United States District Court, N.D. Illinois
E. Cox, U.S. Magistrate Judge.
Abigail Hernandez appeals the decision of the Commissioner of
the Social Security Administration
(“Commissioner”) denying her Supplemental
Security Income (“SSI”) under Title XVI of the
Social Security Act (“the Act”). For the reasons
discussed more fully below, we remand this matter for further
proceedings consistent with this opinion. Plaintiff's
motion for summary judgment is granted [dkt. 14], and the
Commissioner's motion [dkt. 21] is denied.
filed an application for Supplemental Security Income on
March 5, 2012, alleging she became disabled on January 1,
2010, due to memory loss, depression, HIV, and hepatitis C.
R. 133-137, 151. At that time, she was nearly 40 years old.
R. 133. She left school after the ninth grade and has almost
no work history, having last worked very briefly when she was
21. R. 56-57, 141-144. Plaintiff's application was denied
initially and on reconsideration, and she requested an
administrative hearing. R. 88-89, 94-102, 103. On January 30,
2014, an administrative law judge (“ALJ”) held a
hearing at which the plaintiff appeared and testified, and
was represented by counsel. R. 50-97. In addition, Julie Lynn
Bowes testified as a vocational expert (“VE”). R.
April 14, 2014, the ALJ issued a decision denying
plaintiff's application for SSI. R. 31-45. The ALJ
determined that plaintiff was not disabled because she
retained the capacity to perform a limited range of sedentary
work that involved no more than simple, routine, repetitive
tasks; did not require more than brief, superficial
interaction with the public, co-workers, or supervisors; and
involved no more than minor changes in the work environment.
R. 36. Relying on the VE's testimony, the ALJ found that
this allowed plaintiff to perform jobs like document
preparer, addresser, and circuit board assembler, that exist
in significant numbers in the national economy. R. 44-45.
After the Appeals Council denied plaintiff's request for
review, plaintiff filed suit in the Northern District of
Illinois, seeking review of the decision under 42 U.S.C.
was apparently first diagnosed with HIV/AIDS in 2004, but did
not begin treatment until 2008. R. 202, 280. An infectious
disease treatment note from Dr. Jose Bolanos, dated October
16, 2008, indicates that plaintiff's genotype was
resistant to treatment with both nucleoside reverse
transcriptase inhibitors and non-nucleoside reverse
transcriptase inhibitors. R. 214. He also noted that she
suffered from HIV-induced lymphadenopathy and amenorrhea. R.
214. She was an alcoholic who was drinking 40 ounces of beer
a day, and a heroine addict who was undergoing methadone
treatment. R. 214. She had been losing weight and had a
number of other health issues, including hepatitis C. R. 214.
Two weeks later, Dr. Bolanos reported that he planned to
start plaintiff on an HIV medication regimen of Kaletra and
Truvada. R. 206, 218. Plaintiff continued fairly regular
follow-ups with her HIV/AIDS treatment. As such, a large
portion of the record consists of blood chemistry and lab
results. These tests, while for the most part unamplified by
any doctor's interpretation, always show plaintiff's
CD4 or T-cell counts to be very low, often less that 100. R.
285, 287, 292, 300, 335, 534, 604-661.
November 2008, plaintiff reported feeling depressed,
fatigued, and weak. R. 234. She had memory and concentration
problems and lacked motivation. R. 234. Plaintiff claimed she
had not had a drink in 6 months. R. 235. Diagnosis was
dysthmia, rule/out major depression; plaintiff was assigned a
GAF score of 50. R. 236.
missed two or three follow-up appointments in the winter of
2008-2009. R. 265. As of February 12, 2009, she was taking
Methadone, Bactrim, Wellbutrin, Truvada, Reyataz, Norvir, and
Aldara. R. 255.
April 9, 2009, plaintiff had a consultative psychiatric
examination in connection with a previous application for
SSI. Plaintiff reported that she had last had a drink 6
months earlier and had last used heroin a year earlier. R.
250. She said she was “too weak to work.” R. 250.
Dr. Myrtle Mason reported that plaintiff exhibited some lack
of general knowledge and a low average intelligence. R. 252.
Plaintiff's judgement seemed intact, but plaintiff had
difficulty with abstract thinking. R. 252. Her memory was
somewhat impaired. R. 252. Dr. Mason diagnosed plaintiff with
depressive disorder, substance abuse disorder, opiate
dependence, and alcohol abuse. R. 252. She assigned a GAF
score of 60. R. 252.
medical record does not pick up again until April 2012, in
conjunction with plaintiff's current application. On
April 6 2012, plaintiff had another consultative psychiatric
examination, this time with Dr. Ana Gil. R. 351-355. Dr. Gil
noted that plaintiff had a history of chronic alcohol
dependence and last drank the day before the exam. R. 354.
Plaintiff explained that she drank to quell her depression.
R. 351. The doctor also noted that plaintiff was a recovering
opiate addict and was receiving 140 mg. of methadone, and had
been diagnosed with HIV. R. 354. R. 354. Dr. Gil reported
that plaintiff had mild psychomotor retardation, a sad and
restricted affect, and moderately depressed mood. R. 354.
Plaintiff's immediate memory and fund of knowledge were
impaired. R. 354. Dr. Gil diagnosed plaintiff with moderately
severe depressive disorder. R. 355. She did not think
plaintiff was capable of handling her own funds if she
received benefits. R. 355.
mammogram appointment on April 16, 2012, plaintiff reported
using heroin. R. 690. A lesion/hematoma on her left breast
was the result of either injecting the drug, or being struck
by her boyfriend. R. 588. The lesion was benign. R. 368.
Women's clinic notes from April 2012 through November
2012 revealed plaintiff to be going through a number of
problems, including severe cervical dysplasia, hepatitis
infection, and condyloma. R. 564, 565, 568. The doctor noted
that plaintiff had not been compliant with treatment. R. 568.
Thereafter, plaintiff missed a number of HIV follow-up
appointments from the end of April through the end of July
2012. R. 538, 540, 542, 544. On April 25, 2012, Ronald
Havens, Ph.D., reviewed the plaintiff's medical file from
a psychological perspective, on behalf of the state
disability agency. Dr. Havens noted diagnoses of depression
and heroin and alcohol abuse and dependence. R. 387, 392. He
thought that plaintiff would have difficulty with detailed
assignments, but she could understand and remember well
enough to engage in simple assignments. R. 400. Although
moderately limited in maintaining concentration, persistence,
and pace, she could concentrate and persist adequately enough
to perform repetitive, routine tasks. R. 394, 400. She could
interact appropriately with others during brief and
superficial contacts and could accept criticism from a
supervisor. R. 400. Plaintiff could adjust to minor routine
changes in a routine work environment. R. 400.
18, 2012, Dr. Victoria Dow reviewed plaintiff's medical
file as it pertained to her physical condition for the state
disability agency. Dr. Dow felt that plaintiff could lift or
carry 10 pounds occasionally and less than 10 pounds
frequently; stand or walk at least 2 hours in an 8 hour
workday; sit about 6 hours in an 8 hour workday; push or pull
without limitation other than those for lifting or carrying.
R. 403. She could occasionally climb ramps, stairs, ladders,
ropes, or scaffolds, and could occasionally stoop, kneel,
crouch, and crawl. R. 404.
October 2012 appointment, the attending physician reported
that plaintiff continued to have “major issues”
complying with treatment and was missing doses regularly. R.
510. Plaintiff claimed that she was only drinking every other
day, and this allowed her to be more compliant with her
medication regimen. R. 510. The doctor had “the same
conversation with her as always about the dangers of
non-compliance.” R. 510. She missed 2 of her next 3
appointments. R. 505, 508. By December, plaintiff was back to
drinking every day, but had cut down to 3 beers. R. 502. She
missed her January and February 2013 appointments. R. 496,
January 4, 2013, Lionel Hudspeth, Psy.D., reviewed the file
for the state agency and concurred in the earlier opinion of
Dr. Havens. Dr. George Andrews did the same with respect to
Dr. Dow's opinion on January 7, 2013. R. 446-448.
made her March 2013 appointment, blaming her recent absences
on having to take care of her nephew. R. 490. She said she
was taking her medication “more regularly now.”
R. 490. She was also cutting back on her drinking during the
week while watching her nephew. R. 492. Physical exam was
essentially normal and plaintiff had no complaints other than
fatigue. R. 490, 492. She missed her next appointment. R.
487. In May 2013, she was involved in a car accident and
injured her left ankle; there was no fracture or dislocation.
of 2013, plaintiff stated that she was taking her medication
regularly and was feeling well. R. 482. She did report some
weakness and fatigue with methadone treatments, and decreased
appetite. R. 482. She was still drinking. R. 482. Physical
exam was essentially normal aside from joint pain in
plaintiff's left foot; she had strained it in her recent
car accident. R. ...