013, the ALJ issued a written determination finding Claimant not disabled and denying his SSI application. (R. 10-21.) Claimant sought review by the Appeals Council (“AC”), which was denied on September 16, 2014. (R. 1-3.)

         B. Medical Evidence

         Claimant's medical records indicate that he has been a patient at Dreyer Medical Clinic (“Dreyer”) since January 2010. (R. 534.) Dr. Carlos Barrios initially tended to Claimant on January 18, 2010 for psychotherapy and medication management. (Id.) At the time, Claimant's symptoms included grandiose features such as commandeering attitude, flight of ideas, hyper-verbal speech, reckless activities, and mood swings. (Id.) He was prescribed Abilify for bipolar disorder, Intuniv for Attention Deficit Hyperactive Disorder (“ADHD”), and Lamictal as a mood stabilizer. (R. 535.) Dr. Barrios noted he was in otherwise stable condition. (Id.)

         On May 6, 2010, Dr. Ammar Katerji, Claimant's former pediatric neurologist, wrote a letter regarding his treatment of Claimant. (R. 620-21.) Dr. Katerji listed Claimant's impairments as a learning disability, behavior difficulty, ADHD, and seizure disorder. (R. 620.) Dr. Katerji noted that Claimant improved on his medication, but Claimant felt his medication caused tremors and anxiety. (Id.) Dr. Katerji suggested that Claimant remain on his medication. (Id.)

         Claimant continued to visit Dr. Barrios at Dreyer for psychotherapy. Throughout the course of his visits, Claimant reported having altercations with his mother's boyfriend. (R. 543-44.) On July 27, 2010, he reported knee pain without specific injury. (R. 545-46.) After a review of an x-ray, Dr. Barrios concluded that Claimant did not have any fracture or dislocation, but suggested that Claimant lose weight. (R. 549-50, 616-17.) On September 28, 2010, after complaints of drowsiness, Dr. Barrios decreased his dosage of Abilify. (R. 551-52.) On November 8, 2010, Claimant reported decreased drowsiness and felt energetic enough to return to the gym. (R. 555-56.) On March 14, 2011, Dr. Barrios reported that Claimant was dealing reasonably well with his medication and he had good control of his symptoms. (R. 564.) He further reported that Claimant was looking for a job and planned to graduate high school and attend college. (Id.) Claimant asked Dr. Barrios about decreasing his medication and it was agreed that his Intuniv dosage would be decreased. (Id.)

         On July 10, 2011, Claimant began to see Dr. John Zhang at Dreyer. (R. 580-81.) Dr. Zhang noted that Claimant had a history of temporal lobe epilepsy, which causes mood and behavioral disturbances and cognitive impairments. (R. 581.) Dr. Zhang continued to prescribe Claimant Abilify and Intuniv. (Id.) On September 28, 2011, Claimant saw Dr. Brian O'Shaughnessy at Dreyer, who noted that after a neurological examination, he found no significant abnormalities. (R. 592.) He noted that Claimant's headaches may be migraines, but they are “not frequent enough” to warrant preventative medication. (Id.) Dr. O'Shaugnessy also stopped his antiepileptic medication, as Claimant no longer had seizures. (Id.) Dr. O'Shaugnessy's assessments regarding Claimant's seizures are supported by Dr. Katerji, who noted on November 9, 2010 that Claimant had not had “any seizures for a period of time.” (R. 367.)

         On September 21, 2011, state agency doctor Dr. Glen Wurglitz completed Claimant's psychological evaluation. (R. 493-99.) Dr. Wurglitz noted that Claimant's mood was pleasant and stable during the evaluation. (R. 495.) He had a friendly interaction style and his speech quality was steady. (Id.) He was oriented to person, place, time, and the purpose of the office visit. (Id.) With regard to his short-term memory, Dr. Wurglitz found Claimant's memory to be poor and he was unable to remember names and could not recall items without assistance. (Id.) Dr. Wurglitz found Claimant to be cognitively capable of performing tasks with complex instruction. (R. 496-97.) He also found Claimant to be capable of understanding, remembering, and carrying out detailed instructions. (R. 497.) Dr. Wurglitz further opined that Claimant had social traits that may interfere with his interactions with supervisors, coworkers, and the general public to a mild or moderate degree. (Id.) Dr. Wurglitz assessed bipolar disorder, learning disorder, ADHD, history of epilepsy, and educational and occupational problems. (Id.) He gave Claimant a GAF score of 61. (Id.)

         On September 27, 2011, Dr. Roopa Karri of Disability Determination Services completed an internal medical consultative examination. (R. 501-04.) A physical exam returned normal results. (R. 503.) Dr. Karri noted that Claimant had a history of bipolar disorder, anxiety, and a learning disability. (R. 504.) Dr. Karri also reported that Claimant had a history of seizures, but that they were under control even without medication. (Id.) Finally, Dr. Karri noted that Claimant was obese. (Id.)

         On October 7, 2011, Dr. Ellen Rozenfeld completed a Psychiatric Review Technique Form (“PRTF”) and a mental Residual Functional Capacity (“RFC”) assessment. (R. 505-22.) In the PRTF form, Dr. Rozenfeld assessed Claimant for several listings impairments, such as 12.02 for organic mental disorders, 12.04 for affective disorders, and 12.09 for substance addiction disorders. (R. 505.) Dr. Rozenfeld noted that Claimant had mild limitations in activities of daily living and moderate limitations in maintaining social functioning, as well as maintaining concentration, persistence, and pace. (R. 515.) Dr. Rozenfeld reviewed Claimant's medical file and determined Claimant's allegations regarding his activities of daily living were consistent with his medically determinable impairments. (R. 517.) However, Dr. Rozenfeld noted that while Claimant had a long history of treatment, the record showed that he was “doing fairly well.” (Id.) She also noted that Claimant had a severe mental impairment that does not meet or equal a listing impairment and he retained the sufficient mental capacity to perform operations of a routine and simple nature on a sustained basis. (R. 517.)

         In her mental RFC assessment, Dr. Rozenfeld found that Claimant would be moderately limited in his ability to understand, remember, and carry out detailed instructions, maintain attention and concentration for extended periods, interact appropriately with the general public, and get along with coworkers or peers without distracting them or exhibiting behavioral extremes. (R. 519-20.) Dr. Rozenfeld opined that Claimant retained the mental capacity to concentrate on, understand, and remember routine and repetitive instructions. (R. 521.) She further opined that his ability to carry out tasks with adequate persistence and pace would be limited for complex tasks but adequate for routine and repetitive tasks. (Id.) She stated that Claimant would be capable of following an ordinary routine without special supervision and he could make simple, work-related decisions. (Id.) Dr. Rozenfeld concluded that Claimant would be able to work in proximity with others but not on joint or shared tasks. (Id.) He would be able to handle supervisory contact and his ability to handle stress would be adequate to tolerate routine changes in the workplace. (Id.)

         On March 19, 2012, Dr. Barrios wrote a note to the SSA to provide clinical information regarding Claimant's impairments. (R. 626-27.) He reported that he treated Claimant from 2008 through 2011 and during this time, he was diagnosed with bipolar disorder and ADHD. (R. 626.) Dr. Barrios noted that Claimant's bipolar symptoms include mood lability, impulsive behavior, anger problems, physical aggression, and anxiety. (Id.) Dr. Barrios further noted that Claimant had difficulty maintaining self-hygiene, conducting household chores, working on his own, or managing money. (R. 627.)

         On July 6, 2012, Claimant was admitted to Provena Medical Center after experiencing homicidal ideations and hallucinations. (R. 633-34.) He was diagnosed with bipolar disorder and temporal lobe epilepsy. (R. 634.) He was instructed at discharge to follow-up with Dr. Zhang. (Id.)

         C. Individualized Education ...

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