United States District Court, M.D. Pennsylvania
RICHARD P. CONABOY, District Judge.
Here we consider Plaintiff's appeal from the Commissioner's denial of Disability Insurance Benefits ("DIB") under Title II of the Social Security Act. (Doc. 1.) Plaintiff originally alleged disability due to bipolar disorder, anxiety, depression, and hearing voices. (R. 195.) Plaintiff identified his onset date as January 11, 2011. (R. 22.) The Administrative Law Judge ("ALJ") who evaluated the claim, Melvin Benitz, concluded that Plaintiff's severe impairment of depression with bipolar component did not alone or in combination with the non-severe impairments (kidney stones, high blood pressure and sleep apnea) meet or equal the listings. (R. 24.) The ALJ found that Plaintiff had the residual function capacity ("RFC") to perform a full range of work at all exertional levels with certain nonexertional limitations and that he was capable of performing jobs that existed in significant numbers in the national economy. (R. 26-29.) The ALJ therefore found Plaintiff was not disabled under the Act from January 15, 2011, through the date of the decision, May 7, 2013. (R. 29.)
With this action, Plaintiff asserts that the decision of the Social Security Administration should be reversed and benefits awarded or, alternatively, that the case be remanded for further administrative proceedings. (Doc. 11 at 9.) He identifies a single error: "The ALJ committed a reversible error and harmful error of law by failing to discuss multiple GAF scores of 50 or below." (Doc. 11 at 3.)
After careful consideration of the administrative record and the parties' filings, we conclude Plaintiff's appeal is properly granted.
A. Procedural Background
On August 30, 2011, Plaintiff protectively filed an application for DIB. (R. 22.) As noted above, Plaintiff alleges disability beginning on January 15, 2011, due to bipolar disorder, anxiety, depression, and hearing voices. (Doc. 11 at 2; R. 195.) The claim was initially denied on December 2, 2011. (R. 22.) Plaintiff filed a request for a review before an ALJ on December 9, 2011. ( Id. ) On April 9, 2013, Plaintiff appeared and testified at a hearing in Dover, Delaware, before ALJ Norman Bennett. (R. 35-68.) Plaintiff appeared with his attorney, Stephanie Ott. (R. 35.) Vocational Expert ("VE") Ellen Jenkins also testified. ( Id. ) ALJ Melvin Benitz issued his decision on May 7, 2013, finding that Plaintiff was not disabled under the Social Security Act through the date of the decision. (R. 29.) On June 5, 2013, Plaintiff requested a review with the Appeal's Council. (R. 8.) The Appeals Council issued its decision on December 15, 2014, denying Plaintiff's request. (R. 4-9.)
On February 11, 2015, Plaintiff filed his action in this Court appealing the Acting Commissioner's decision. (Doc. 1.) Defendant filed her answer and the Social Security Administration transcript on April 29, 2015. (Docs. 9, 10.) Plaintiff filed his supporting brief on June 11, 2015. (Doc. 11.) Defendant filed her opposition brief on July 13, 2015. (Doc. 12.)
B. Factual Background
Plaintiff was born on November 4, 1967. (R. 28.) He was forty-three years old on the alleged disability onset date. ( Id. ) Plaintiff has a at least a high school education. ( Id. ) In the October 24, 2011, Disability Report, he reported that he stopped working in January 2011 because of his conditions. (R. 195.) Plaintiff told his doctors and therapists that he was fired from his last job after a motor vehicle accident. (R. 257, 269.) After losing his job, Plaintiff applied for unemployment insurance and collected it for eighteen months. (R. 46, 547.) Plaintiff has past relevant work as a lawn worker and tractor trailer driver. (R. 28, 62.)
1. Impairment Evidence
Plaintiff was hospitalized voluntarily at Mount Nittany Medical Center from January 19, 2011, to January 25, 2011. (R. 254-59.) He presented with severe depression as well as auditory and visual hallucinations. (R. 254.) On January 20th, he was assessed with a GAF score of 35. (R. 259.) During his hospitalization, Plaintiff realized that he needed to stay on his medications. ( Id. ) Upon discharge, his hallucinations had stopped, his mood was "great, " his affect was "improved, " and his anxiety was "gone." (R. 254.) His GAF at discharge was assessed at 45, and he was prescribed Lithium, Risperdal, and Klonopin. (R. 254-55.)
The next day Plaintiff followed up regarding medications and made arrangements for counseling at Catholic Charities. (R. 266.) He reported to caseworker Karen Hart that Lithium helped with his mood, his sleep was better with Klonopin, and he had no nightmares since starting Risperdal. (R. 267.) He also reported that he has a hallucination of a gargoyle named Maximus telling his to slow down and take a nap. (R. 267.) Ms. Hart assessed his GAF at 55. (R. 269.)
On March 2, 2011, Plaintiff saw Abdollah Nabavi, M.D. (R. 270.) Plaintiff told Dr. Nabavi that he had not been taking all of his medications and he was looking for a job. ( Id. ) Dr. Nabavi assessed that Plaintiff's mood was "a little down, " his speech was normal and relevant, he had no thought or perceptual disorder, and his affect was congruent. ( Id. ) Plaintiff's GAF was assessed at 65, and he was told to continue counseling. ( Id. )
Plaintiff returned to Dr. Nabavi on March 23, 2011, and April 6, 2011. (R. 271.) Dr. Nabavi's assessments included that Plaintiff had good judgment and insight, was alert and oriented, and had intact memory functioning. (R. 271-72.) At the March 23rd visit, Plaintiff reported that family members noticed his mood was "kind of down, " and at the April 6th visit, he reported "I am doing good." (R. 271.)
At Plaintiff's June 8, 2011, visit to Dr. Nabavi, he reported zoning out, paranoia, and auditory hallucinations. (R. 271.) Dr. Nabavi advised Plaintiff to talk with his primary care physician to get a neurological consultation. ( Id. )
During this time period Plaintiff was also going for counseling to Catholic Charities. (R. 325-31.) Sharon Felson was his therapist from January through August 2011. ( Id. ) She assessed the following GAF scores: 35 on January 31st; 33 on February 22nd; and 40 on March 21st. (R. 336, 341, 348.) Ms. Felson described Plaintiff as fearful, anxious, and inflexible about what he was capable of doing and how he negotiated the everyday world, noting that Plaintiff stated he would never work again if he could not drive a truck. (R. 327-28.)
On September 12, 2011, Plaintiff called Community Hospital reporting suicidal ideation and hallucinations. (R. 301.) On September 13, 2011, Plaintiff was admitted to the hospital because of depression and suicidal ideation. (R. 274, 305.) He reported auditory hallucinations of screams. (R. 275.) On admission Plaintiff was assessed with a GAF score of 25. (R. 274.) At his discharge on September 19, 2011, his GAF was assessed at 50. (R. 274, 276.) During his hospitalization, Plaintiff attended therapy, started to take Lithium again, and was prescribed Seroquel. (R. 276.)
On September 29, 2011, Plaintiff went to Delaware Health & Social Services Division of Substance Abuse & Mental Health. (R. 281.) He reported that he had been stable since his hospitalization. ( Id. )
Plaintiff saw Duane D. Shubert, M.D., on October 5, 2011, and reported depression. (R. 286.) Plaintiff continued to see Dr. Shubert monthly through January 2012. (R. 286, 295-97.) Dr. Shubert noted on October 5th that Plaintiff's mood was depressed but his affect was appropriate and his thought process was normal. (R. 285.) Dr. Shubert assessed Plaintiff to have a GAF of 50. (R. 286.)
On May 14, 2012, Plaintiff went to Dover Behavioral Health Systems for depression and suicidal ideation. (R. 369.) Plaintiff again had hallucinations and was paranoid about his neighbor. ( Id. ) Plaintiff was admitted with a GAF of 25 and discharged on May 21st with a GAF of 50. (R. 373, 370.) During his hospitalization, Plaintiff "did well" and was back on medication, taking Seroquel, Lithium, and Trazadone. (R. 370.)
In January 2013, Plaintiff saw his therapist, social worker Heather Carpenter. (R. 514-15.) She assessed that Plaintiff was alert and oriented, his mood was euthymic, his affect congruent, he had no suicidal or homicidal ideation and his thought process was coherent and relevant. ( Id. ) She noted that Plaintiff was focused on obtaining disability benefits. ( Id. )
Plaintiff returned to Dover Behavioral Health Systems on February 21, 2013, reporting an increase in auditory hallucinations, paranoia, and suicidal ideation because he believed his disability hearing was cancelled when it was delayed. (R. 518.) He was admitted with a GAF of 20. ( R. 527. ) His Seroquel dosage was increased with good results. (R. 520.) His GAF at discharge from inpatient care on February 28th was 45. (R. 523.) Plaintiff then attended the partial hospitalization program until March 22, 2013. (R. 518.) On March 22nd, Plaintiff was assessed with a GAF score of 60. ( Id. ) The Discharge Summary also noted that because Plaintiff had five hospitalizations in the previous two years, he was appropriate for a referral to a higher level of care such as intensive case management. ( Id. )
On March 8, 2013, Plaintiff reported to Ms. Carpenter at Sussex County Mental Health that he had gone to Dover Behavioral Health because he was "more stressed out" and experiencing nightmares, irritable mood, mood swings and angry outbursts. (R. 512.) He told her about an altercation he had in the Walmart parking lot the day he went to the ...