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Claywell v. Colvin

United States District Court, S.D. Indiana, Indianapolis Division

November 17, 2014

CAROLYN W. COLVIN Commissioner of the Social Security Administration, Defendant.


MARK J. DINSMORE, Magistrate Judge.

Christopher Claywell ("Plaintiff" or "Claywell") requests judicial review of the final decision of the Commissioner of the Social Security Administration ("Commissioner" or "Defendant") denying his application for Social Security Disability Insurance Benefits ("DIB") under Title II of the Social Security Act ("the Act"). See 42 U.S.C. ยงยง 416(i), 423(d). For the reasons set forth below, the Magistrate Judge recommends that the decision of the Commissioner be AFFIRMED.

Procedural History

Claywell filed an application for DIB in June 2011 alleging an onset of disability on April 10, 2010. Claywell's application was denied initially on September 19, 2011 and on reconsideration on November 7, 2011. Claywell requested a hearing, which occurred via video conference before Administrative Law Judge ("ALJ") Julia D. Gibbs on September 11, 2012. The ALJ concluded Plaintiff was not disabled at any time from his alleged onset date through the date of the ALJ's September 28, 2012 decision. The Appeals Council denied Claywell's request for review on December 18, 2013, rendering the ALJ's decision final. Claywell filed his Complaint with this Court on February 12, 2014.

Factual Background and Medical History

Plaintiff was 47 years old and had a high school education at the time of the ALJ's decision. [R. at 19.] He had work experience as a setup man, assembler, and sales clerk, [ id. ], but left his last job after his employer went out of business in 2009. [R. at 31.] He began collecting unemployment benefits, [ id. ], and obtained an associate degree in medical assisting in May 2012. [R. at 33.] Two weeks prior to the hearing before the ALJ, Plaintiff began working at an auto parts store. [R. at 30-31.]

Plaintiff alleges a disability onset date of April 10, 2010. [R. at 11.] Plaintiff's primary care physician both before and after this time was Dr. Marc Davisson. [R. at 16.] The earliest medical evidence in the record is from 1999 and shows Plaintiff had a history of sleep apnea, hypertension, and atrial fibrillation. [R. at 340.] Records from Dr. Davisson's office, however, indicate that these problems were well-controlled by 2008. [ See, e.g., R. at 444-45.]

The record contains no significant records from the months before or after the alleged onset of disability in April 2010. [R. at 16; see also Dkt. 16 at 2-3.] In November 2010, Plaintiff saw Dr. Davisson for a "[p]reventative checkup." [R. at 227.] He noted Plaintiff's history of atrial fibrillation, hypertension, and sleep apnea, [R. at 226], but did not describe any particular complaints or symptoms. [R. at 226-27.]

In June 2011, Dr. Davisson conducted a follow-up examination and diagnosed depression, osteoarthritis, and asthma in addition to Plaintiff's previously diagnosed conditions. [R. at 228.] Plaintiff complained of wheezing, back pain, and joint pain. [R. at 243-44.] Dr. Davisson prescribed medication and ordered a follow-up in six months. [R. at 229.] Two weeks later, Plaintiff returned with complaints of paroxysm, but by the time he saw Dr. Davisson, his heart rate and rhythm were regular. [R. 247.]

In 2011, Plaintiff also saw Dr. Davisson with complaints of poor circulation in his right foot. [R. at 250.] An ultrasound, however, revealed no occlusion, no significant stenosis, and no plaque. [ Id. ]

On August 23, 2011, Dr. Victoria Martin performed a medical consultative examination. [R. at 273-76.] Plaintiff reported fatigue, anxiety, depression, sleep disturbance, weakness, back pain, joint pain, wheezing, and shortness of breath. [R. at 274.] Dr. Martin noted Plaintiff's history of knee pain, depression, sleep apnea, obesity, and atrial fibrillation. [R. at 273-74.] Plaintiff reported that he could not "stand or walk very far, " but said he was "going to school for medical assisting" and was "taking classes to get unemployment." [R. at 273.] Dr. Martin observed no difficulty while ambulating and no obvious fatigue or shortness of breath. [R. at 275.] Plaintiff could not fully squat and had an abnormal gait because of the size of his thighs, but his range of motion was "essentially within normal limits with the exception of [decreased] lumbar flexion." [ Id. ] His muscle strength, sensation, grip strength, and motor control were normal. [ Id. ] Dr. Martin ordered a pulmonary function test, but the administrator noted Plaintiff did not exert maximal effort, and the test produced "0 good results." [R. at 280.] Dr. Martin concluded that the patient "would have difficulty working" due to his "morbid obesity and knee pain, " and that it would be "hard for him to walk 2 hours in a given 8-hour shift." [R. at 275-76.]

State agency physician Dr. J.V. Corcocan reviewed the record on September 16, 2011. [R. at 308-15.] He determined Plaintiff could occasionally lift and carry up to 20 pounds, frequently lift and carry up to 10 pounds, stand and/or walk for 6 hours in an 8-hour day, and sit for 6 hours in an 8-hour day. [R. at 309.] He cited Dr. Martin's examination to support his conclusions. [ Id. ] State agency physician Dr. J. Sands reviewed the record and affirmed Dr. Corcocan's assessment on November 5, 2011. [R. 330.]

On August 24, 2011, Plaintiff underwent a psychological consultative examination performed by Dr. Kenneth McCoy. [R. at 283.] Plaintiff reported that he had never received inpatient psychiatric care or counseling, but had received outpatient psychiatric care from his internist. [ Id. ] He reported "depression and anxiety" accompanied by confusion and worrying, [ id. ], and said he had experienced difficulty "getting along with others for the past 5 to 10 years." [R. at 285.] He stated he had thoughts of self-harm, but had no history of suicide attempts or plans to harm himself. [R. at 283.] Plaintiff was cooperative and had "average" or "low average" verbal abilities and memory. [ Id. ] Dr. McCoy assigned a Global Assessment of Functioning (GAF) score of 55, corresponding to "moderate symptoms" or "moderate difficulties in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers)." [R. at 17, 286.] He concluded that Plaintiff would "probably struggle in a work environment due to chronic pain and associated irritability and difficulty interacting with others." [R. at 285.]

State agency psychologist Dr. Kari Kennedy reviewed the record on September 12, 2011. [R. at 304.] She concluded Plaintiff could understand, carryout, and remember simple instructions; make judgments appropriate to unskilled work; respond appropriately to coworkers and work situations; and deal with changes in a routine work setting. [ Id. ] She found that Plaintiff was only partially credible and noted that his reports of not getting along with coworkers were not consistent with his history of employment. [ Id. ] She also suggested that his lack of treatment for mental impairments indicated the impairments were not as severe as he alleged. [ Id. ] State agency psychologist Dr. William Shipley affirmed Kennedy's assessment. [R. at 329.]

On October 7, 2011, Plaintiff began psychological counseling at Meridian Services mental health clinic. [R. at 334.] His case coordinator identified his problems as "major depression" and "generalized anxiety disorder." [ Id. ] She assigned a GAF score of 35, [ id. ], corresponding to "some impairments in reality testing or communication, " such as illogical or irrelevant speech, or "major impairments in several areas, such as work or school, family relations, judgment, thinking, or mood." [Dkt. 16 at 8 n.2.] Plaintiff's mood was "depressed and anxious, " and he reported depression about "being laid off work and having to be retrained in a new field." [R. at 335.] He also reported that he became angry easily, did not enjoy being around people, and had "anxiety with family life and 13 year old son." [R. at 374, 379.] Plaintiff did not trust other people, [R. at 383], but could "go out to social events, " such as car shows or visits to the zoo. [R. at 374.] Plaintiff also had a "linear" and "logical" thought process, [R. at 335], and his counselor noted that he was enrolled in vocational school. [R. at 374.]

Plaintiff returned for counseling sessions on October 21, 2011, [R. at 381], and November 4, 2011. [R. at 384.] The counselor focused on helping Plaintiff assess "his true hopes and goals" and "assess their feasibility, " [R. at 386], but Plaintiff did not return for further counseling. [R. at 387.]

Plaintiff next saw Dr. Davisson on December 16, 2011 for a 6-month "recheck" of his conditions. [R. at 446.] The doctor noted Plaintiff's previously diagnosed hypertension, depression, osteoarthritis, atrial fibrillation, sleep apnea, and asthma. [ Id. ] He reported that the hypertension was benign, that the asthma and atrial fibrillation were "controlled" with medication, and that Plaintiff appeared "rested" despite the sleep apnea. [ Id. at 446-47.] Plaintiff had a "blunted affect, " and Dr. Davisson continued Plaintiff on Cymbalta and Valium to manage his depression. [R. at 447-48.] Plaintiff reported back pain, but his musculature and range of motion were normal. [R. at 448.]

In June 2012, Plaintiff returned to Dr. Davisson for a routine medical exam. [R. at 453.] Dr. Davisson again noted the previously described diagnoses and reviewed Plaintiff's medications. [R. at 453-54.] He reported that the sleep apnea was "controlled" and the osteoarthritis was under "fair control, " but that Plaintiff still had back and joint pain. [R. at 454-55.] Plaintiff's musculature and range of motion remained normal, and he had "[n]o unusual anxiety or evidence of depression." [R. at 456.]

On August 13, 2012, Dr. Davisson completed a form prepared by Plaintiff's attorney. [R. at 416.] He listed Plaintiff's diagnoses as sleep apnea, atrial fibrillation, hypertension, asthma, depression, osteoarthritis, and obesity. [ Id. ] Plaintiff's prognosis was "fair, " and Dr. Davisson stated that the "sustainability of an [8-hour] work day" was "moderated by [Plaintiff's] obesity, arthritis, fatigue, and motivation." [ Id. ] He added that Plaintiff "occasionally" needed a cane to ambulate. [ Id. ]

The ALJ conducted a hearing on September 11, 2012. [R. at 26.] Plaintiff testified that he had been working at an auto parts store for two weeks, [R. at 30], but reported difficulty lifting parts, using the computer to look up information, and accurately counting change. [R. at 31.] He confirmed that he obtained a degree for medical assisting in May 2012, but expressed doubt about working as a medical assistant because of a lack of computer skills. [R. at 33-34.]

Plaintiff testified that he had difficulties with his sleep apnea and atrial fibrillation, and that he would often lie down for three to four hours per day. [R. at 35.] He testified that he was not allowed to do so while working at the auto parts store, and that this prolonged standing caused knee and back pain, [R. at 35-36], but he was able to work six days each week without missing any time. [R. at 42.]

On questioning by his attorney, Plaintiff testified that he had problems with anxiety and depression, had crying spells, and had trouble dealing with people. [R. at 40.] On questioning by the ALJ, he reported that his job at the auto parts store required selling to the public, both in person and over the phone. [R. at 42.] Doing so caused stress because people would "get on [his] nerves." [R. at 43.]

Plaintiff further testified that he could stand for five to ten minutes; that he could sit for thirty minutes; that he could walk for twenty or thirty feet; and that he could lift five pounds without difficulty. [R. at 43-44.] He noted, however, that he had been standing for longer ...

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