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Nelson v. Berryhill

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

January 16, 2018

NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.


          Michael T. Mason, United States Magistrate Judge

         Claimant, Antoinette Nelson (“Claimant”) brings this motion to reverse the final decision of the Commissioner of Social Security (“Commissioner”), denying Claimant's claim for Disability Insurance Benefits (“DIB”) and Supplemental Security Income (“SSI”) under 42 U.S.C. §§ 416(i) and 423(d) of the Social Security Act (“the Act”). The parties have consented to the jurisdiction of the United States Magistrate Judge pursuant to 28 U.S.C. § 636(c). This Court has jurisdiction to hear this matter pursuant to 42 U.S.C. § 405(g) and 138(c)(3). For the reasons stated below, Claimant's motion to reverse the final decision of the Commissioner [21] is granted, and the Commissioner's motion for summary judgment [24] is denied.

         I. BACKGROUND

         A. Procedural History

         On April 10, 2012, Claimant filed a Title II DIB application and a Title XVI SSI application, alleging a disability onset date of January 6, 2012. (R. 186-98.) Plaintiff later amended her disability onset date to May 26, 2011. (R. 14, 34.) Her claim was denied initially on July 31, 2012, and again upon reconsideration on January 28, 2013. (R. 119-22, 128-36.) Claimant filed a hearing request on January 31, 2013 pursuant to 20 C.F.R. § 404.929 et seq. (R. 146-48.) On October 29, 2014, the ALJ issued a written decision denying Claimant's claims for DIB and SSI. (R. 11-24.) Claimant then requested review by the Appeals Council. (R. 9-10.) On May 27, 2016, the Appeals Council denied her request for review, at which time the ALJ's decision became the final decision of the Commissioner. (R. 1-6); Zurawski v. Halter, 245 F.3d 881, 883 (7th Cir. 2001). Claimant subsequently filed this action in the District Court.

         B. Medical Evidence

         Claimant seeks DIB and SSI for disabling conditions stemming from a bulging disc, pinched nerves in back, and back problems. (R. 227.)

         1. Relevant Medical Records

         On April 14, 2011, Claimant saw Dr. Dallas Bogner at Thedacare Physicians and reported intermittent pain in her lower back. (R. 473.) She was referred to physical therapy and physiatry. (R. 477.) Claimant was again recommended physical therapy as well as steroid injections on June 24, 2011. (R. 596-98.)

         On April 30, 2012, Claimant saw Dr. Karl Greene, who reported that Claimant's symptoms have failed to respond effectively to chiropractic interventions, physical therapy interventions, and the use of nonsteroidal anti-inflammatory medications and a recent lumbar injection. (R. 613-15.) A cervical MRI taken on May 4, 2012 revealed minimal to mild degenerative cervical spondylosis and disc bulging. (R. 611.)

         On September 21, 2012 Claimant saw Dr. Bogner regarding low back pain and depression. (R. 640.) Dr. Bogner opined that depression was a new diagnosis due to the pain and losing custody of her children. (R. 641.) On October 5, 2012, Claimant reported that her pain was at a five out of ten and that the medication allowed her to function. (R. 634.) Dr. Bogner noted that Claimant had a steroid injection that was possibly mildly helpful and had been meeting with physical therapy. (Id.) Claimant's depression was listed as severe. (R. 635-36.)

         Claimant presented to Dr. Ashley Warmoth on October 17, 2013 regarding her depression. (R. 649.) Claimant had started Prozac one month prior, but was not noticing any improvement overall. (Id.) Dr. Warmoth filled out a Mental Health Questionnaire and opinion Residual Functional Capacity (“RFC”) on July 8, 2013. (R. 720-22.) Dr. Warmoth indicated that Claimant was diagnosed with depression and that her limitations could be expected to last for twelve months or longer. (R. 721.) Claimant was noted to have moderate restriction of activities of daily living, marked difficulties in maintaining social functioning, moderate deficiencies of concentration, persistence or pace; and there was insufficient evidence to determine whether there were episodes of deterioration or decompensation. (R. 722.) Dr. Warmoth also estimated that Claimant would be absent from work about four days per month as a result of her impairments. (Id.)

         2. Agency Consultants

         On July 31, 2012, State Agency consultant Dr. Pat Chan reviewed Claimant's medical evidence of record and opined that she was not disabled. (R. 73-82.) Dr. Chan determined that Claimant had some exertional limitations and that Claimant can occasionally lift 20 pounds, frequently lift 10 pounds, stand or walk about 6 hours in an 8 hour work day, sit about 6 hours of a normal work day and should avoid stooping frequently. (R. 79.) He opined that she would have “unlimited” ability to kneel, crouch and crawl. (R. 79-80.) Dr. Chan also considered Listing 1.04 due to Claimant's impairments. (R. 78.) Susan Donahoo, Psy.D., reviewed Claimant's file on January 28, 2013 and considered Claimant's condition under Listing 12.04. (R. 102.) Dr. Donahoo stated that Claimant had no restriction of activities of daily living, no difficulties in maintaining social functioning, no difficulties in maintaining concentration, persistence or pace, and no repeated episodes of decompensation. (Id.) Dr. Ronald Shaw reviewed Claimant's file on January 25, 2013 and gave the same RFC finding in regards to exertional limitations as Dr. Chan and opined that Claimant was not disabled. (R. 103- 04, 106.)

         C. Claimant's Testimony

         At the date of the hearing, Claimant was thirty-three years old and living with her fiancé and six-year old daughter. (R. 35.) She had no income but received $30 of Food Share a month. (R. 36.) Claimant worked for Countrywide Paramedics doing drug and alcohol testing from 2009-2012, but she stopped the part-time work in 2012 after moving to Wisconsin and because the job required her to sit or stand for too long. (R. 40-41.) When asked to explain in her own words why she felt she was disabled she stated that she had been struggling since 2007, when she began having back problems. (R. 42.) Movements such as bending, lifting, stretching, walking for long periods of time, sitting for long periods of time, and doing everyday things had become very difficult. (Id.) The back pain was all through her back, and she also had pain in her shoulder and neck. (R. 44.)

         II. ...

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