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Stewart v. Colvin

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

March 31, 2017

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


          Michael G. Gotsch, Sr. United States Magistrate Judge

         On August 6, 2015, Plaintiff Adam James Stewart ("Stewart") filed a complaint in this Court seeking remand of the Social Security Administration's ("SSA's") final administrative decision denying the continuation of his Disability Insurance Benefits ("D.I.B.") based on the SSA's termination of benefits effective November 15, 2011. On April 18, 2016, Stewart, filed his Opening Brief and a Medical Summary and Statement of Relevant Facts. On July 26, 2016, the Defendant, Commissioner of Social Security, ("the Commissioner"), filed a Memorandum in Support of the Commissioner's Decision and a Summary of Relevant Medical Evidence and Testimony, to affirm the ALJ's denial of DIB. Stewart filed a reply brief on September 29, 2016. 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).

         I. Procedure

         On August 6, 2008, the SSA found Stewart was disabled because of Post-Traumatic Stress Disorder ("PTSD"), migraines, a back injury, multiple concussions, hearing loss, and high blood pressure, as of January 14, 2016, and therefore awarded him D.I.B. [DE 10 at 116]. The SSA determination date of Stewart's disability is known as the Comparison Point Decision ("C.P.D."). Upon regular review of Stewart's eligibility for D.I.B., pursuant to 20 C.F.R. § 404.1589, the SSA terminated his benefits as of November 15, 2011, and sent him a Notice of Disability Cessation. [DE 10 at 113-16]. The termination date of Stewart's D.I.B. is the date of Stewart's medical improvement. On November 15, 2011, the date of cessation, the SSA sent a Notice of Disability Cessation to Stewart, terminating Stewart's D.I.B. [DE 10 at 113-16]. On December 8, 2011, Stewart filed a request for reconsideration before a Disability Hearing Officer. On May 22, 2012, the Disability Hearing Officer concluded that Stewart was not eligible for D.I.B. After filing a timely written appeal, Stewart attended an evidentiary hearing with the SSA Disability Hearing Office on February 26, 2014. The hearing was held before an ALJ, in Valparaiso, Indiana, where a vocational expert and two medical experts testified. On March 28, 2014, the ALJ issued his decision finding Stewart was not disabled as of November 15, 2011, the date of cessation of his D.I.B. Stewart appealed the ALJ's decision on April 4, 2014, to the SSA's Appeals Council. On June 3, 2015, the Appeals Council denied Stewart's request for review citing the ALJ's decision. Stewart now seeks judicial review of the Commissioner's final decision pursuant to sentence four of 42 U.S.C. § 405(g) by filing his complaint in this Court on August 6, 2015.


         Stewart was born on March 22, 1984, and was 21 years old on the disability onset date of January 14, 2006. Stewart is a high school graduate and enlisted in the National Guard where he received military training at the School of Infantry in Fort Benning, Georgia. In December 2004, Stewart entered into active duty for tours in Iraq. While in Iraq, Stewart incurred service-related injuries, which included a back injury and PTSD. After an honorable discharge, Stewart received treatment through the Department of Veteran's Affairs (" VA"). Stewart previously worked as a laborer in an auto repair shop and worked as a maintenance worker. Stewart can complete basic household tasks, pay bills, and has cared for pets, which helps reduce his stress.

         A. Plaintiffs Testimony

         When asked about his physical impairments, Stewart testified that he continues to have lower back pain, flashbacks, episodes of anxiety, and migraine headaches. Stewart testified that his migraine headaches are triggered by noise, smell, and sound. When asked about physical limitations, Stewart stated that he could lift and carry objects up to thirty pounds, for five to seven minutes at a time. Stewart also stated that he uses a cane for walking, even though it has not been prescribed. Furthermore, Stewart stated that he has difficulty kneeling and climbing stairs as he feels pressure in this back. Stewart also testified that the VA assessed him with an eighty-percent disability and that he receives VA benefits as a result. When asked about his mental limitations, Stewart stated that he suffers from depression and has trouble with learning new things and following directions.

         At his February 26, 2014, evidentiary hearing, Stewart testified that he remained incarcerated in Plainfield, Indiana after a DUI arrest on January 10, 2014. Stewart testified that his incarceration prevented access to any medication except those prescribed for his high blood pressure and high cholesterol. Stewart stated he purchased Tylenol or Advil through the prison commissary to alleviate his lower back pain. Stewart further testified that he had not participated in any work assignments or light-duty assignments while incarcerated.

         B. Medical Evidence

         When Stewart was initially approved for D.I.B. in 2008, he was diagnosed with a closed head injury, a back injury, a cervical strain, migraines headaches, PTSD, and hearing loss. Stewart received treatment for PTSD through the Northern Indiana Healthcare VA from 2009 through 2011. After receiving D.I.B., the S.SA. subsequently undertook a periodic review of Stewart's disability status. Stewart continues to argue that he is in fact disabled. The record before this Court documents Stewart's medical history dating from his C.P.D. of August 6, 2008, and includes records prior to and subsequent to Stewart's medical improvement date of November 15, 2011. The record also includes medical reports from consultative psychological disability examiners, medical records from the VA, the State agency psychological opinions, and a confidential health summary and case analysis from the Social Security Administration.

         Records from Stewart's treatment at the Northern Indiana Healthcare VA show that Stewart was assessed with a fifty percent service-connected disability for PTSD, a fifty percent service-connected disability for migraine headaches, a ten percent service-connected disability for lumbar sacral or cervical strain, a ten percent service-connected disability for tinnitus, a zero percent service-connected disability for impaired hearing, and eighty percent service-connected disability overall. [DE 10 at 462]. Stewart maintained treatment for his PTSD through the Northern Indiana Healthcare VA until 2011 when he stopped responding to its notifications to reschedule appointments.

         On January 20, 2012, as part of the re-evaluation of his D.I.B. eligibility, Dr. Bradford J. Eaton, a consultative examining psychologist, conducted a psychological evaluation of Stewart. Dr. Eaton's exam notes show that Stewart was fully oriented during the examination and that he maintained logical thought processes. Dr. Eaton observed that Stewart carried a cane but did not rely on it. Dr. Eaton also observed that Stewart was able to solve mental arithmetic problems, recalled short-term and remote memory, complete word analogies, and interpret proverbs. Stewart informed Dr. Eaton that he was able to maintain daily function, was independent, and had no difficulties with routine living tasks. Stewart also informed Dr. Eaton that he does arts and crafts and was currently making camouflage clothing for hunters. Dr. Eaton diagnosed Stewart with PTSD and a GAF score of 65. Finally, Dr. Eaton concluded that Stewart appeared capable of managing his finances independently.

         On February 3, 2012, Dr. Stacia Hill, the State Agency psychological consultant, completed a Psychiatric Review Technique Form in which she opined as to Stewart's mental Residual Functional Capacity ("R.F.C."). Dr. Hill concluded that Stewart was cognitively capable of unskilled work-like tasks on a sustained basis without special considerations in a competitively, though not necessarily highly social, work environment. Dr. Hill also found that Stewart had mild restrictions in activities of daily living, mild difficulty in social functioning, moderate limitation in concentration, persistence, and pace, and no episodes of decompensation of extended duration.

         On July 11, 2012, Mark Henson-Bohlen, a clinical Licensed Master Social Worker who had been working with Stewart at the South VA since June 22, 2012, wrote a letter on Stewart's behalf describing Stewart's military history and opining that Stewart shows symptoms of PTSD. Mr. Henson-Bohlen stated that Stewart had been deployed in Iraq and described his various military duties. Mr. Henson-Bohlen also stated that Stewart was involved in combat situations. Further, Mr. Henson-Bohlen opined that Stewart has symptoms of PTSD including nightmares, flashbacks, fear of crowds, and panic attacks and that he was easily startled. Finally, Mr. Henson-Bohlen stated that Stewart had headaches, stomach problems, and back pain.

         During the February 2014, evidentiary hearing before the ALJ, Dr. Leon Fischer, a board-certified family physician who had reviewed Stewart's medical records, testified as an impartial medical expert at the evidentiary hearing regarding Stewart's work ability. Dr. Fischer stated that Stewart should be able to lift and carry fifty pounds occasionally and twenty-five pounds frequently as well as sit, stand, and walk for six hours in an eight-hour workday. Dr. Fischer also stated that Stewart can frequently climb, balance, stoop, kneel, crouch, or crawl and that the medical evidence did not establish any severe hearing difficulty. Further, Dr. Fischer testified that Stewart's current R.F.C. would be applicable back to at least 2011. Finally, Dr. Fischer testified that based on Stewart's R.F.C, he would be capable of meeting the physical and mental demands of his past relevant work, and meet medium physical exertional work.

         Dr. Jeffery Andert, an impartial psychological expert, then testified on Stewart's mental abilities. Dr. Andert's opinion was based on his conclusion that Stewart suffered from an affective disorder, as either a major depressive disorder or a depressive disorder not otherwise specified. Dr. Andert testified that Stewart suffered from PTSD and an indicated potential substance addiction disorder. Further, Dr. Andert found that Stewart's impairment caused limitations in his ability to work, including "a mild restriction of activities of daily living; moderate difficulties in maintaining social functioning; moderate difficulties in concentration, persistence, or pace . . . and one or two episodes of deterioration[1]." [DE 10 at 83-84]. Dr. Andert found that Stewart could also perform, make decisions, and respond to simple and repetitive tasks. Dr. Andert concluded that Stewart could not handle a fast-paced work environment or a position with production quotas, could not work in environments where supervisors monitored the employer for more than one-third of the day.

         Lastly, Dr. Leonard M. Fisher[2], a non-examining vocational expert ("VE"), testified having reviewed Stewart's record. Dr. Fisher identified alternative jobs, as listed in the Dictionary of Occupational Titles ("DOT"), that a person with Stewart's R.F.C., age, and work experience would be capable of performing. Dr. Fisher testified that Stewart had past work as a janitor-maintenance, infantry-crewmember, and reconnaissance/radio operator citing DOT 382.664-010; DOT 378.367-010; and DOT 378.684-10. At the hearing, the ALJ presented a number of hypotheticals to Dr. Fisher to complete an assessment of Stewart's work capabilities. Dr. Fisher opined that Stewart would be able to perform medium unskilled work in occupations such as cleaner-industrial, laborer-stores, and cleaner-manufactured buildings citingee DOT 381.687-018; DOT 922.687-058; DOT 869.687-018.

         C. The ALJ's Determination

         After the February 2014 hearing, the ALJ issued a written decision on his findings. The ALJ applied the eight-part test prescribed through Social Security regulations in reaching his conclusion that as of November 15, 2011, Stewart was no longer disabled. See 20 C.F.R. § 404.1594.

         At Step One, the ALJ identified the Comparison Point Decision ("C.P.D.") as August 6, 2008 when Stewart was originally found disabled. The ALJ found that Stewart's medically determinable impairments included a closed head injury, degenerative disc disease, migraines, hearing loss, and PTSD. Further, the ALJ found that Stewart's disability ended as of November 15, 2011. The ALJ cited to both testimony and a financial statement, which showed that Stewart was not receiving D.I.B. The ALJ also found that Stewart was not engaged in substantial gainful activity ("S.G.A."). At Step Two, the ALJ found that the medical evidence established that Stewart had not developed any additional impairments from the C.P.D. through November 15, 2011. Accordingly, the ALJ found that Stewart had the same impairments that he had at the time of C.P.D.

         Then at Step Three, the ALJ applied the medical improvement standard and determined that Stewart did not have an impairment or combination of impairments listed impairment found in Appendix 1. 20 C.F.R. § 404, App. 1. Next at Step Four, the ALJ determined that Stewart had experienced a medical improvement as of November 15, 2011. Further, the ALJ considered the entire medical record, determined Stewart's R.F.C. as of November 15, 2011, and determined that Stewart's medical improvement related to his ability to work because it resulted in an increase in Stewart's R.F.C. The ALJ skipped Step Five, because the medical improvement was related to Stewart's ability to do work, and therefore a determination of any medical improvement exceptions was not necessary.

         In Step Six, the ALJ found Stewart's impairments were considered severe. 20 C.F.R. § 404.1521. The ALJ found that Stewart's impairments cause more than minimal limitation in his ability to perform basic work activities. Finally, at Step Seven, the ALJ determined based on Stewart's R.F.C, age, education, and past work experience that he could perform past relevant work as a janitor-maintenance. The ALJ determined that this type of work does not require the performance of work-related activities precluded by Stewart's assessed R.F.C. 20 C.F.R. § 404.1565. The ALJ concluded that Stewart can make a successful adjustment to other work, and found that Stewart was not disabled.

         D. Appeals ...

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