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Reinhart v. Berryhill

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

March 6, 2017

NANCY A. BERRYHILL, Acting Commissioner of the U.S. Social Security Administration, [1]Defendant.


          HON. MARIA VALDEZ United States Magistrate Judge

         This action was brought under 42 U.S.C. § 405(g) to review the final decision of the Commissioner of Social Security (the “Commissioner”) denying Plaintiff Mark Reinhart's (“Plaintiff”) claim for Disability Insurance Benefits. The parties have consented to the jurisdiction of the United States Magistrate Judge pursuant to 28 U.S.C. § 636(c). For the reasons that follow, Plaintiff's Motion for Summary Judgment [Doc. No. 16] is granted and the Commissioner's cross-motion for Summary Judgment [Doc. No. 23] is denied. The decision of the Commissioner is reversed, and the case is remanded for further proceedings consistent with this Memorandum Opinion and Order.



         On March 26, 2012, Plaintiff filed a claim for Disability Insurance Benefits, alleging disability since October 31, 2003. (R. 191-94.) The claim was denied initially and upon reconsideration, after which Plaintiff timely requested a hearing before an Administrative Law Judge (“ALJ”). (R. 89-102, 111-15, 124-27.) The hearing was held on April 17, 2013 before ALJ William Mackowiak. (R. 59-88.) Plaintiff personally appeared and testified at the hearing and was represented by counsel. (R. 59-88.) Vocational Expert Aimee Mowery also testified. (R. 82-88.)

         On April 25, 2013, the ALJ denied Plaintiff's claim for Disability Insurance Benefits, finding him not disabled under the Social Security Act. (R. 23.) The Social Security Administration Appeals Council then denied Plaintiff's request for review, leaving the ALJ's decision as the final decision of the Commissioner and, therefore, reviewable by the District Court under 42 U.S.C. § 405(g). See Haynes v. Barnhart, 416 F.3d 621, 626 (7th Cir. 2005). (R. 1-6, 7-9.)


         Plaintiff was born on May 14, 1962 and was 50 years old at the time of the ALJ hearing. (R. 61.) He has completed high school and a couple years of college. (Id.) He lives with his partner in Country Club Hills, IL. (R. 72, 244.) From 1983 to 2003 Plaintiff was employed as an office manager at a grocery store. (R. 66-68, 231.) Plaintiff stopped working in October of 2003 due to his back and leg pain and fatigue. (R. 68-69.)

         A. Medical Evidence

         As a preliminary note, some Plaintiff's medical records consisted of records prior to his alleged onset date of October 31, 2003. Plaintiff was diagnosed with human immunodeficiency virus (“HIV”) prior to the earliest treatment of record. (R. 793.) In 1992, Plaintiff presented to Dr. Behnam Zakhireh, M.D. at Ingalls Memorial Hospital to treat his HIV. (Id.) While under Dr. Zakhireh's care, Plaintiff received antiviral medication to help manage his HIV. (R. 793-94.) In the late 1990s, Plaintiff underwent two lumbar surgeries for a herniated disc. (R. 784, 1160.)

         In September of 2003, Plaintiff presented to Dr. Howard Robinson, M.D. at Ingalls Memorial Hospital for low back pain that radiated through his right buttock into his thigh, calf, and foot. (R. 1160.) Dr. Robinson prescribed Plaintiff pain medication and epidural steroid injections. (R. 1161.) In November 2003, Plaintiff self-discontinued his antiviral treatment. (R. 793-94.)

         In March of 2004, Plaintiff reported to Dr. Peter Iagmin, M.D. at Ingalls Memorial Hospital, with complaints of low back pain and right thigh, leg, and foot pain. (R. 1172.) During Plaintiff's stay, Dr. Lawrence Wilkin, M.D., Ph.D. performed an electromyography[3] (“EMG”) which revealed lumbar radiculopathy.[4] (Id.) Before he was discharged, Plaintiff received pain medication. (R. 1171.)

         In May of 2004, Plaintiff underwent a lumbar spinal surgery performed by Dr. Martin Luken III, M.D. at Ingalls Memorial Hospital to alleviate his chronic lower lumbar radiculopathy. (R. 786-88.) After surgery, Plaintiff reported improvement in his leg pain, but continued to experience low back pain. (R. 791.) He was given pain medications and shortly discharged. (R. 792.)

         In general, Plaintiff's file does not contain medical records for the years 2005, 2006, and 2007.

         In December of 2008, Plaintiff presented to Oak Forest Hospital and was diagnosed with pneumonia. (R. 390.) Then, in July of 2009, Plaintiff was admitted to Oak Forest Hospital for shingles accompanied with nausea and chest pain. (R. 392.) During that visit, Plaintiff reported that he had contracted shingles on two prior occasions. (Id.)

         In March of 2011, Plaintiff reported anxiety and trouble sleeping to his doctors. (R. 672.) He was prescribed Valium. (R. 674.) In May of 2011, Plaintiff was admitted to Oak Forest Hospital and diagnosed with pneumonia. (R. 419.) A CAT scan taken during his stay showed a nodule in his right lung. (R. 423.) He was also treated for diarrhea. (R. 423.) In July 2011, Plaintiff presented to Advocate South Suburban Hospital again for diarrhea. (R. 321.) His doctors performed a partial colectomy.[5] (R. 324.) In October 2011, Plaintiff was scheduled for bronchoscopy[6] to remove the nodule found in his lung. (R. 588-90.)

         In May of 2012, medical consultant Dr. Vidya Madala, M.D. reviewed Plaintiff's medical file and completed a Physical Residual Functioning Capacity (“RFC”) Assessment of Plaintiff. (R. 90-92.) In making her determination, Dr. Madala did not rely on the evidence from Ingalls Memorial Hospital which contains Plaintiffs medical records from 2003 and 2004. (R. 90-94, 965-1217.) Dr. Madala's report stated that there was insufficient evidence between Plaintiff's alleged onset date of October 31, 2003 and Plaintiff's date last insured of December 31, 2008, to evaluate Plaintiff's RFC. (R. 92-94.) Ultimately, she concluded that Plaintiff was not disabled on any date through December, 31, 2008. (R. 93.) Medical consultant David Gilliland, Psy.D. also performed a Mental Residual Functioning Capacity (“MFRC”) Assessment of Plaintiff. (R. 92-94.) Dr. Gilliland concluded that Plaintiff's MRFC could not be established due to the lack of psychiatric records between 2003-2008. (R. 92.)

         B. Plaintiff's Testimony

         On April 17, 2013, Plaintiff appeared for his scheduled hearing and testified before an ALJ. (R. 61-88.) Plaintiff testified that he had not worked since October 31, 2003. (R. 67-68.) Plaintiff had previously worked primarily as a cash office manager for a grocery store, but was trained to run all the departments within the store. (R. 67.) His responsibilities included managing receipts, balancing books, handling bank drops, and supervising 30 employees. (R. 67, 232.) Plaintiff testified his responsibilities required him to stand and walk throughout the work day and that he never sat during his shift. (R. 67.) Plaintiff initially worked 40-50 hours per week, but later reduced his schedule to 25 hours per week due to his back problems. (R. 67-68.) Plaintiff testified that in October 2003, at which point he was working part-time, he could no longer stand and needed to lie down during his shift. (R. 68- 69.) He was also having trouble concentrating on tasks such ...

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