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Hall v. Colvin

United States District Court, M.D. Pennsylvania

May 23, 2017

ALETHEA L. MILLER HALL, Plaintiff
v.
CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant

          MEMORANDUM

          William J. Nealon United States District Judge.

         On October 7, 2015, Plaintiff, Alethea L. Miller Hall, filed this instant appeal[1] under 42 U.S.C. § 405(g) for review of the decision of the Commissioner of the Social Security Administration (“SSA”) denying her application for supplemental security income (“SSI”)[2] under Title XVI of the Social Security Act, 42 U.S.C. § 1381, et seq. (Doc. 1). The parties have fully briefed the appeal. For the reasons set forth below, the decision of the Commissioner denying Plaintiff's application for SSI will be vacated.

         BACKGROUND

         Plaintiff protectively filed[3] her application SSI on April 30, 2010, alleging disability beginning on April 30, 2010, due to a combination of “Panic Disorder, Anxiety Disorder, and Depression Disorder.” (Tr. 73, 136).[4] This claim was initially denied by the Bureau of Disability Determination (“BDD”)[5] on September 24, 2010, and Plaintiff filed a request for an oral hearing on September 30, 2010. (Tr. 93-105). On October 31, 2011, an oral hearing was held before administrative law judge Edward Brady, (“ALJ”). (Tr. 46-72). On November 21, 2011, the ALJ issued an unfavorable decision, finding Plaintiff not disabled. (Tr. 75-90). On January 18, 2012, Plaintiff filed a request for review with the Appeals Council. (Tr. 427-433). On November 2, 2012, the Appeals Council denied Plaintiff's appeal and upheld the ALJ's decision. Plaintiff filed an initial appeal with the United States District Court for the Middle District of Pennsylvania, and, on May 2, 2014, the appeal was granted and the case was remanded to the Commissioner for further proceedings. (Tr. 434-452). On April 7, 2015, a remand hearing was conducted before the ALJ, and Plaintiff and impartial vocational expert, Connie Abraham, (“VE”), testified. (Tr. 398-422). The ALJ issued a second decision denying Plaintiff's SSI claims on June 16, 2015. (Tr. 359-374). This decision became final when the Appeals Council failed to act within sixty (60) days. (Tr. 359-374).

         Plaintiff filed the instant complaint on October 7, 2015. (Doc. 1). On December 22, 2015, Defendant filed an answer and transcript from the SSA proceedings. (Docs. 9 and 10). Plaintiff filed a brief in support of her complaint on June 5, 2016. (Doc. 14). Defendant filed a brief in opposition on July 5, 2016. (Doc. 16). Plaintiff filed a reply brief on July 20, 2016. (Tr. 17).

         Plaintiff was born in the United States on May 28, 1986, and at all times relevant to this matter was considered a “younger individual.”[6] (Tr. 133). Plaintiff graduated from high school in 2005, and can communicate in English. (Tr. 135, 137). Her employment records indicate that she previously worked as at several restaurants and retail stores. (Tr. 137).

         In a document entitled “Function Report - Adult” filed with the SSA, Plaintiff indicated that she lived in a house with her family. (Tr. 531). From the time she woke up to the time she went to bed, Plaintiff dressed and fed her children and took them to school, cleaned and prepared dinner, picked up her children from school, ate dinner, played with her kids, relaxed, and then went to bed. (Tr. 532). Her husband would help her with these tasks on days when she had “a hard time going places.” (Tr. 532). She had no problem with personal care tasks such as dressing and bathing, and was able to prepare meals, clean, do the laundry, and shop in stores about twice a month. (Tr. 532-534). She was able to drive a car, but not unaccompanied due to the fear of having a panic attack alone. (Tr. 534). When asked to check items which her “illnesses, injuries, or conditions affect, ” Plaintiff did not check lifting, squatting, bending, reaching, walking, kneeling, talking, hearing, stair climbing, seeing, following instructions, or using hands. (Tr. 536). She explained that she could not stand for too long because it would cause her “to feel panicky.” (Tr. 536).

         Regarding concentration and memory, Plaintiff did not need special reminders to take care of her personal needs or to go places, but did need a reminder to take her medicine. (Tr. 533, 535). She could pay bills, handle a savings account, use a checkbook, and count change. (Tr. 534). She could pay attention for a few minutes, followed written and spoken instructions well, was not able to finish what she started, and did not hand stress or changes in routine well. (Tr. 536-537).

         Socially, Plaintiff tried to “go out once a day, ” visited her mom and dad once a week, and did not go anywhere on a regular basis. (Tr. 534-535). She watched television, listened to music, and played with her children daily. (Tr. 535). She stated that she became annoyed quickly with others. (Tr. 536).

         At her remand hearing on April 7, 2015, Plaintiff testified that she was prescribed and had been taking Lexapro for her mental health impairments, including panic and anxiety. (Tr. 406). She testified that she experienced a fear of going places, which is medically termed ‘agoraphobia, ' because she was afraid she would have a panic attack in public. (Tr. 407). She stated that she was only able to go places when accompanied by her husband due to fear of panic attacks. (Tr. 411). She also stated that she experienced a form of Obsessive Compulsive Disorder that caused her to perform ritual checking. (Tr. 407). She testified that up until a month before her hearing, she did not have health insurance, and she took only natural supplements to treat her anxiety and panic. (Tr. 412). She noted that she was able to take care of her four (4) young children because she had help when she needed it, but that she did not feel she could respond to needs of those in the “outside world” because there was a lack of help and comfortableness. (Tr. 413). She stated her “comfort zones” included her house, her parents' home, church, and her children's school. (Tr. 414). She described experiencing short-lasting panic attacks that lasted up to one (1) hour, which she stated she would have a few times a week on average, and longer lasting ones that would last up to one (1) month with a feeling of constant dread, with her last one occurring in the summer before the remand hearing. (Tr. 415).

         MEDICAL RECORDS

         On August 2, 2010, Plaintiff underwent a consultative examination performed by Stephen Timchack, Ph.D. (Tr. 253). It was noted that she was anxious, fidgety, cooperative, polite, well-groomed, and respectful. (Tr. 256). Plaintiff's self-reported symptoms included feeling sweaty, faint, and dizzy, having a rapid heart rate, feeling a chronic sense of doom and fear, and having an excessive fear of the community and large crowds of people. (Tr. 259). Her mental status examination revealed she had: fleeting eye contact; impoverished recent and remote memory; a highly anxious mood with affect congruent to mood; quick-paced speech consistent to that of an individual with significant anxiety; a logical and goal-directed thought process; intact sustained attention and concentration; marginally developed insight and judgment for her age; and a low average IQ range. (Tr. 256-258). Her diagnoses included Panic Disorder with Agoraphobia, Cluster B Personality Traits, Orthostatic Hypertension, Tachycardia, and suspicion of Hyperthyroidism. (Tr. 259). Dr. Timchack opined that Plaintiff had a guarded prognosis that would be more favorable if she participated in intensive outpatient psychotherapy and medication management. (Tr. 259).

         On August 6, 2010, Dr. Timchack completed a Questionnaire, and opined that Plaintiff had: slight restrictions in her ability to understand, remember and carry out short, simple instructions; moderate restrictions in her ability to understand, remember, and carry out detailed instructions; marked restrictions in her ability to make judgments on simple work-related decisions; moderate restrictions in her abilities to interact appropriately with the public, supervisors, and co-workers; and moderate restrictions in her ability to respond appropriately to work pressures in a usual work setting and to changes in a routine work setting. (Tr. 251).

         On August 12, 2010, Joseph Barrett, Ph.D., completed a Psychiatric Review Technique and a Mental Residual Functional Capacity form. (Tr. 261). In the Psychiatric Review Technique, Dr. Barrett opined that Plaintiff had mild restriction in activities of daily living; moderate difficulties in maintaining social functioning and concentration, persistence, or pace; and one (1) to two (2) repeated episodes of decompensation. (Tr. 271). He stated that Plaintiff's exam was within normal limits aside from some “recent memory problems.” (Tr. 273). In the Mental RFC form, Dr. Barrett opined that Plaintiff was moderately limited in her ability to carry out very short and simple instructions; to work in coordination with or proximity to others without being distracted by them; to interact appropriately with the general public; to accept instructions and respond appropriately to criticism from supervisors; and to respond appropriately to changes in the work setting. (Tr. 273-275).

         On September 8, 2010, Plaintiff had an appointment with Adnan Saba, M.D. (Tr. 277-279). It was noted that Plaintiff experienced panic attacks up to three (3) times a week, with some lasting all month, that she felt she got angry easily, that she always felt hot, that she could not stand for a long time because it caused her to feel lightheaded and weak, and that, during a panic attack, her heart would race and she would be short of breath. (Tr. 277). An examination revealed Plaintiff: was anxious-looking; was alert and oriented in all three (3) spheres; had fluent speech; was able to lift and carry up to twenty (20) pounds occasionally; was able to stand and walk for less than one (1) hour; was unlimited in pushing and pulling; could engage in postural activities; and should avoid extreme temperatures, poor ventilation, humidity, fumes, odors, and gases. (Tr. 278-279). Dr. Saba's impression was that Plaintiff had panic attacks with agoraphobia and possible hyperthyroidism. (Tr. 279).

         On September 16, 2010, Plaintiff underwent an Intake Evaluation at Valley Counseling Associates.[7] (Tr. 281). Plaintiff's self-reported symptoms included trouble sleeping, memory problems, low self-esteem, trouble concentrating and making decisions, irritability, anxiety, nervousness, panic attacks, mood swings, anger problems, and phobias. (Tr. 284). Her mental status examination revealed she was cooperative, anxious, had an appropriate affect, had coherent speech and a relevant thought process, had intact orientation and memory, had intact concentration and judgment, had intact insight, and had sufficient self-control. (Tr. 286). Her Axis I diagnosis was Anxiety Disorder, Axis II diagnosis was Borderline Personality traits, and her Axis III diagnosis was hyperthyroidism. (Tr. 286).

         On September 23, 2010, Theodore Waldron completed a Physical RFC form. (Tr. 288). He opined Plaintiff could: occasionally lift and/ or carry up to twenty (20) pounds and frequently up to ten (10) pounds; sit, stand and/ or walk for about six (6) hours in an eight (8) hour workday; was unlimited in pushing and pulling within the aforementioned weight restrictions; could frequently bend, stoop, kneel, crouch, and crawl; could occasionally climb ramps and stairs, but never ladders; and should avoid concentrated exposure to extreme temperatures, wetness, humidity, noise, vibration, fumes, odors, dusts, gases, poor ventilation, and hazards. (Tr. 288-290).

         On October 6, 2010, Plaintiff underwent a consultative examination by Lenora Herrmann Finn, Ph.D. (Tr. 299). It was noted that Plaintiff was ruminative, socially withdrawn, passively dependent, anxious in all modalities, irritable, and had poor judgment. (Tr. 299). Her ...


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