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John C. v. Saul

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

October 23, 2019

JOHN C., Plaintiff,
v.
ANDREW M. SAUL, Commissioner of the Social Security Administration, [1] Defendant.

          MEMORANDUM OPINION AND ORDER

          Susan E. Cox, Magistrate Judge.

         Plaintiff John C. (“Plaintiff”)[2] appeals the decision of the Commissioner of the Social Security Administration (“Commissioner”) denying his disability application for Supplemental Security Income (“SSI”) under Title XVI of the Social Security Act (the “Act”). The parties have filed cross motions for summary judgment.[3] As detailed below, the Court grants Plaintiff's motion for summary judgment [dkt. 16] and denies the Commissioner's motion for summary judgment [dkt. 26]. The Administrative Law Judge's decision is reversed and remanded for further proceedings consistent with this opinion.

         I. Background

         a. Factual Background and Procedural History

         This case is brought the Court after a remand ordered on March 1, 2016. Carbaugh v. Colvin, 2016 WL 792299, at *6 (N.D. Ill. Mar. 1, 2016). As such, much of the facts remain the same from this court's previous decision. See Carbaugh v. Colvin, 2016 WL 792299. The court refers back to the facts included in the prior opinion. On December 13, 2011, Plaintiff filed a claim for SSI under the Act, alleging disability beginning December 6, 2011 due to impairments arising from diabetes mellitus, extreme obesity with a body mass index (“BMI”) in excess of 55, stomach bleeding, and heart problems. (R. 155-60, 166.) The claim was denied initially and upon reconsideration, after which Plaintiff timely requested a first hearing before an Administrative Law Judge (“ALJ”), which was held on May 24, 2013. (R. 1-37.) On June 19, 2013, the ALJ denied Plaintiffs claim for SSI again, finding him not disabled under the Act. (R. 48-67.) The Social Security Administration Appeals Council then denied Plaintiffs request for review, leaving the ALJ's decision as the final decision of the Commissioner and thus reviewable by the District Court under 42 U.S.C. § 405(g). See Haynes v. Barnhart, 416 F.3d 621, 626 (7th Cir. 2005).

         Plaintiff was born in 1967 and was forty-five years old at the time of his first hearing. (R. 162.) He completed eighth grade before dropping out of school, but has difficulty reading. (R. 5, 30, 331.) He worked as a general service technician at a tire store for fifteen years and has also done warehouse and cleaning work. (R. 230.) Medical records show that Plaintiff has struggled with losing weight: his weight was 420 pounds in December 2011, dropped to 406.8 pounds in January 2012, rose to 418.7 pounds in July 2012, fell to a low of 401.7 pounds on in February of 2013, and rose back up to 414.2 pounds in April 2013. (R 272, 289, 369, 378, 490.) By 2015, Plaintiffs BMI had risen to 61. (R 771).

         One of Plaintiff s treating physicians, Dr. Austin, maintained records reflecting Plaintiffs reports of vision problems, left knee pain, and left shoulder pain, as well as mental health symptoms including depression, insomnia, and nightmares. (R. 271, 367, 369, 374, 375.) Dr. Austin completed a “Physical Residual Functional Capacity Questionnaire” on April 12, 2012. (R. 326-28.) After naming Plaintiffs diagnoses as diabetes type two, depression, obesity, and leukocytosis, she described his “knee pain secondary to obesity, ” in both knees as “sharp, 10/10” and “worse with walking.” Though she found that Plaintiffs symptoms would “rarely” interfere with the attention and concentration required to complete simple work tasks, she estimated that he could sit only 10 minutes at a time before needing to stand and could stand only 45 minutes at a time before needing to sit down or walk around. She opined that he could sit for less than two hours total and stand or walk for less than two hours total in an eight-hour workday, and that he needed a job that would permit shifting positions at will from sitting, standing, or walking. She opined that he could lift 10 pounds frequently but 20 pounds only rarely and 50 pounds never. (R. 327.)

         The record also contains notes of Plaintiffs mental health symptoms and treatment, and widely varying opinion evidence as to Plaintiff s work-related mental limitations. (R. 221-25; 331-35; 348-49, 500-31.) In a Formal Mental Status Evaluation performed on July 13, 2012, psychologist Harvey I. Friedson, Psy.D., observed that Plaintiff had difficulty reading. Plaintiff could recognize letters and could read the words “bed” and “apple” but could not put the letters together to read the words “glove” or “breakfast.” Dr. Friedman opined, “[h]e does appear functionally illiterate.” In his conclusions, Dr. Friedman diagnosed Plaintiff as “Functionally Illiterate by Presentation, ” with a nonspecified depressive disorder. (R. 329-33.) In another Social Security ordered psychiatric evaluation in 2012, Dr. Bell opined that Plaintiff had a euthymic mood and diagnosed anxiety disorder and mild mental retardation. (R. 348-49.) In June of 2014, Dr. Galligan, PsyD. diagnosed Plaintiff with a major depressive disorder. (R. 1043.) In January 2015, Dr. Krishna Raol, M.D., diagnosed plaintiff with diabetes, morbid obesity, and depression. (R. 838).

         At the May 24, 2013 hearing, the ALJ asked Vocational Expert James J. Radke (“VE”) to assume “a younger individual with a limited education” and Plaintiffs past work, who could lift and carry 20 pounds occasionally and 10 pounds frequently; could stand or walk for six hours in an eight-hour work day and sit for six hours in a normal workday with normal rest periods; could only occasionally crouch, kneel, or crawl; and could not work at heights, climb ladders, frequently negotiate stairs, or operate moving or dangerous machinery. The VE opined that Plaintiff's past work as an auto repair assistant would not be feasible, but that such an individual could perform jobs available in northeastern Illinois, including the jobs of cashier, mail clerk, and cleaner. (R. 32-34.)

         The ALJ issued a first written decision on June 19, 2013, following the five-step analytical process required by 20 C.F.R. § 416.920. At step one, the ALJ found that Plaintiff had not engaged in substantial gainful activity since his application date of December 13, 2011. At step two, the ALJ concluded that Plaintiff had severe impairments of obesity and diabetes mellitus; he did not consider Plaintiff's elevated white blood cell count, left shoulder pain, or mental impairments to be severe. At step three, the ALJ concluded that Plaintiff did not have an impairment or combination of impairments that met or medically equaled the severity of a listed impairment. The ALJ then determined Plaintiff retained the Residual Functional Capacity (“RFC”) to perform light work, except that he is unable to work at heights, climb ladders, or frequently negotiate stairs; he may only occasionally crouch, kneel, or crawl; and he should not operate moving or dangerous machinery. At step four, the ALJ concluded that Plaintiff could not perform any of his past relevant work. (R. 53-60.) He also found that Plaintiff was a younger individual with “limited education, ” and that transferability of job skills was not material in Plaintiff's case. (R. 60.) At step five, based the VE testimony and the findings about Plaintiff's age, education, work experience, and RFC, the ALJ concluded that Plaintiff could perform jobs existing in significant numbers in the national economy, leading to a finding he was not disabled under the Act. (R. 60-62.)

         As noted above, this Court issued an earlier remand in Plaintiff's case, concluding that the “ALJ failed to support his finding regarding plaintiff's educational attainment” and that the “ALJ erred in his analysis of the treating physician's opinion.” (R. 659, 662.) We now remand the ALJ's second decision decided on December 12, 2016 for those same two reasons and because the ALJ did not properly assess Plaintiffs mental impairments.

         b. The ALJ's Decision

         The ALJ, Jose Anglada, issued a written decision on December 12, 2016. (R. 542-58.) The ALJ found Plaintiff was not under a disability, as defined in the Social Security Act, at any time since December 13, 2011 - the date the application was filed. (R. 557.) At step one, the ALJ found Plaintiff had not engaged in substantial gainful activity since the date of application, December 13, 2011. (Id.) At step two, the ALJ concluded that Plaintiff had the severe impairments of obesity, obstructive sleep apnea, and diabetes. (R. 554.) The ALJ noted that Plaintiffs obesity, obstructive sleep apnea, and diabetes “cause more than minimal work-related restrictions and are therefore severe under the regulations.” (Id.) However, the ALJ noted that all impairments other than those three “are non-severe or not medically determinable as they have been responsive to treatment, cause no more than minimal vocationally relevant limitations, have not lasted or are not expected to result in more than minimal work-related restriction for a continuous period of at least 12 months, are not expected to result in death, and/or have not been properly diagnosed by an acceptable medical source as defined in the regulations.” (Id.) At step three, the ALJ determined that Plaintiff did not have an impairment or combination of impairments that met or medically equaled the severity of one of the listed impairments of 20 C.F.R. Part 404, Subpart P, Appendix 1. (R. 549.) The ALJ determined that Plaintiff has the residual functional capacity to perform light work and can lift and carry no more than 20 pounds occasionally and 10 pounds frequently; can be on his feet standing/walking about six of eight hours per workday and sit about six hours with normal rest periods; is unable to work at heights, climb ladders, or frequently negotiate stairs; may only occasionally crouch, kneel, or crawl; and should avoid operation of moving or dangerous machinery. (R. 550.) At that hearing, the VE testified that a person of Plaintiff s age, education, work experience and residual functional capacity would be able to perform the requirements of representative occupations of housekeeping cleaner, assembler, and cafeteria attendant. (R. 556). The ALJ concluded that claimant's education level is irrelevant as “the jobs cited by the vocational expert...do not have literacy requirements.” (R. 555.) During Plaintiffs hearing, Plaintiff also testified that he is unable to read and comprehend warning labels on products and that he is unable to write a complete sentence. (R. 597, 600.)

         II. Social Security Regulations ...


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