United States District Court, N.D. Illinois, Eastern Division
BOBBY E. ANDREWS, Plaintiff,
CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant.
MEMORANDUM OPINION AND ORDER
Michael T. Mason United States Magistrate Judge.
Bobby Andrews (“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”). 42 U.S.C. §1382a(a)(3)(A). The parties have
consented to the jurisdiction of a United States Magistrate
Judge pursuant to 28 U.S.C. § 636(c). Claimant asks that
the court reverse the decision of the Commissioner (Dkt. 18),
and the Commissioner asks that the decision be affirmed.
(Dkt. 22, 23.) 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.
applied for SSI on May 16, 2012, alleging that he had been
disabled since January 31, 2008, due to short-term memory
loss, seizures, and alcoholism. (R. 197-203, 232.) His
application was denied initially and on reconsideration (R.
68-89), and he filed a request for an administrative hearing.
(R. 131-33.) On July 17, 2014, an administrative law judge
(“ALJ”) convened a hearing at which Claimant
testified and was represented by counsel. (R. 33-67.) In
addition, Cheryl Hoiseth testified as a vocational expert
(“VE”). (R. 56-67.) On August 28, 2014, the ALJ
denied the Claimant's application for SSI, finding that
he was not disabled because he was capable of performing his
past relevant work as a custodian/institutional cleaner, as
well as other jobs that exist in significant numbers in the
national economy. (R. 15-27.) This became the final decision
of the Commissioner when the Appeals Council denied the
Claimant's request for review on July 2, 2015. (R. 1-3.)
See 20 C.F.R. §§404.955; 404.981. That
decision is now before the court for review under 42 U.S.C.
was born on June 18, 1966 (R. 197), making him 48 years old
on the date of the ALJ's decision. He has a ninth-grade
education, taking special education classes throughout his
schooling and can “write a little bit, but . . .
can't read.” (R. 43.) Claimant has a limited work
history. He was a school custodian from 2005 to 2008, and
prior to that, worked sporadically as a laborer through a
temp agency. (R. 216-17, 238-40.) He also briefly held a
custodial job for three or four months in 2014, until he had
a seizure at work. (R. 45.) Claimant is single and lives with
his older sister. (R. 42)
medical record begins with the Claimant presenting to the
emergency room on June 12, 2012, after experiencing a
seizure. (R. 341.) He said he had been binge drinking and was
off Dilantin, a medicine used to treat seizures. (R. 342.)
The admission note indicates he was stressed and anxious.
(Id.) Lab results confirmed his alcohol level was
0.19. (R. 351.) A month later, Claimant was back after
suffering another seizure. (R. 392.) The event had lasted 3-4
minutes, according to a family member, and Claimant had
bitten his tongue. (Id.) Examination confirmed
abrasion and bite marks. (R. 393.) Claimant reported he had
not taken Dilantin in a year and drank a six pack of beer a
day. (R. 392.) Lab tests showed his Dilantin level was less
than 0.8 - the therapeutic range is 10.0 to 20.0. (R. 393,
401.) A CT brain scan revealed no evidence of acute
inter-cranial process. (R. 398.)
began seeing Dr. Tais Crawford at Cook County Hospital Clinic
for treatment in December of 2012. (R. 423.) On January 9,
2013, the doctor confirmed diagnoses of epilepsy,
unspecified, and alcohol abuse, and ordered a prescription
for phenytoin (or Dilantin). (R. 495.) She ordered lab work
and instructed Claimant to return in six months. (R. 497-98.)
state disability agency arranged consultative physical and
psychological exams for Claimant on January 19, 2013. (R.
411-14, 416-19.) At the physical exam, Dr. Lopez observed
Claimant to be alert and oriented. (R. 414.) Claimant had a
normal gait, normal range of motion in his spine and all
extremities. (R. 413.) Motor strength and grip strength were
both normal. (Id.) Reflexes and sensation were
normal as well. (R. 414.) Dr. Lopez reported Claimant's
affect was normal, his memory was intact, and there was no
sign of depression or anxiety. (Id.)
Michael Stone performed the consultative psychological exam.
(R. 416.) Claimant denied abusing alcohol at that time and
said he was attending AA meetings. (Id.) He said his
cousin helped him with things like filling out forms.
(Id.) Dr. Stone reported that Claimant's affect
was depressed and anxious; his mood was dysthymic and
dysphoric. (R. 417.) Thought content was positive for
depression and anxiety, but there was no suicidal ideation.
(Id.) Dr. Stone noted that Claimant had difficulty
maintaining a consistent level of attention and concentration
during the examination. (Id.) There was evidence of
impaired memory: Claimant could recall three objects
immediately and after one minute, but not after three or five
minutes. (R. 418.) He was able to identify the President but
not the Mayor. (Id.) He could identify four large
cities in the United States, but not the past four
Presidents. (Id.) Even simple mathematical
calculations were somewhat difficult for Claimant.
(Id.) He didn't grasp that a hat and a shirt
were both clothing, or that an apple and a banana were both
fruit. (Id.) He didn't understand the meaning of
common proverbs. (Id.)
Stone concluded that Claimant suffered from depressive
disorder and generalized anxiety disorder, in addition to
memory problems, a seizure disorder and a history of alcohol
abuse. Claimant's prognosis was guarded. (R. 419.) Dr.
Stone didn't feel he would be capable of managing his own
funds if he were granted benefits. (Id.)
February 2013, state agency physicians reviewed the file and
the results of the consultative exams in order to assess
Claimant's residual functional capacity
(“RFC”) assessment, among other things. (R.
76-88.) As related to his mental health, Dr. Terry Travis
determined that Claimant's depression and anxiety
amounted to severe impairments. (R. 81.) In his view,
Claimant suffered from moderate limitations in activities of
daily living, social functioning, and concentration,
persistence and pace. (Id.)
returned to the County Hospital Clinic in May 2013 for a
refill of his medication and lab tests. (R. 480.) He saw Dr.
Crawford for a follow-up on his seizure disorder on August
12, 2013. (R. 458.) He reported that he had passed out on
July 29, 2013. (Id.) Dr. Crawford noted he had been
compliant with his medications. (Id.) Lab tests
showed elevated levels of glucose, cholesterol, and
triglycerides. (R. 459.) Claimant reported he suffered from
intermittent headaches. (R. 460.) Dr. Crawford increased
Claimant's Dilantin dosage. (R. 461.)
October 25, 2013, Claimant had another appointment with Dr.
Crawford for a check-up and a refill of his prescription. (R.
450.) He denied feeling depressed or hopeless over the
previous two weeks. (R. 451.) Dr. Crawford completed a
Seizures Medical Source Statement for Claimant's attorney
on October 31, 2013. (R. 423-26.) She indicated Claimant
suffered from convulsive seizures and had hyperlipidemia. (R.
423.) He had no warning of his seizures and lost
consciousness and bit his tongue during episodes, which
occurred twice a week. (R. 423, 424.) Claimant described them
as headaches accompanied by tremors. (R. 423.) Dr. Crawford
felt Claimant was capable of low stress work. (R. 424.)
Exertion could bring on a seizure; he should not lift more
than ten to twenty pounds occasionally. (R. 424-25.) They
resulted in loss of vision focus and light-headedness. (R.
425.) Dr. Crawford reported Claimant was compliant with
taking medication, but missed dosages on July 29, 2013.
(Id.) She added that Claimant had poor self-esteem,
short attention span, and memory problems. (R. 426.)
had additional lab tests done on October 31, and November 13,
2013. (R. 436-37, 441.) On March 10, 2014, during another
visit with Dr. Crawford, Claimant complained of dizziness and
giddiness. (R. 432.) Claimant told the doctor he had been off
alcohol for a few months. (R. 502.) Liver function tests were
abnormal. (R. 432.) Dr. Crawford noted Claimant had been
adherent to his medication regimen and increased his Dilantin
dosage. (R. 502, 505.) Lab work showed that his cholesterol
and triglycerides levels were elevated. (R. 503.) His last
EEG in December 2013 was normal. (R. 432.) Claimant denied
being hopeless or depressed over the previous two weeks. (R.
administrative hearing, Claimant testified that he began
having seizures when he was a child, and that they worsened
with age. (R. 50.) The last job he held for an extended
period of time was as a custodian at a school. (R. 44.) He
said he had to leave that job in 2008 because he had a couple
of seizures and fell and hurt his back. (Id.) He
worked briefly as a janitor early in 2014 but, again, that
job ended when he had a seizure while at work. (R. 44-45.) He
had hoped to keep that job indefinitely; he had been briefly
homeless just before that. (R. 51.)
a typical day, he did very little: “[b]asically just
get up and sit outside.” (R. 45.) When he couldn't
sit outside, he would stay in and watch TV. (R. 47.) He was
able to shower and dress himself, but he didn't cook. (R.
46.) His sister took care of that. (Id.) She also
did the grocery shopping, but he sometimes went with ...