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Sergent v. Berryhill

United States District Court, N.D. Indiana, Hammond Division

March 8, 2017

NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.


          JON E. DEGUILIO Judge.

         In this case, plaintiff Thomas Alan Sergent appeals the denial of his claim for Social Security Disability Insurance Benefits. For the following reasons, the Court remands this matter to the Commissioner for further proceedings consistent with this opinion.


         A. Procedural Background

         Sergent sought disability insurance benefits on October 15, 2014, alleging an onset date of February 12, 2013, which was amended to April 17, 2013. (Tr. 195, 210). Sergent indicated that he was unable to work due to bilateral upper extremity radiculopathy, tinnitus, degenerative disc disease of the cervical spine, headaches, and post-traumatic stress disorder (“PTSD”). Sergent's application was denied initially and on reconsideration. (Tr. 102, 132-38). An Administrative Law Judge (“ALJ”) held a hearing, during which Sergent appeared with counsel and testified, along with a vocational expert (“VE”) who testified. (Tr. 34-88). The ALJ decided that even though Sergent suffered from the severe impairments of spinal disorder, headache disorder, and anxiety disorder or PTSD, he could still perform light work in a quiet environment that was limited (in relevant part) to simple routine repetitive tasks that were not performed at a production rate pace and involved no more than occasional decision making, few changes in the work setting, occasional interaction with coworkers and supervisors, and no tandem tasks or interaction with the general public. (Tr. 15-28). One of the hypotheticals posed to the VE considered these same limitations (which were ultimately contained in Sergent's assigned residual functional capacity (“RFC”)[1]), and the VE testified that such a restricted individual could still perform work as a cleaner, packager, and marker. Thus, the ALJ determined that Sergent was not disabled since he could perform these other jobs. The Appeals Council denied review, making the ALJ's decision the final decision of the agency. (Tr. 1-3). Sergent filed a timely complaint seeking judicial review of that decision, and this Court has jurisdiction pursuant to 42 U.S.C. § 405(g).

         B. Medical Background

         Sergent was born on November 28, 1963 and is currently 53 years old. (Tr. 89). Over his lifetime, he has had three main skilled careers ranging from medium to very heavy exertional levels. Initially, he worked in building maintenance. (Tr. 82). Sergent was later a combat engineer and heavy equipment horizontal engineer while serving in Iraq and Afghanistan. (Tr. 44). Following his service overseas, Sergent worked as a firefighter/security officer. (Tr. 44-46).

         While the subject of Sergent's appeal concerns his mental limitations, it was Sergent's physical limitations that prevented him from continuing work as a firefighter and security officer. (Tr. 45). In March 2012, diagnostic imaging of Sergent's spine documented mild disc disease and early osteopenic changes of the cervical spine. (Tr. 320). Sergent underwent a consultative medical examination in November 2014, which reflected that he had a tender cervical spine with decreased range of motion. (Tr. 869-70). In addition to noting his mental and emotional conditions, this report noted that Sergent suffered from neck pain and a history of degenerative joint disease of the cervical spine. In December 2014, J.V. Corcoran, M.D., conducted a physical RFC assessment and found that Sergent could perform restricted light work. (Tr. 95-100). Dr. Corcoran's assessment was affirmed by B. Whitley, M.D., in February 2015. (Tr. 116). However, Sergent does not challenge the ALJ's assessment of his physical limitations, and therefore, the Court turns to his documented mental limitations.

         It is undisputed that Sergent suffers from PTSD. Sergent testified that his PTSD bothers him the most, and he was medically retired from the National Guard primarily on account of his PTSD. (Tr. 43, 53). Because he doesn't handle uncontrolled environments or unfamiliar people well, he rarely leaves his house. (Tr. 53, 55, 57, 65-67, 76, 79). Sergent wasn't even comfortable during his disability hearing because it was held in a government building that he described as a “high-value target.” (Tr. 55). Sergent described being in public as “nerve-racking, ” and explained that loud noises or situations that remind him of combat or his war enemies “trigger” his PTSD symptoms. (Tr. 67, 71-73). Sergent indicated that once he becomes anxious from a triggering event, it can take him several hours to recover to a normal controlled state. (Tr. 56). Dr. Krage, Sergent's long-time psychologist, prescribed medication to treat Sergent's PTSD, but Sergent was told that he did not have to take it after reporting that the medication made him feel “numb” and “stupid, ” and it interfered with his needed ability to feel in control and alert. (Tr. 54, 72). Sergent continues to engage in talk therapy once a month, and as recommended by Dr. Krage, Sergent attends “Pets and Vets” on a weekly basis with his service dog. (Tr. 53-54, 69). Sergent explained that his service dog really assists with keeping his anxiety down and he feels comfortable attending a closed meeting designed only for veterans suffering from PTSD. (Tr. 56, 69).

         Sergent has routinely been documented by doctors as being oriented, neatly groomed and dressed, cooperative and pleasant, coherent as to thought process, good as to insight and judgment, and without memory issues or suicidal/homicidal ideations. (Tr. 484, 488-89, 746-47, 763, 884-887). However, some of these same medical records and various others demonstrate that Sergent has continued to experience various serious symptoms of his anxiety and PTSD. (Tr. 458, 484-85, 488, 490-92, 746, 767, 769, 886). In January 2014, Sergent presented for a PTSD evaluation which indicated that he was easily distracted, apprehensive, anxious, impaired as to judgment, had poor insight, and it noted that he suffered from moderate to severe impairment in psychological, social, and occupational functioning, and moderate to severe impairment in judgment and impulsivity. (Tr. 780-82).

         In December 2014, Amy S. Johnson, Ph.D., conducted a consultative examination and concluded that Sergent had only mild restriction in performing activities of daily living and moderate difficulties in maintaining social functioning and concentration, persistence or pace. (Tr. 94). Further, Dr. Johnson found that Sergent could understand, remember, and follow simple instructions, but he was limited to work that involved brief, superficial interactions with fellow workers, supervisors, and the public. (Tr. 99). Additionally, Dr. Johnson deemed that within these parameters and in the context of performing simple, routine, repetitive, concrete, tangible tasks, Sergent was able to sustain the necessary attention and concentration to perform work with reasonable pace and persistence. (Tr. 99). B. Randal Horton, Psy.D., reviewed Sergent's file and affirmed Dr. Johnson's assessment in February 2015. (Tr. 109, 114).

         Dr. Krage completed a mental impairment questionnaire in September of 2014. (Tr. 337-40). Dr. Krage believed that Sergent had mild restrictions in his activities of daily living and moderate difficulties in social functioning and maintaining concentration, persistence or pace. (Tr. 340). Dr. Krage also believed that Sergent was moderately limited in five of seventeen listed areas of mental functioning, as well as markedly limited in his ability to maintain attention and concentration for extended periods. (Tr. 339). About a year later, Dr. Krage reported that Sergent's condition varied from being “moderately to severely impaired by PTSD, ” that despite treatment “his PTSD symptoms have remained constant with little to no improvement, ” and that his “ability to effectively interact with others is significantly impacted by his internal distress and can be further exacerbated due to normal daily stressors.” (Tr. 888-89).


         Because the Appeals Council denied review, the Court evaluates the ALJ's decision as the final word of the Commissioner of Social Security. Schomas v. Colvin, 732 F.3d 702, 707 (7th Cir. 2013). The Court will affirm the Commissioner's denial of disability benefits if it is supported by substantial evidence. Craft v. Astrue,539 F.3d 668, 673 (7th Cir. 2008). Substantial evidence consists of “such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” Richardson v. Perales,402 U.S. 389, 401 (1971). It must be “more than a scintilla but may be less than a preponderance.” Skinner v. Astrue, 478 F.3d 836, 841 (7th Cir. 2007). Thus, even if ‚Äúreasonable minds could ...

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