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Glenn H. v. Saul

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

November 18, 2019

GLENN H., Plaintiff,
ANDREW SAUL, Commissioner of Social Security, Defendant.


          SARA L. ELLIS United States District Judge

         Plaintiff Glenn H. seeks to reverse the final decision of the Commissioner of the Social Security Administration denying his application for disability insurance benefits (“DIB”) under Title II of the Social Security Act, 42 U.S.C. §§ 416(i), 423. Because the Court concludes that the Administrative Law Judge (“ALJ”) failed to consider and resolve multiple sources of contradictory evidence, the Court reverses the ALJ's decision and remands this case to the Social Security Administration for further proceedings consistent with this Opinion.


         I. Procedural History

         Born September 4, 1963, Glenn H. worked as a carpenter for decades until a 2012 injury. AR 209-10. Glenn H. applied for DIB on August 23, 2013, alleging disability beginning August 23, 2012. AR 423-29. The agency denied his application both initially and on reconsideration. AR 261-72, 274-90. On September 14, 2016, following Glenn H.'s timely request, the ALJ held a hearing at which Glenn H., a medical expert, a psychological expert, a vocational expert, and Glenn H.'s wife testified. AR 205-59. On December 1, 2016, the ALJ issued his opinion finding that Glenn H. was disabled within the meaning of the Social Security Act from August 23, 2012 to March 13, 2014, but that Glenn H. has been able to perform substantial gainful activity since March 14, 2014 based on his improved medical condition. AR 182-204. The ALJ found that Glenn H.'s impairments medically equaled Appendix Listing 1.02(B) from August 23, 2012, through March 13, 2014. AR 191; 20 C.F.R. Pt. 404, Subpt. P, App. 1, § 1.02(B). For the period thereafter, the ALJ found that medical improvement occurred and Glenn H. retained the residual functional capacity (“RFC”) to perform a limited range of light work, AR 192; that he was unable to perform his past work, but could perform other jobs existing in the national economy, AR 195; and was therefore not disabled under the Social Security Act after March 13, 2014, AR 196. On March 27, 2018, the Appeals Council declined to review the ALJ's decision, causing it to constitute the final decision of the Commissioner. AR 1-7; Luna v. Shalala, 22 F.3d 687, 689 (7th Cir. 1994) (“Because the Appeals Council denied review of Luna's application, the ALJ's decision became the final decision of the Secretary[.]”); 20 C.F.R. § 404.981.

         II. Relevant Medical History

         A. Glenn H.'s Injury and Recovery

         At work on August 23, 2012, Glenn H. fell about fifteen feet from a ladder, striking his head and losing consciousness, fracturing both wrists, his face and jaw, and injuring his left shoulder and neck. AR 744-45, 793, 1284-89. He required surgery to repair his jaw and facial fractures. AR 749-52. He had surgery on his right wrist in January 2013 and a partial right wrist fusion in July 2013. AR 606-07, 615-17. He had a left shoulder labrum tear for which he had surgery in November 2012. AR 608-09. MRIs of Glenn H.'s cervical spine revealed disc bulges and foraminal stenosis. AR 874-75.

         The restrictions on how much weight Glenn H. could lift and the use of his wrists limited the progress of his overall healing. AR 847, 853-55, 857, 878, 2283, 2728, 3438. In March 2013 and June 2014, Glenn H.'s doctors found his spinal injury was at “maximum medical improvement” (“MMI”). AR 643-44, 839. Doctors found his wrists at MMI in March 2014, AR 845, 904, and his left shoulder at MMI by May 2014, AR 645-48, 3427-28. He underwent a functional capacity evaluation (“FCE”) on June 26, 2014, AR 2769-76 (summary report), 2779- 2812 (full report), in which the evaluator found that Glenn H. had the physical capacity for light work, but that he was unable to maintain a position, standing or sitting, for longer than fifty minutes before having increased back and neck pain. AR 2769.

         After his 2012 injury, Glenn H. reported lower back pain, complaining of worsening back pain from 2014 through 2016, with flare-ups resulting from attempted activity. AR 853-55, 3415-16, 3419-22, 3424-26, 3548-53. Lumbar MRIs showed disc bulges, contact with the L5 nerve root, and “multiple sites of potential pain generation.” AR 854, 2292, 3398-99. Doctors found limited lumbar range of motion, meralgia paresthetica in Glenn H.'s left leg, and positive straight leg raise tests. AR 854, 2462, 3416, 3420, 3422, 3426, 3479. His physical therapy included treatment for his lower back from 2014 through 2015. AR 884, 2667, 2691-2767, 2813-49, 2852-2914. In 2016, he saw a chiropractor for repeated exacerbations of back pain with radiation into his legs. AR 3555-61. In May 2015, he received an evaluation for fusion surgery; without fusion surgery, doctors opined that his back was at MMI. AR 3416, 3421.

         Glenn H. has also received diagnoses of a traumatic brain injury, post-concussion syndrome, and a cognitive disorder. AR 564, 811, 969, 998, 1292-93, 2462, 3520, 3553. Neurologists and other providers have evaluated and treated his dizziness, hearing loss and tinnitus, headaches, memory issues, and personality changes. AR 573, 596, 598, 794, 993-98, 3519-21, 3527-29, 3548-53. Dr. Colin A. Brietzke, Psy.D., conducted a neuropsychological evaluation in January and February 2014 that found weakness in fine motor functioning and neuropsychological measures, and mood and personality changes. AR 825-35. Dr. Brietzke diagnosed a traumatic brain injury, personality change due to traumatic brain injury, and mild neurocognitive disorder. AR 826. Dr. Nancy Landre, Ph.D., conducted another neuropsychological evaluation in July 2014 that found that Glenn H. had impaired fine motor speed but normal cognitive performance, and “clearly abnormal” psychological testing suggesting mood and somatoform disorders. AR 972-81. Dr. Landre opined that Glenn H. was not able to work from a psychological standpoint, that he had not reached MMI from a neuropsychological perspective, but that with treatment “he should be able to resume some work activity within the next one to three months, with gradual increases in responsibilities and hours worked as his psychological condition improves.” AR 978. Dr. Chirag Raval, M.D., conducted an examination in July 2014 and diagnosed depression secondary to a medical condition and cognitive disorder secondary to mild traumatic brain injury. AR 966-69.

         III. Hearing Testimony

         Glenn H. testified that he has not worked since his accident. AR 209. Currently, he testified that he is not able to work because his back issues cause numbness and pain in his legs, occasionally his back goes out altogether, and he has sharp pains and occasional swelling and stiffness in his wrists. AR 213. He takes either Advil, Tylenol, or prescription pain medication depending on the severity of his pain each day. AR 213. Glenn H. also testified that he is no longer taking medication for his depression since the medications he tried did not help, they either made him more depressed or caused harmful side effects. AR 214. His head injury has caused him frequent headaches and issues with both memory and focus. AR 216.

         Dr. Ashok Jilhewar, M.D., testified to Glenn H.'s various physical impairments. AR 220-33. He identified and summarized the injuries that resulted from Glenn H.'s fall and added the exacerbation of his lower back pain since 2014. AR 221-28. Dr. Jilhewar found that because of Glenn H.'s bilateral wrist fractures, his impairments equaled Listing 1.02(B) from August 23, 2012, through March 13, 2014. AR 228. On March 14, 2014, the treating hand surgeon reported Glenn H. “was doing ‘okay'” and objective clinical findings had improved. AR 228. Dr. Jilhewar found that from March 14, 2014 onward, Glenn H. was limited to “light physical capacity, ” meaning that he could ...

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