United States District Court, N.D. Illinois, Eastern Division
MEMORANDUM OPINION AND ORDER
JEFFREY COLE MAGISTRATE JUDGE
plaintiff, Gerald Ray, seeks review of the final decision of
the Commissioner of the Social Security Administration
denying his application for Disability Insurance Benefits
under Title II of the Social Security Act, 42 U.S.C. §
423(d)(2). Mr. Ray asks the court to reverse and remand the
Commissioner's decision, while the Commissioner seeks an
order affirming the decision and a motion for summary
initially applied for Disability Insurance Benefits on May
16, 2012, alleging that he had been disabled since July 1,
2008 (R. 18). His claim was denied initially and on
reconsideration (R. 80, 85). Mr. Ray filed a written request
for a hearing on February 4, 2013 (R. 18, 90).
convened a hearing on April 9, 2014, at which Mr. Ray was not
represented by counsel (R. 54). The ALJ continued the hearing
to allow Mr. Ray to seek representation (R. 54). At the
second hearing on July 1, 2014, Mr. Ray appeared and
testified and was represented by counsel (R. 31). Julie Bose
testified as the Vocational Expert (“VE”) (R.
10, 2014, the ALJ found that Mr. Ray was not disabled and
denied his application for Disability Insurance Benefits
because of his ability to perform his past work as an
accountant (R. 26). The ALJ's decision became the
Commissioner's final decision on October 5, 2015, when
the Appeals Council denied Mr. Ray's request for review
(R.1). See 20 C.F.R. §§ 404.955. Mr. Ray appealed
the decision to the United States District Court for the
Northern District of Illinois under 42 U.S.C. § 405(g),
claiming that the ALJ's decision was unsupported by
substantial evidence (R. 12).
was born on November 21, 1953, making him 59 years old as of
his alleged onset date of May 16, 2012. (R. 22, 174). He has
a high school education, plus four years of college. (R. 22).
According to his work history report, he worked as a liquor
department clerk at a Walgreens from the fall of 1991 to the
fall of 1992. (R. 179, 194). He then worked as a senior staff
accountant at an accounting firm from 1998 to 2001. (R. 194).
Finally, he worked as a senior staff accountant at another
accounting firm from 2003 to 2006. (R. 194). As a liquor
clerk at Walgreens, he used machines, tools, or equipment.
(R. 197). In this role, he would walk for one hour, stand for
four to six hours, climb for one hour, stoop for one hour,
and not sit. (R. 197). The heaviest amount he lifted during
this job was twenty pounds, and he frequently lifted ten
pounds. (R. 197). As a senior staff accountant, Mr. Ray
reported that he used machines, tools, equipment, and
technical knowledge and skill and completed written reports.
(R. 195). In a typical work day, he would walk for one hour,
stand for two hours, sit for six hours, climb for two hours,
stoop for one hour, kneel for two hours, crouch for one hour,
crawl for one hour, handle big objects for three hours, reach
for two hours, and write for four hours. (R. 195). In this
role, the heaviest weight that he lifted was fifty pounds,
and he frequently lifted twenty-five pounds (R. 195). When
his temporary position at an accounting firm expired June 1,
2006, Mr. Ray stopped working. (R. 178).
August 30, 2012, Dr. Peter Biale, MD completed an Internal
Medicine Consultative Examination, as ordered by the Bureau
of Disability Determination Services. (R. 262). Dr. Biale
spent thirty minutes with Mr. Ray before writing his report.
(R. 262). Mr. Ray complained of a disability due to diabetes
and lower back problems. (R. 262). Dr. Biale observed that
Mr. Ray had a rather wide-based gait. (R. 263). He noted that
when Mr. Ray moved from sitting to the supine position and
back up he complained of lower back pain. (R. 263). His
eyesight in both his left and right eyes was 20/40. (R. 263).
He had full range of motion of cervical spine, limited
lumbosacral spine range of motion with flexion of forty
degrees and extension of 15 degrees, right and left lateral
flexion of fifteen degrees, and tenderness in the paraspinal
muscles. (R.264). His motor strength 5/5 in his upper and
lower extremities. (R. 264). His straight leg raise test was
positive at ten degrees in the right side, and his sensory
was diminished in left lower extremity. (R. 264). Dr. Biale
noted full range of motion in all joints and no redness,
swelling, or thickening. (R. 264). Mr. Ray could bear his own
weight, and had no difficulty getting on and off the
examination table. (R. 264). He did, however, have difficulty
squatting. (R. 264). Regarding Mr. Ray's mental state,
Dr. Biale noted that he was alert, oriented, cooperative,
polite, sincere, his memory was intact, he was able to
concentrate and pay attention, had good hygiene, and was
dressed appropriately. (R. 265).
Biale's clinical impressions were that Mr. Ray suffered
from diabetes mellitus Type II under treatment with oral
medications. (R. 265). He found Mr. Ray's glycemia to be
poorly controlled. (R. 265). He also found that Mr. Ray had
developed gastroparesis, which was under treatment, and
suffered from diabetic neuropathy, which caused persistent
pain in the lower extremities. (R. 265). He also suffered
from lower back pain and sciatic pain in the right lower leg.
Radiological Examination from August 30, 2012, which was
ordered by the Bureau of Disability Determination Services,
revealed mild to moderate degenerative joint disease, and
that osteopenia had appreciated throughout all aspects of the
lumbosacral spine with some small osteophytes as well. (R.
December 19, 2012, Dr. Charles Carlton also performed an
Internal Medicine Consultative Examination for the Bureau of
Disability Determination Services. (R. 269). Dr. Carlton
spent thirty minutes with Mr. Ray. (R. 269). Mr. Ray told Dr.
Carlton that Dr. Malik at Provident Hospital was his primary
care provider and that he had no insurance or medical care.
(R. 270). He lost his medical card in July 2011. (R. 270).
Consequently, Mr. Ray said that he used the emergency
department at Provident Hospital as primary care. (R. 270).
The examination revealed full painless range of motion in all
joints and some decreased range of motion at the lumbar
spine. (R. 272). Mr. Ray had normal grip strength and was
alert and oriented. (R. 272). However, Dr. Carlton did
recommend that Mr. Ray have a consultative evaluation with a
psychologist. (R. 272).
Carlton's clinical impressions were that Mr. Ray suffered
from diabetes, high blood pressure, peripheral neuropathy,
reports of chronic back pain and sciatic pain, reports of
vision problems, and reports of depression. (R. 272). He
believed that Mr. Ray could sit and stand, walk greater than
50 feet without an assistive device, handle objects using
both hands, and lift up to twenty pounds. (R. 273). Dr.
Carlton thought that there was no need for Mr. Ray to use an
assistive device and observed that he had no difficulty
getting on and off the table. (R. 273). He observed that Mr.
Ray had mild difficulty walking on his toes and heels and
tandem walking and had moderate difficulty squatting and
rising. (R. 273). He found that Mr. Ray had no difficulty
opening doors, buttoning, zipping, tying shoes, no degree of
weakness, and no difficulty holding pens or holding a cup.
(R. 274). He had normal range of motion in all categories.
(R. 274). His right eye vision was 20/30 and his left eye
vision was 20/40. (R. 277).
Dennis Karamitis performed a Formal Mental Status Evaluation
for the Bureau of Disability Determination Services on
December 22, 2012. (R. 280). Dr. Karamitis spent 45 minutes
with Mr. Ray. (R. 280). Mr. Ray told Dr. Karamitis that he
got a total of three to four hours of sleep each night. (R.
281). He reported suicidal ideations but no attempts (R.
281). Dr. Karamitis found that he was cooperative and
self-disclosing, with a depressed mood and affect. (R. 281).
His mood was restricted in range, blunted, flat, and sad. (R.
281). Mr. Ray said that he fell victim to physical abuse as a
child and adolescent and was shot and sustained knife
inflicted stab wounds and a head injury. (R. 283). Dr.
Karamitis found that Mr. Ray's performance on the mental
status portion was “somewhat consistent with his level
of education but also compromised by the depression that
currently has a hold on him and is quite notable for the
delay in which he was able to provide answers.” (R.
27, 2013, Mr. Ray went to Cook County hospital, complaining
of back pain. (R. 291). His diagnosis was back pain and
neuropathy. (R. 293). The doctor's impression was that he
suffered from severe multilevel degenerative spondylosis of
the cervical spine, causing significant bilateral
neurocozoaminal narrowing of the spine. (R. 319-20). On
February 15, 2014, Mr. Ray went to the hospital complaining
of pain in the left side of his neck, shoulder, and scapula.
(R. 322). The medical report noted straightening of the
normal cervical lordosis, probably from muscle spasms, severe
degenerative spondylosis of the mid to lower cervical spine
with disc space narrowing, and mild degenerative changes of
the thoracic spine. (R. 322).
March 12, 2014, Mr. Ray saw Dr. Mallick and complained that
his neck and back was locking up. (R. 288). On March 17,
2014, Mr. Ray went to Cook County Hospital complaining of
cramping in his right foot. (R. 286).
Administrative Hearing Testimony
1, 2014, Mr. Ray had his second hearing with the
(R. 33). First, he testified that he last worked at an
accounting firm, Levy and Rabyne in Skokie, Illinois, for
approximately one month. (R. 35). The last time that Mr. Ray
had a job lasting longer than a few months was with the
International Academy of Design and Technology, where he was
hired do a compliance audit. (R. 36). Mr. Ray testified that
he would not be able to competently execute the duties of an
accountant today because of his inability to concentrate due
to the pain in his back and his legs. (R. 36).
then testified that he had been experiencing pain in his
lower back since 2008. (R. 36). The pain ran from his neck to
his shoulders and lower back and radiated down his legs, more
the right leg than the left. (R. 36). He felt tingling and
numbness in his legs, and had cramps in his feet,
specifically around his toes. (R. 37). It hurt him to both
walk and sit for an hour or more. (R. 36).
Winston Burke at Provident Hospital had given him pain
medication. (R. 37). More specifically, he testified that he
took Gabapentin, Tramadol, and Ibuprofen. (R. 37). He began
taking the Ibuprofen in 2008, but only recently began taking
Gabapentin. (R. 37). He took these medicines every three to
four hours. (R. 37). He was also on Metformin for his
diabetes, which he testified had not gotten better or worse
as a result of the medicine. (R. 39).
started experiencing extreme neck pain in February of 2014,
going to the doctor for pain on February 15, 2014. (R. 38).
He testified that the pain got progressively worse each day,
and he feared that if he did not see a doctor he would not be
able to get off the couch. (R. 38). He ended up calling an
ambulance, and in the emergency room the doctor told him that
his neck had “locked up” due to chronic arthritis
in his neck. (R. 38). The doctors ...