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Lakes v. Colvin

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

September 14, 2016

TERRIE LAKES, Plaintiff,
v.
CAROLYN W. COLVIN, Acting Commissioner of the U.S. Social Security Administration, Defendant.

          ORDER

          Susan E. Cox U.S. Magistrate Judge

         Plaintiff, Terrie Lakes, appeals the decision of the Commissioner of the Social Security Administration (“Commissioner”) denying her Supplemental Security Income under Title XVI of the Social Security Act (“the Act”). Defendant's motion for summary judgment to affirm the Commissioner's decision is denied; the Court grants Plaintiff's motion for the reasons outlined below, and remands for further proceedings consistent with this opinion.

         STATEMENT OF FACTS

         I. PROCEDURAL HISTORY

         On September 24, 2013, Plaintiff filed an application for Supplemental Security Income under Title XVI of the Act, alleging a disability onset date of September 1, 2013, due to impairments arising from mental illness and high blood pressure (also known as “hypertension”). R. at 185, 202. Plaintiff's claims were denied initially on December 19, 2013; denied upon reconsideration on July 10, 2014; and denied upon hearing in front of an Administrative Law Judge (“ALJ”) on December 16, 2014. R. at 81-87, 88-95, 96-116. Plaintiff then appealed the ALJ's unfavorable decision, but the Appeals Council denied review on June 23, 2015, thereby rendering the ALJ's decision the Commissioner's final decision. R. at 1; see Villano v. Astrue, 556 F.3d 558, 561-62 (7th Cir. 2009). Plaintiff subsequently filed a complaint in this Court on August 21, 2015, appealing the Commissioner's denial of benefits. Pl.'s Br. 1. This Court has jurisdiction pursuant to 42 U.S.C. § 1383(c).

         II. OVERVIEW

         Plaintiff's medical record details that Plaintiff primarily suffers from hypertension, depression, and headaches. See, e.g., R. at 382. At the ALJ's hearing, Plaintiff testified that she experiences sharp headache pain; that her blood pressure is not controlled; that her medications make her dizzy, sleepy, and groggy; and that she lies down due to headaches several times daily. R. at 109. Plaintiff also alleged her depression causes her to not want to get out of bed or eat, and to be withdrawn from family and friends. R. at 109. Additionally, at the time of the ALJ's hearing, Plaintiff was fifty-one years old; five feet, two-and-three-fourths inches tall; and weighed 178 pounds. R. at 26, 27. Based on Plaintiff's height and weight, she had a resulting body mass index (BMI) of 31.36. R. at 344. With a BMI of 31.36, Plaintiff suffered from Level I obesity. SSR 02-1p, 2002 WL 34686281, at *2.

         III. THE ALJ'S DECISION

         The ALJ found that Plaintiff was not disabled under the Act during the period from September 24, 2013 (the date Plaintiff filed her disability application), through December 16, 2014 (the date of the ALJ's decision). R. at 115-16. The ALJ found that Plaintiff had four severe impairments: hypertension, migraine headaches, obesity, and major depressive disorder. R. at 101. These impairments were labeled “severe” because they “significantly limit [Plaintiff's] ability to perform basic work activities.” R. at 101. The ALJ concluded that Plaintiff does not have an impairment or combination of impairments that meets or medically equals the severity of any of the impairments listed in 20 C.F.R. Part 404, Subpart P, Appendix 1. R. at 101.

         After consideration of the entire record, the ALJ determined that Plaintiff's residual functional capacity (“RFC”) allowed her to perform medium work, which includes “simple, routine, and repetitive tasks; work in an environment free of fast-paced production requirements; simple work related decision making; and few, if any, changes in work setting.” R. at 103. Then, based on the medical evidence, Plaintiff's testimony, the medical expert's testimony, the vocational expert's testimony, third party statements, and the ALJ's own assessment of Plaintiff's RFC, the ALJ concluded that although Plaintiff had no past relevant work, she was able to perform the requirements of occupations such as hospital cleaner, laundry worker, sorter, and child care attendant. R. at 114-15. Accordingly, the ALJ found Plaintiff was “not disabled” under the Act. R. at 115.

         In her opinion, the ALJ considered several medical opinions to determine Plaintiff's disability status, including the opinions of Dr. Allen Heinemann, Ms. Kristin Reitz, and Dr. Munawar Sultana. R. at 112. Dr. Heinemann is a medical expert and licensed clinical psychologist who did not personally exam Plaintiff, but testified at the ALJ's hearing after reviewing Plaintiff's medical records. R. at 109. Dr. Heinemann opined that according to the available medical records, Plaintiff's mental impairments did not meet listing 12.04 because the B criteria was not met, even though the A criteria was sufficient. R. at 109. Dr. Heinemann stated that although Plaintiff had been diagnosed with major depressive disorder, her activities of daily living and social functioning were only mildly limited, though her ability to concentrate, persist, and maintain pace was moderately limited. R. at 109. Ultimately, Dr. Heinemann found that Plaintiff “could perform unskilled work” and that “jobs where there is a slower pace, would be possible.” R. at 110. The ALJ afforded Dr. Heinemann's opinion substantial weight because even though Dr. Heinemann did not personally examine Plaintiff, his opinion was “consistent with the medical evidence of record, ” and he had “superior professional qualifications to Ms. Reitz.” R. at 112.

         Ms. Reitz is a treating social worker who personally examined Plaintiff during individual therapy sessions. R. at 107. Ms. Reitz opined that Plaintiff's impairments could cause Plaintiff to be absent from work more than three times per month. R. at 112. Ms. Reitz also believed that Plaintiff's ability to maintain attention and concentration for extended periods, to complete a normal workday without interruptions from psychological based symptoms, and to perform at a consistent pace without an unreasonable number of rest periods was markedly limited. R. at 112. Ms. Reitz further opined that Plaintiff's depression caused moderate restriction in Plaintiff's daily activities, marked difficulties in Plaintiff's social functioning, and moderate difficulties in Plaintiff's concentration. R. at 112. The ALJ did not accord Ms. Reitz's opinion much weight because it was only “based on a one month treating relationship, consisting of 4 visits.” R. at 112. The ALJ also believed that Ms. Reitz's opinion set forth “very restrictive severe limitations which [were] inconsistent with her treatment notes showing generally fairly intact mental status exams, ” and that her opinion was “inconsistent with the remainder of the medical evidence of record, which shows negative mental health screens and the consultative examination, which shows no more than mild depression as well as with Dr. Heinemann's opinion.” R. at 112.

         Dr. Sultana is a treating physician who personally examined Plaintiff and consistently monitored Plaintiff's hypertension. R. at 105. Dr. Sultana's treatment notes generally show Plaintiff had normal physical findings, with the exception of hypertension. R. at 110. Dr. Sultana did not feel comfortable filling out Plaintiff's functional capacity evaluation because she “did not have [the] training or equipment to do the evaluation for work capacity.” R. at 106. Dr. Sultana did however provide a letter ...


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