United States District Court, M.D. Pennsylvania
DAVID E. MOATS, Plaintiff,
CAROLYN W. COLVIN, Defendant
For David E Moats, Plaintiff: Steven M. Rollins, LEAD ATTORNEY, Rollins Law Office, Harrisburg, PA.
For Carolyn W Colvin, Defendant: Kate Louise Mershimer, U.S. Attorney's Office, Harrisburg, PA.
THOMAS M. BLEWITT, United States Magistrate Judge. Judge Nealon.
REPORT AND RECOMMENDATION
THOMAS M. BLEWITT,
United States Magistrate Judge.
On March 5, 2014, Plaintiff David E Moats filed, through counsel, a Complaint appealing the final decision denying his Title II application for disability insurance benefits (" DIB"). (Doc. 1). This matter has been referred to the undersigned Magistrate Judge for preparation of a report and recommended disposition. This Court has jurisdiction over this case pursuant to 42 U.S.C. § 405(g). For the reasons stated herein, we recommend that the final decision of the Commissioner denying Plaintiff's claim be VACATED and REMANDED.
II. BACKGROUND & PROCEDURAL HISTORY.
On August 9, 2010, Plaintiff, a 46 year old inventory control specialist protectively filed his application for DIB alleging disability due to neck injury, mental illness and allergy. (TR 223). Plaintiff asserts that he became unable to work due to his conditions on March 29, 2010. The record reflects, however, that the instant application was not Plaintiff's first application for benefits. Plaintiff previously applied for, and received, a closed period of disability from February 2, 2005, though July 1, 2007, due to the combination of chronic pain as a result of cervical degenerative disc disease and severe depression and anxiety. On July 2, 2007, Plaintiff returned to full-time work with no significant medical restrictions.
Plaintiff filed this, his second, application for benefits after he was separated from his employment on March 29, 2010, due to what he believes were performance issues as a result of a reoccurrence of the conditions that previously rendered him disabled. (TR 35). Specifically, Plaintiff testified that his employer let him go because he frequently (two times per month) left work to attend doctor's appointments, and because he gradually began to have increased difficulty concentrating, staying awake, and remembering until he was no longer able to meet his work quotas. (TR 37-38). Plaintiff also reported, however, that at least one other employee was let go on the same day. Id. Following the termination of his employment, Plaintiff reported that he collected unemployment benefits for most of 2010 and, as is required to qualify for unemployment, he certified that he was able and available to work. (TR 66-67, 197-98). When asked what type of work he was able and available to perform, he reluctantly admitted that he would have been able to talk to people on the phone during the period of time he filed for unemployment, but that he thought it " probably wouldn't have worked out." Id.
Plaintiff's application for benefits was initially denied on February 2, 2011. At Plaintiff's request, a hearing was held before ALJ Sharon Zanotto in Harrisburg, Pennsylvania on July 16, 2012. Plaintiff appeared at the hearing with counsel and testified about the his impairments. Plaintiff testified that as a result of prior motor vehicle accidents he experiences pain in his cervical spine that radiates to his head, shoulders and down his spine to C7. (TR 46-47). He reported that the performance of tasks that require him to reach in front of his body, like doing dishes, or reaching above his head causes him pain in both arms. (TR 47). He also testified that he experiences pain when moving his head up and down or left to right, when he bends or stoops, and when he lifts or carries objects. (TR 48). Plaintiff stated that he experiences discomfort after sitting for long periods, and needs to get up and walk around. Id. He asserted that he could occasionally drive short distances but relies on his companion, Margaret Kelly, to drive him to medical appointments and to the grocery store because he feels it is unsafe to drive for greater distances due to his seizure disorder. Plaintiff testified that his mental impairments result in agoraphobia, and that he rarely leaves his second floor walk-up apartment. (TR 34, 41-42).
With respect to his activities of daily living, Plaintiff gave several different accounts. Initially, Plaintiff testified that, even though he lives alone, he does not do any household chores as a result of his impairment. (TR 34, 61). He later recanted his statement, however, and admitted that he occasionally cleans a few dishes but otherwise uses disposable dishware, is able to microwave frozen dinners, clean his bathroom, and is able to take out his trash in small two to three-pound bags. (TR 61-66). Plaintiff also explained that Ms. Kelly visits his apartment five times per month to bring him groceries or take him shopping, do his laundry, and drive him to medical appointments. (TR 44-45, 57). He asserted, however, that he has not dusted, swept, or mopped his apartment since he moved in due to his depression. (TR 64).
The medical evidence of record, as developed before the ALJ, reflects that Plaintiff's treatment was conservative with routine visits for medication management. Notably, Plaintiff received very little medical or psychiatric care during the relevant period, and asserted that this was due to a lack of medical insurance. Plaintiff obtained new insurance, and was reportedly in the process of re-establishing care, on the date of his administrative hearing. Plaintiff's longtime treating physician, Richard Prensner, M.D., reported that Plaintiff's problems of chronic pain, hypercholesterolemia and epilepsy were " stable" in April 2010. (TR 274). The most recent MRI imaging dated April 2005 reveals shallow osteophytes and mild foraminal narrowing at C3-C4, C5-C6, and C6-C7, but no evidence of herniation or impingement. (TR 341). Further, January 2011 examination records reflect that Plaintiff had full strength in all of his extremities, was able to get on and off the examination table and ambulate normally without difficulty. (TR 328). Treatment records reflect that Plaintiff's pain was considerably lessened by narcotic medications; however, some side-effects were noted, including memory issues and impaired ability to concentrate. Plaintiff's medical records also reflect that he has a history of seizures. On November 13, 2009, however, Dr. Prensner noted that Plaintiff's seizures were well-controlled by medication, and that his last seizure was in May 2008. (Tr. 281, 503).
On July 9, 2012, to assist the ALJ in her determination, Certified Registered Nurse Practitioner (" CRNP") Allison Pra, a source who reportedly treated Plaintiff at Kline Health Center, completed a medical source statement on Plaintiff's behalf. CRNP Pra opined that Plaintiff could: occasionally and frequently lift up to ten pounds; stand or walk for four hours per eight-hour workday; sit up to eight hours per workday with a sit-stand opinion permitting him to stand or walk for five minutes after every thirty minutes spent sitting; push or pull with his lower extremities on a slightly less than frequent basis (50% of the workday); occasionally stoop or squat, and push or pull with his arms or lift with his arms in front of his body on a slightly less than occasional basis (25% of the workday); reach overhead on a less than occasional basis (10% of the workday); and never twist or climb. (TR 579-80). CRNP Pra also opined that Plaintiff should avoid concentrated exposure to extreme heat, extreme cold, wetness, hazards or heights, fumes, odors, dust or poor ventilation, and noted that Plaintiff would require approximately four ten-minute breaks in excess of those customarily provided in ...