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Vanfleet v. Colvin

United States District Court, N.D. Indiana, South Bend Division

August 15, 2014

CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant.



On October 7, 2013, Plaintiff Bethann M. VanFleet ("VanFleet") filed her complaint in this Court. On February 10, 2014, VanFleet filed her opening brief requesting that this Court reverse this cause altogether. In the alternative, VanFleet seeks a remand of this matter to the Commissioner for further consideration with the principles outlined in her brief. On May 18, 2014, Defendant Commissioner of Social Security, Carolyn W. Colvin ("Commissioner") filed her response brief. VanFleet filed a reply on May 29, 2014. This Court may enter a ruling in this matter based on the parties consent, 28 U.S.C. § 636(c), and 42 U.S.C. § 405(g).


On September 7, 2010, VanFleet filed her application for Title II Disability Insurance Benefits ("DIB") and Title XVI Supplemental Security Income ("SSI") pursuant to 42 U.S.C. §§ 416(i), 423 alleging a disability due to degenerative disc disease, obesity, and a history of carpal tunnel syndrome with an initial onset date of September 1, 2006, but amended to March 12, 2008 at her administrative hearing. (Doc. No. 7 at 16, 18). Her claims were denied initially on December 21, 2010, and also upon reconsideration on February 23, 2011. ( Id. at 16). VanFleet appeared at a hearing before an Administrative Law Judge (ALJ) on February 22, 2012 ( Id. ).

On May 9, 2012, the ALJ issued a decision holding that VanFleet was not disabled (Doc. No. 7 at 32). The ALJ found that VanFleet met the insured status requirements of the Social Security Act through December 31, 2010 ( Id. at 18). The ALJ also found that VanFleet had not engaged in substantial gainful activity since March 12, 2008, and her degenerative disc disease, obesity, and history of carpal tunnel syndrome constituted severe impairments. ( Id. ). However, the ALJ found that VanFleet does not have an impairment of combination of impairments that met of medically equaled one of the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1 (Doc. No. 7 at 19). The ALJ found that VanFleet retained the residual functional capacity ("RFC") to perform sedentary work as defined in 20 C.F.R. §§ 404.1567(a), 416.967(a). However, she should never climb ladders, ropes, or scaffolds; should no more than occasionally climb ramps or stairs, balance, stoop, kneel, crouch, or crawl; cannot sustain any one position, either sitting or standing, for greater than thirty minutes; must alternate positions once every thirty minutes; and is limited to performing frequent, but not constant gross manipulation ( Id. at 20). The ALJ then found that VanFleet is capable of performing her past relevant work as a document preparer or microfilming ( Id. at 30).

On August 22, 2013, the Appeals Council denied review of the ALJ's decision making it the Commissioner's final decision (Doc. No. 7 at 6). See Fast v. Barnhart, 397 F.3d 468, 470 (7th Cir. 2005); 20 C.F.R. § 404.981. On October 7, 2013, VanFleet filed a complaint in this Court seeking a review of the ALJ's decision.


A. Facts

VanFleet was a thirty-four year old female at the time the ALJ denied her claims. She has a GED and performed past relevant work as a document preparer or microfilming at a data bank.

1. Claimant's Hearing Testimony

At the hearing, VanFleet testified she suffered from back pain that radiated down her legs, headaches, and a numbing pain in her hands due to carpal tunnel syndrome. VanFleet testified her back goes out approximately six times a month during which she is incapacitated for one to two days. She explained that when she is incapacitated, she works to alleviate her pain by lying in bed, using a heating pad and TENS unit[1], and taking hot baths in Epsom salt. She testified that her prior medical treatment had included physical therapy, but that the therapy did not successfully loosen any muscles. She also noted that she takes pain medication with only one reported side effect, an upset stomach. VanFleet indicated her headaches, occurring daily, cause nausea and sensitivity to light and motion, which cause further pain. She testified to having difficulty with her hands allowing her to write only half a page before experiencing a tingling sensation, but claimed that she maintains the ability to button and zip.

VanFleet explained that in a typical day she prepares her children for school, assists them with dressing, makes breakfast, and when she "feels up to it" completes household chores. (Doc. No. 7 at 65). When she is not incapacitated, VanFleet asserted that she is able to do light household work including dishes and vacuuming, but is unable to perform activities that require bending. VanFleet also stated that she is able to drive to complete errands and attend medical appointments. She testified daily activities require frequent breaks due to pain and on days when her back is out, she receives assistance from her parents with whom she lives.

VanFleet stated her back pain enables her to sit for approximately fifteen minutes and stand for approximately ten to fifteen minutes. In addition, VanFleet stated she could lift a gallon of milk and walk approximately one block before she experiences the feeling of bolts "ripping out of her back." (Doc. No. 7 at 61).

2. Medical Evidence Regarding Back Pain and Carpal Tunnel Syndrome

VanFleet first complained of back pain to her primary treating physician, Dr. Patrick Fleming, on August 31, 2006. Dr. Fleming continued to treat VanFleet through 2008, at which time she changed physicians to Dr. Manjeet Geeta. On April 9, 2008, she was referred to an orthopedist, Dr. Richard Oni, and underwent a microdiskectomy due to disc herniation at L4-L5 with right lower radiculopathy[2]. Following the procedure, VanFleet had complete relief of her symptoms, but returned to Dr. Oni on July 17, 2008, with complaints of returned back pain. Dr. Oni prescribed a medicaiton regimen to alleviate pain, but, VanFleet continued to complain of persistent pain. On November 12, 2008, VanFleet received a steroid injection with no relief of pain. Dr. Oni referred VanFleet to physical therapy and continued to prescribe pain medication. Following ongoing complaints of pain, Dr. Oni ordered a CT discogram on February 9, 2009, which showed mild degenerative disc disease at L3-L4, moderate degenerative disc disease a L4-L5, and extensive degenerative disc disease at L5-S1. Dr. Oni recommended corrective surgery and strongly advised VanFleet to quit smoking.

VanFleet underwent the spinal fusion[3] on August 6, 2009, and obtained complete relief of her symptoms. Prior to her corrective surgery, VanFleet complained of wrist pain and underwent an electromyography around July 31, 2009, which revealed chronic moderate bilateral median mononeuropathy at the wrist consistent with bilateral carpal tunnel syndrome.[4] VanFleet underwent two carpal tunnel surgeries by Dr. Richter on November 18, 2009, and December 11, ...

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