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Summers v. Berryhill

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

March 30, 2017

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



         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 William Summers' (“Plaintiff”) claim for Social Security Disability Insurance Benefits (“DIB”). 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. 20] is granted and the Commissioner's Cross-Motion for Summary Judgment [Doc. No. 21] is denied.


         I. Procedural History

         The Plaintiff filed his dual applications for DIB and Supplemental Security Income (“SSI”) on March 1, 2012, alleging a disability onset date of May 11, 2007 due to diabetes, knee pain, degenerative disc disease, and neuropathy. (R. 167, 169.) The Plaintiff's application for SSI was granted on May 9, 2012 finding the Plaintiff had: major joint dysfunction, Diabetes Mellitus, peripheral neuropathy, and spine disorders, and finding the Plaintiff was disabled because the Plaintiff's disability met Listing 1.02A. (R. 73, 77;) see also 20 C.F.R. pt. 404P, § 1.02A. However, the Plaintiff's application for DIB was denied on May 9, 2012, and was again denied upon a December 11, 2012 reconsideration. (R. 76, 87.) The Plaintiff then timely requested a hearing before an Administrative Law Judge (“ALJ”) on December 21, 2012. (R. 103.)

         The hearing was held on September 3, 2013 before ALJ Lorenzo Level. (R. 31-63.) The Plaintiff personally appeared and testified at the hearing, and was represented by counsel. (Id.) Vocational Expert (“VE”) James Breen also testified. (Id.) The ALJ issued a written opinion on February 28, 2014, denying the Plaintiff's claim for DIB and finding him not disabled under the Social Security Act. (R. 14-30.) The Social Security Administration Appeals Council (“AC”) then denied the Plaintiff's request for review on July 14, 2015, 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). (R. 1-6.); see also Haynes v. Barnhart, 416 F.3d 621, 626 (7th Cir. 2005).

         II. Factual Background[2]

         The Plaintiff was born on July 25, 1956 and was fifty-seven years old at the time of his administrative hearing. (R. 34.) He has completed some high school and lives with his wife in Wood Dale, IL. (R. 72, 212, 214.) Between 1984 and 2007, the Plaintiff held various jobs in carpentry and carpet installation, inspection, and maintenance. (R. 222.) The Plaintiff stopped working in October of 2007 allegedly due to back and leg pain, and fatigue. (R. 68-69.)

         A. Medical Evidence

         Although the Plaintiff presented treatment records between the years 2005 and 2007, the Plaintiff's records contain a large gap between 2007 and 2012, when the Plaintiff resumed treatment with his primary care physician Dr. Narendra Dabhade, M.D.

         The Plaintiff first presented to Rush Oak Park Hospital on September 9, 2005, complaining of a history of lower back discomfort with radiation to the right lower extremities. (R. 312.) The Plaintiff was treated by Dr. Sandeep Amin, M.D., and received an epidural steroid injection. (Id.) The Plaintiff received two additional epidural steroid injections from Dr. Amin on September 24, 2005 and October 7, 2005. (R. 315, 318.)

         The Plaintiff also presented to Dr. Dabhade on March 9, 2006 complaining of low back pain. (R. 320). The Plaintiff's spine was imaged using a magnetic resonance imaging (“MRI”) scan. (Id.) The MRI revealed degeneration of the L4-L5 and L5-S1 intervertebral discs with some degree of loss of hydration, and a mild degree of degenerative changes of the L3-L4 discs. (Id.) The MRI also revealed minimal disc space narrowing at ¶ 5-S1 and some degree of fatty marrow signal of the endplates. (Id.) The MRI lastly found no focal disc herniation, disc forming or spinal stenosis at all levels of the lumbar spine and visualized thoracic spine. (Id.) No significant change was found between the Plaintiff's MRI and a prior lumbar MRI on September 14, 2004. (Id.)

         The Plaintiff returned to Dr. Dabhade on June 21, 2006 complaining of pain in his right buttock radiating down to his big toe, which caused tingling and numbness on the plantar aspect of the foot with some burning pain. (R. 321.) Dr. Dabhade found the Plaintiff had right mild chronic L4-5, S1 radiculopathy; fairly severe right polyneuropathy, more so involving the peroneal nerves; and that the peripheral neuropathy is most likely secondary to Diabetes Mellitus. (R. 322.)

         The Plaintiff also presented to Dr. Dabhade on an outpatient basis on October 9, 2007; November 20, 2007; and December 4, 2007, generally complaining of constant 3/10 or 4/10 pain and weakness, that progressed to 7/10 pain in his upper limbs, right lower limb, and lower back. (R. 334-37.) This pain caused the Plaintiff to be unable to sleep, and caused him pain when performing other bodily functions such as sneezing, coughing, or swallowing. (Id.) Dr. Dabhade diagnosed the Plaintiff with Diabetes Mellitus, peripheral neuropathy, lumbosacral radiculopathy, myalgia, joint pain, and frozen shoulder. (Id.) For those ailments, Dr. Dabhade prescribed Glimepiride, Metformin, Gabapentin, Benicar, Prevacid, and Vicodin. (Id.) Likewise, on November 8, 2007 Dr. Dabhade recommended the Plaintiff use a walker due to osteoarthritis of the lower leg and lumbosacral radiculopathy. (R. 251, 253-54, 349.)

         The Plaintiff resumed treatment with Dr. Dabhade approximately five years later on April 6, 2012, in relevant part complaining of severe pain in the legs with muscle spasms; chronic lower back, knee, and neck pain; difficulty bending, stooping or sitting for any period of time; difficulty walking more than 10-15 feet due to pain; and tingling and numbness in the extremities. (294-96, 327-32, 341-44, 347.) Dr. Dabhade found that the Plaintiff also had limited flexion in both knees. (Id.) Dr. Dabhade further summarized his findings from his consultation in an April 17, 2012 submission to the Commissioner, stating the Plaintiff had marked tenderness in the lower back at ¶ 10/10 level of pain; marked tenderness of both knees with 45 degree flexion; upper right back tenderness; and cervical tenderness of 2. (R. 345.) Dr. Dabhade also found the Plaintiff to have chronic low back pain with “DJD L.S. Spine [degenerative joint disease of the lumbar spine]” with spinal stenosis; chronic neck pain with cervical radiculopathy; chronic knee pains with severe arthritis and severe limitation in mobility; Diabetes Mellitus uncontrolled with peripheral neuropathy; obesity; and gait disorder with back and leg pains and spasms. (R. 346.) In Dr. Dabhade's opinion, the Plaintiff was totally disabled and was not able to engage in any gainful activity. (Id.) Though the Plaintiff presented additional medical records following these visits, they are largely illegible or pertain to ailments not applicable here.

         B. Plaintiff's Testimony

         The Plaintiff also presented at the administrative hearing and offered his testimony. (R. 37-57.) The Plaintiff testified that his last full-time job was in 2006 as a carpet inspector. (R. 40.) There, he was required to lift his approximately 45-pound tool box, but he later lightened its weight to approximately five pounds. (Id.) The Plaintiff also testified that his pain would cause him problems with his job performance as he would have difficulty going up and down stairs or getting on his knees to examine problems. (Id.)

         The Plaintiff also testified that he only had minimal miscellaneous work activity after he left his final full-time position in 2007, working part-time for a maximum of a two or three months. (R. 37.) At this part-time employment, he was required to manipulate small packages between five and fifteen pounds, and had to quit when he was asked to lift heavier boxes. (Id.) The Plaintiff also had to drive for this employment; however, while the Plaintiff could tolerate shorter driving periods of about ten minutes, the Plaintiff stated he could not tolerate driving for periods of 45 minutes to an hour. (R. 38.) For longer assignments, he would have to get out of the truck to stretch. (Id.)

         The Plaintiff also worked for the Northwest Package Delivery Company in 2008, where he was responsible for delivering small envelopes. (R. 43-44.) The Plaintiff testified that he had no trouble performing the job, but the driving aspect of the job bothered him because he would be sitting for hours at a time. (R. 44.) He ...

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