United States District Court, N.D. Illinois
WILMA D. AUTMAN, Plaintiff,
CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant.
E. Cox United States Magistrate Judge
Wilma Autman (“Plaintiff”) seeks judicial review
of a final decision of the Commissioner of Social Security
(“Commissioner”) denying Plaintiff disability
insurance benefits or supplemental security income under
Title II (“DIB”) and Title XVI
(“SSI”) of the Social Security Act. The Court
grants the Plaintiff's motion for summary judgment (Dkt.
29), and denies the Commissioner's motion
for summary judgment (Dkt. 30). The court reverses the
Commissioner's decision and remands the case for further
proceedings consistent with this opinion.
April 8, 2011, Plaintiff filed an application for DIB and
SSI, alleging an onset date of September 26, 2009, which was
later amended to April 22, 2011. (R. at 137, 521.) She was
forty-nine years old at the time of her application. (R. at
137.) After a hearing before an ALJ in June 2012, the ALJ
issued an opinion denying Plaintiff's claim for benefits
on August 29, 2012. (R. 100-115) The Appeals council denied
review of Plaintiff's claim making the ALJ's decision
the final decision of the Commissioner. (R. at 92-97.)
Plaintiff then filed a civil action, pursuant to 42 U.S.C.
§§ 405(g) and 1383(c). In April 2014, this court
issued an order remanding Plaintiff's case for a new
hearing. (R. at 478.)
second hearing in front of ALJ Spalo (“ALJ”)
occurred on October 16, 2014. (R. at 52.) The ALJ denied
granting SSI and DIB to Plaintiff. (R. at 23-45.) The
ALJ's opinion found, inter alia, that: 1)
Plaintiff met the insured status requirements of the Social
Security Act through June 30, 2015; 2) Plaintiff had not
engaged in substantial gainful activity since April 22, 2011;
3) Plaintiff's severe impairments were lumbago, obesity,
asthma, diabetes mellitus, and plantar fasciitis of the right
foot; 4) Plaintiff's impairments do not meet, either
individually or in combination, the severity requirements of
the listing in 20 CFR Part 404, Subpart P, Appendix 1; 5)
Plaintiff had the residual functional capacity
(“RFC”) to perform light work, with several
restrictions; and 6) Plaintiff could perform her past
relevant work as a supervisor and recreation aide. (R. at
26-40.) Plaintiff again requested review of the second
ALJ's opinion, which was also denied, making ALJ
Spalo's decision the final decision of the Commissioner.
(R. at 1-3.) Plaintiff then filed this civil action pursuant
to 42 U.S.C. §§ 405(g) and 1383(c).
October of 2009 Plaintiff saw Dr. Caneva, a podiatrist, after
a recent trip to the emergency room for pain in her right
foot. (R. at 334.) Dr. Caneva diagnosed Plaintiff with
plantar fasciitis and a bunion. (R. at 333.) Dr. Caneva took
an x-ray of Plaintiff's foot, which revealed the ankle
was intact and there was no fracture in the foot.
(Id.) Dr. Caneva prescribed a treatment plan to
Plaintiff and continued to see her through 2012 for her
plantar fasciitis. (R.at 332-334.)
2011, Plaintiff visited the Will County Community Health
Center self-reporting heaviness in her legs, numbness in part
of her foot and headaches. (R. at357.) In a later visit to
Will County in the same month, Plaintiff also reported foot
and back pain, bilateral leg pain, migraines, and five
slipped disks. (R. at 356.) The five slipped disks are not
confirmed in any medical report contained within the record.
April 2011, Plaintiff saw Dr. Singh for the first time, where
he diagnosed her with unspecific hypertension, diabetes
mellitus, and mixed hyperlipidemia. (R. at 409.) Plaintiff
treated with Dr. Singh through 2014, and he diagnosed her
with impaired glucose, malaise, fatigue, plantar fasciitis.
(R. at 406, 658.) During this time, Dr. Singh also noted that
Plaintiff's gait was within normal limits and that no
motor sensory loss was appreciated. (R. at 658.) Dr. Singh
also noted that plaintiff had normal range of motion in the
spine. (R. at 407.)
2011, Plaintiff received a consultative examination from Dr.
Simon. (R. 377) Dr. Simon diagnosed Plaintiff with
intermittent lower back pain, chronic right foot pain post
surgery, and asthma. (R. at 380.) Dr. Simon also noted that
Plaintiff's sensory exam to touch was satisfactory. (R.
at 381.) Dr. Simon further noted that the Plaintiff's
gait was normal and she was able to walk fifty feet without
support. (Id.) Also in June 2011, Plaintiff received
a venous duplex ultrasound which revealed no evidence of deep
venous thrombosis. (R. at 365.) A further study revealed no
significant arterial occlusive disease.
1, 2012, at the behest of the ALJ in anticipation of
Plaintiff's first hearing, Dr. Sai Nimmagadda provided an
opinion as a medical expert. Dr. Nimmagadda did not examine
Plaintiff, but upon review of the records available to him at
the time of the opinion, he determined that Plaintiff could
sit for 2 hours, walk for thirty minutes and stand for one
hour. (R. at 396.) He further opined that Plaintiff could
sit, stand, and walk for up to six hours in an eight- hour
work day. (Id.) Dr. Nimmagadda said Plaintiff could
use her hands for all activity, her feet to operate foot
controls, and have exposure to all environmental factors.
2013, Plaintiff went to Silver Cross emergency room twice in
one week, both times related to a headache; a CT scan was
done and indicated mild mucosal thickening in her sinuses.
(R. at 815, 888-90.) In April 2014, Plaintiff went to St.
Joseph emergency room for back pain radiating down to her
legs. (R. at 896.) An MRI and CT scan were completed and
Plaintiff was diagnosed with multilevel degenerative joint
disease with stenosis and intractable back pain. (R. at
906-10.) When medication failed to improve Plaintiff's
pain, she was admitted to the hospital. (R. at 897.)
Plaintiff was admitted to the hospital on April 2, 2014, and
was discharged on April 4, 2014; her diagnosis at the time of
discharge included multilevel degenerative joint disease with
stenosis and “intractable back pain.” (R. at
returned to the emergency room within the same month for
persisting back pain. (R. at 912.) After examination,
Plaintiff was diagnosed with chronic back pain and increased
radicular pain. (R. at 916.) Once again, Plaintiff's
condition did not improve, and she was admitted to the
hospital. While in the hospital, she was treated by Dr. Maen
Martini, a pain specialist, who recommended an epidural
steroid injection and facet block injections to alleviate the
radiating pain, tingling, and numbness that Plaintiff
reported; Plaintiff received an epidural steroid injection
the following day. (R. at 916, 919.) Plaintiff was admitted
to the hospital on April 30, 2014, and discharged on May ...