United States District Court, Northern District of Indiana, South Bend Division
RAYMOND L. HOCHSTETLER, Plaintiff,
CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant.
OPINION AND ORDER
JON E. DEGUILIO JUDGE UNITED STATES DISTRICT COURT
On July 1, 2013, Plaintiff Raymond Hochstetler filed a complaint in this Court seeking review of the final decision of the Defendant Commissioner of Social Security. [DE 1.] The matter is fully briefed and ripe for decision. For the reasons stated below, the Court REMANDS this matter to the Commissioner for further proceedings.
I. Procedural History
Mr. Hochstetler filed an application for disability insurance benefits in March 2011 and an application for supplemental security income in April 2011. (Tr. 298–311.) His applications were denied in June 2011, and again on reconsideration in July 2011. (Tr. 131–34.) A hearing was held before Administrative Law Judge Romona Scales in December 2011 (Tr. 90–130), after which she issued a decision denying both claims (Tr. 138–51). The Appeals Council granted a request for review of that first decision and remanded the case back to the ALJ for further consideration of certain evidence and its effect on Mr. Hochstetler’s residual functional capacity. (Tr. 157–61.)
A hearing was held on November 15, 2012, again before ALJ Scales. (Tr. 42–89.) On December 28, 2012, the ALJ issued her decision, again denying both claims. (Tr. 14–34.) The Appeals Council denied a request to review the second decision on May 13, 2013. (Tr. 1–3.) This suit followed.
Mr. Hochstetler was born on September 17, 1964, and was 48 years old on the date the ALJ rendered her decision. (Tr. 45.) He has an eighth grade education. (Tr. 47.) Mr. Hochstetler alleges a disability onset date of April 14, 2006 (Tr. 14), and claims disability based on both physical and mental impairments.
A. Medical Evidence of Physical Impairments
Mr. Hochstetler claims several physical impairments contribute to his disability, including Chronic Obstructive Pulmonary Disorder (“COPD”) and musculoskeletal issues with his knees, lower back, and hands.
Medical records of Mr. Hochstetler’s physical impairments date to late 2006. On November 6, 2006, he presented to the Bowen Center for a psychiatric assessment. Relative to his physical condition, the notes from that assessment indicate that the ring finger on his right hand was causing him pain, which he described as potentially having been the result of a work injury. (Tr. 480.) Notes from a December 1, 2006, psychiatric evaluation state that Mr. Hochstetler had undergone surgery on his left hand. (Tr. 474.)
On December 7, 2010, Mr. Hochstetler was brought to Woodlawn Hospital for anxiety. During that examination, he reported osteoarthritis in his knees, which caused “chronic pain.” (Tr. 511.) Additionally, a chest x-ray showed advanced COPD. (Id.)
On May 13, 2011, Mr. Hochstetler presented to Randall Coulter, D.O., at MedStat Urgent Care & Occupational Health for a consultative examination. (Tr. 548.) Dr. Coulter’s review of systems listed “skeletal abnormalities (arthritis), joint pain (low back and knees), and joint stiffness (low back and knees).” (Id.) Mr. Hochstetler’s gait was slightly unsteady and he used a cane to ambulate. (Tr. 549.) He could raise his legs both in a seated and supine position, but with some difficulty due to low back pain. (Id.)
A few days later, Mr. Hochstetler presented to M. Brill, M.D., for the opinion of the state agency medical consultant. (Tr. 554–61.) Dr. Brill noted symptoms of emphysematous pulmonary changes and knee pain. (Tr. 555.) Dr. Brill opined the Mr. Hochstetler did not “need” his cane for ambulation and that there was also no objective loss of strength or x-ray evidence of arthritis that would limit Mr. Hochstetler’s ability to walk or stand. (Tr. 560.)
On August 17, 2011, Mr. Hochstetler presented to the Four County Counseling Center for a mental evaluation. Relevant to Mr. Hochstetler’s physical condition, Despina Moise, M.D., noted that he had arthritis in his knees and walked with a cane. (Tr. 607.) Thirteen days later, Mr. Hochstetler reported his arthritis to case worker Mary Osburn of the Four County Counseling Center, who further noted that he walked with a cane. (Tr. 677.)
On February 11, 2012, Mr. Hochstetler presented to Woodlawn Hospital for coughing and chest tightness caused by smoke inhalation. (Tr. 831.) A radiology report stated that Mr. Hochstetler had “[m]ild hyperexpansion and flattening of the diaphragm suggestive of COPD.” (Tr. 835.)
On August 23, 2012, Mr. Hochstetler was evaluated by William Terpstra, M.D., of Wagoner Medical Center. Mr. Hochstetler reported pain in his lower back, hands, and right knee. (Tr. 661.) Dr. Terpstra’s report stated that Mr. Hochstetler’s fine and gross motor movements were normal; that he could walk on tiptoes and heels, as well as tandem walk and squat; and that his gait and station were normal. (Tr. 662.)
On October 9, 2012, Mr. Hochstetler presented to Lisa Ronback, M.D., of Rochester Orthopedics, complaining of pain in his thumb and that his fingers go numb and turn white after an accident on his moped five days earlier. (Tr. 839.) The report states that Mr. Hochstetler has arthritis and shortness of breath without chest pain. (Id.) A physical examination showed a scaphoid fracture of the right wrist and joint laxity in his left hand. (Tr. 840.) After a subsequent evaluation on October 23, 2012, Dr. Ronback determined that Mr. Hochstetler could continue to work at his current job with a splint. (Tr. 842.)
B. Medical Evidence of Mental Impairments
On November 6, 2006, Mr. Hochstetler presented to the Bowen Center. Mr. Hochstetler reported hearing voices and alcohol dependence. (Tr. 479.) On December 1, 2006, he returned to the Bowen Center for a psychiatric evaluation by Snieguole Radzeviciene, M.D. (Tr. 473.) Dr. Radzeviciene concluded that Mr. Hochstetler suffered from “Social Anxiety Disorder” due to panic attacks, paranoia, depression, insomnia, and “auditory hallucinations once a week.” (Tr. 473–77.) Dr. Radzeviciene also assessed that Mr. Hochstetler had limited judgment, poor insight, low intellect, and a grossly intact memory, but that he exhibited good concentration at the time of the evaluation. (Tr. 476.) Dr. Radzeviciene assessed a global assessment of functioning (“GAF”) score of 50 at the time of admission. (Tr. 477.)
On January 16, 2007, Mr. Hochstetler presented to psychologist Patrick Utz, Ph.D., of Indiana Rehabilitation Services for an interview and the administration of intellectual testing. (Tr. 491.) Mr. Hochstetler reported panic attacks and depression. (Tr. 492.) The Wechsler Adult Intelligence Scale III showed that he measured in the “high Borderline range” with a score of 78. (Tr. 492.) The Wechsler Memory Scale III showed that Mr. Hochstetler had “no major memory problems.” (Tr. 493.) Dr. Utz assessed a GAF score of 50. (Tr. 493.)
On January 31, 2007, Mr. Hochstetler presented to a social worker at the Bowen Center for a report on his psychiatric status. The report, which was countersigned by Dr. Radzeviciene, assessed that Mr. Hochstetler suffered from a social phobia due to panic attacks. (Tr. 503.) Mr. Hochstetler seemed cooperative and coherent, but his thought process was somewhat loose with fragmented run-on sentences. (Tr. 501.) The report stated that Mr. Hochstetler would “struggle with remembering simple tasks or instructions” and that the he would not be “reliable at any work situation” because of his inability to leave his house. (Tr. 503–04.) The report further stated “even if he got to work, he would lose focus . . . and not be able to finish a specific task.” (Tr. 504.) The report estimated the probable duration of impairment to be “lifetime and continuous.” (Tr. 505.) The report stated a GAF score of 55 to 60. (Tr. 500.)
On December 7, 2010, Mr. Hochstetler was brought to Woodlawn Hospital by EMS for anxiety. (Tr. 511.) Kevin O’Brien, M.D., found evidence of paranoia, alcohol intoxication, and the presence of THC; Dr. O’Brien subsequently referred Mr. Hochstetler to the Four County Counseling Center. (Tr. 512.)
On December 30, 2010, Mr. Hochstetler presented to the Four County Counseling Center. (Tr. 522.) He initially received an Intake/Biopsychosocial examination, which noted mood disturbance, audio hallucinations, depression, paranoia, and problems with substance abuse. (Tr. 525–28.) During the interview, he seemed agitated, hyper-vigilant, anxious, and irritable. (Tr. 526.) While he had fair eye contact and intact memory, he showed low intelligence with “loose, scattered thoughts” and “rapid speech.” (Tr. 525–26.) Mr. Hochstetler stated that he takes care of his ill mother, but “it takes him a long time to do any chore including making meals for himself.” (Tr. 525.) The report stated a GAF score of 40 and estimated his prognosis as “poor.” (Tr. 525, 529.)
Mr. Hochstetler received continuing services from the Four County Counseling Center, including regular meetings with Dr. Moise. On February 1, 2011, Dr. Moise conducted an initial psychiatric evaluation. Dr. Moise observed that Mr. Hochstetler was very guarded, suspicious, uncooperative, very irritable, and unable to focus. (Tr. 530–31.) He portrayed good eye contact, but it was in the form of an intense stare. (Tr. 531.) While he could recall remote events, he could not recall recent events, including the current month. (Tr. 531.) Dr. Moise also noted insomnia and that Mr. Hochstetler experienced auditory hallucinations, which told him to “kill others.” (Tr. 530.) Dr. Moise assessed a GAF score of 40 and recommended medication and a reference for case management. (Tr. 534–35.)
Mr. Hochstetler continued to see Dr. Moise over the next several months and experienced ups and downs in his mental state during that time. In February through September 2011, Mr. Hochstetler showed some improvement in his mental state, appearing calmer and experiencing fewer or less intense hallucinations. (Tr. 540, 542, 563, 566, 597, 619, 631.) During early November 2011, Mr. Hochstetler was unable to obtain his medication due to financial difficulties. (Tr. 769.) On November 22, 2011, Dr. Moise noted that he was once again hearing voices and having trouble leaving his home due to anxiety. (Tr. 766.) On December 20, 2011, Dr. Moise noted that Mr. Hochstetler was hearing voices telling him to harm others, which he was able to ignore, and that he would avoid others “so as not to get too angry at anyone.” (Tr. 754.)
In early January 2012, Mr. Hochstetler was able to afford some medication. (Tr. 749.) On January 17, 2012, Dr. Moise noted that the voices were better, but still bothering him on occasion. (Tr. 734.) He appeared to be coping with daily activities, but would isolate himself fearing that he would react negatively to others. (Id.) His mood was described as “up and down.” (Id.) In July 2012, he reported sleeping well and that he experienced no mood or psychotic symptoms. (Tr. 703.) However, in August 2012 (while taking his medication), Mr. Hochstetler experienced a deterioration where he started experiencing auditory hallucinations (“the voices talk to me all the time now”) and persecutory delusions (feeling that people were “after” him), both of which had worsened over the proceeding weeks. (Tr. 691.) Mr. Hochstetler’s symptoms “started after he went to work[;] he stated that a co-worker kept threatening to hurt him, and he felt scared every day he went to work. He finally asked for a transfer, but unfortunately they do not have as many hours for him in the new department.” (Tr. 691.) Dr. Moise prescribed a new medication. (Tr. 691.)
On August 17, 2011, Dr. Moise completed a Mental Impairment Questionnaire. (Tr. 603.) Dr. Moise listed clinical findings including: psychotic disorder, polysubstance dependence, alcohol abuse, auditory hallucinations, paranoia, mood swings such as irritability and hostility, low intelligence, and poor memory. (Tr. 603–04.) Dr. Moise further stated that Mr. Hochstetler had difficulty thinking and concentrating with loosening associations that make him unable to perform work-like activities. (Tr. 604.) While medications helped reduce irritability and psychotic symptoms, Dr. Moise listed the prognosis as guarded. (Tr. 604.) Dr. Moise stated that Mr. Hochstetler’s impairments lasted or were expected to last over twelve months, and would likely cause him to be absent from work more than three times a month. (Tr. 604–05.) Dr. Moise further opined that “he would not be able to work around others productively” and due to “low intelligence level [and poor memory], he would not be able to learn and carry out instructions.” (Tr. 606.)
On June 6, 2011, state agency consultant Stacia Hill, Ph.D., completed a Mental Residual Functional Capacity Assessment. (Tr. 592–94.) Dr. Hill opined that Mr. Hochstetler was: not significantly limited in his ability to remember locations and work-like procedures, or to understand and remember very short and simple instructions; moderately limited in remembering detailed instructions; not significantly limited in sustained concentration and persistence, except moderately limited in ability to carry out detailed instructions; not significantly limited in social interaction; and not significantly limited in adaptation, except moderately limited in ability to respond appropriately to changes in work setting. (Tr. 592–93.) Dr. Hill additionally opined that Mr. Hochstetler can understand, remember, and carry-out simple tasks; can relate at least superficially on an ongoing basis with co-workers and supervisors; can attend to task for sufficient periods of time to complete tasks; and can manage the stresses involved with simple work. (Tr. 594.) This assessment was affirmed by state agency consultant Donna Unversaw, Ph.D., on June 28, 2011. (Tr. 599.)
C. Hearing Testimony
At the 2012 hearing, testimony was heard from Mr. Hochstetler, case manager Sarah Silance, and Vocational Expert (“VE”) Leonard Fisher. (Tr. 42–43.)
1. Mr. Hochstetler’s Testimony
Mr. Hochstetler is not married and lives alone. (Tr. 46.) He attended school through eighth grade, has problems reading and writing longer words, and can perform only simple addition and subtraction. (Tr. 47–48.)
At the time of the hearing, Mr. Hochstetler worked part-time at Modern Materials, doing production line work. (Tr. 48.) He has worked there since approximately June 2012, with hours varying anywhere from eight to twenty-four hours per week, though on two occasions he worked approximately thirty-nine hours. (Tr. 48–49.) He stated that he does not receive more hours partly because of scheduling and partly because he would not be able to work full-time, since he cannot handle that many hours on his feet. (Tr. 49.) He described having some focus issues on the job (Tr. 49, 65) and that he usually makes it through about four hours of work before his feet start to get bad (Tr. 60). He further testified that he is pushing himself harder while at work and would ideally stand for no longer than an hour and a half at one time. (Tr. ...