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Smith v. Berryhill

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

June 11, 2018

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


          Honorable Michael T. Mason, United States Magistrate Judge

         Plaintiff Omega Smith (“Claimant”) filed a motion for summary judgment seeking reversal of the final decision of the Commissioner of Social Security (“Commissioner”), finding that her disability ended on November 1, 2012. The Commissioner has filed a cross-motion asking the Court to uphold the previous decision. For the reasons set forth below, Claimant's motion for summary judgment (Dkt. 15) is granted and the Commissioner's motion for summary judgment (Dkt. 16) is denied.

         I. Background

         A. Procedural History

         In a previous determination by an Administrative Law Judge (“ALJ”) (that is not in the record before the Court), Claimant was found to be disabled and entitled to Supplemental Security Income (“SSI”) as of June 9, 2009 due to Listing level major depressive disorder and generalized anxiety. (R. 76.) But on November 21, 2012, following a periodic review of Claimant's disability, the Social Security Administration (“SSA”) determined that Claimant's condition had improved and her disability had ended as of November 1, 2012. (R. 76, 78-80, 82.) This determination was upheld at the reconsideration level following a hearing by a Disability Hearing Officer (“DHO”). (R. 89-100, 105-115.) Claimant then requested a hearing before an Administrative Law Judge (“ALJ”), which was held on November 24, 2014. (R. 42.) On March 16, 2015, the ALJ issued a written decision, affirming the decision that Claimant's disability ended on November 1, 2012. (R. 22-36.) On August 26, 2016, the Appeals Council denied Claimant's request for review, making the ALJ's decision the final decision of the Commissioner. (R. 1-3.) This action followed.

         B. Relevant Medical Evidence

         1. Treating Physicians

         Again, Claimant was previously granted benefits in 2009 for Listing level depression and anxiety. The medical records from that time period are not in the record before the Court. However, it appears that, among other things, Claimant suffered from obesity, appetite disturbance, sleep disturbance, difficulty concentrating and thinking, and paranoia. (R. 394.)

         The medical records currently before the Court date back to July 2009 and demonstrate visits with psychiatrist Dr. Doshi about every three months through 2014. (R. 269-73.) At the first visit in July 2009, Dr. Doshi assessed general anxiety disorder and depression, and a GAF score of 40-50. (R. 269.) Over the course of her treatment with Dr. Doshi, Claimant often reported she was “doing well.” (R. 270-73.) At other times, she reported lingering anxiety and increased symptoms due to certain events. (Id.) For example, she complained of increased depression following the 2010 holiday season and increased anger following a verbal altercation in 2012. (R. 271-72.) She also reported that she suffers from nightmares. (R. 271.) Throughout this period, Claimant continued to take Prozac and Klonopin.

         In November 2011, Claimant's counselor, Ms. Neely, completed an updated mental health assessment. (R. 324-33.) The mental status exam yielded normal results. (R. 324.) Claimant reported she enjoyed watching television, shopping, and her son's school activities. (R. 330.) She explained that she gets support from her mother and grandmother, and can “usually” communicate with others. (Id.) Overall, things were “going well, ” though she admitted to “some anxiety when dealing with family.” (R. 332.) Claimant's diagnoses and GAF score were the same as previously assessed by Dr. Doshi. (R. 333.)

         In April 2012, Claimant reported to the ER complaining of back pain after lifting a heavy object. (R. 307.) She described a history of depression. (Id.) She was given pain medication and discharged. (R. 301.) Claimant returned to the ER in August 2012 due to bilateral knee pain and swelling. (R. 315.) The examining physician assessed arthritis, prescribed pain medication, and advised Claimant to follow up with a primary care physician. (R. 314.)

         Ms. Neely completed another updated health assessment in November 2012. (R. 369-78.) Though the mental status exam was normal, Claimant reported she had good days and bad days, and had been suffering from recent mild knee pain. (R. 369, 371.) She said she keeps to herself because she does not communicate well with others. (R. 375.) Overall she was doing well, and taking her medication as prescribed. (R. 377.) By early 2013, Claimant's suicidal ideations had increased due to the holiday season. (R. 379.) She was doing “about the same” in April 2013, and she was sleeping well, but “irritable at times.” (R. 408). Her complaints of knee pain also continued at that time. (R. 464.) She had no complaints in January 2014, though her grandmother was doing poorly. (R. 407.) Her Klonopin dosage was increased later that year. (Id.) Also, in August 2014, Claimant was treated for tendinitis in her left foot. (R. 436-39.)

         By January 2015, Dr. Doshi described Claimant as “stable enough.” (R. 413.) Dr. Doshi also completed a mental impairment questionnaire. (R. 404-06.) He indicated that Claimant's medication partially helps her symptoms and described her prognosis as “ongoing.” (R. 404.) He indicated that Claimant suffered from: change in personality, irrational fear, emotional withdrawal, difficulty concentrating, panic attacks, isolation, sleep disturbance, and decreased energy. (R. 405.) He opined that Claimant suffers from marked limitations in activities of daily living and maintaining concentration, persistence and pace; extreme limitations in social functioning; and four or more episodes of decompensation. (Id.)

         At general physical visits over the years, Claimant usually denied feeling “down, depressed or hopeless” in response to ...

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