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Singleton v. Commissioner of Social Security

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

April 4, 2017



          Michael G. Gotsch, Sr. United States Magistrate Judge

         Plaintiff Nancy Singleton (“Singleton”) filed her complaint in this Court seeking reversal and remand of the Social Security Commissioner's final decision to deny her application for Disability Insurance Benefits (“DIB”) and Supplemental Security Income (“SSI”) under Title XVI of the Social Security Act. For the reasons discussed below, this Court reverses and remands the Commissioner's final decision.

         I. Procedure

         Singleton filed claims for DIB and SSI on March 24 and 26, 2012, alleging disability beginning March 29, 2011. The Social Security Administration (“SSA”) denied Singleton's application initially on June 28, 2012, and upon reconsideration on December 28, 2012. On November 8, 2013, a hearing was held before an administrative law judge (“ALJ”) where Singleton and an impartial vocational expert appeared and testified. The ALJ denied Singleton's claims on March 17, 2014, at Step Two of the evaluation process finding that Singleton was not disabled because her impairments were not severe. On July 8, 2015, the Appeals Council denied Singleton's request for review, making the ALJ's decision the final decision of the Commissioner.

         On September 3, 2015, Singleton filed a complaint in this Court seeking remand of the Commissioner's decision. On January 18, 2016, Singleton filed her opening brief. Thereafter, on April 21, 2016, the Commissioner filed a responsive memorandum asking the Court to affirm the decision denying Singleton benefits. Singleton filed her reply brief on May 5, 2016. The Court may enter a ruling in this matter based on the parties' consent pursuant to 42 U.S.C. § 405(g) and 28 U.S.C. § 636(c)(1).

         II. Relevant Background

         A. Plaintiff's Testimony

         Singleton was 53 years old, at the time of filing for disability. She has a high school education and a strong work history having reported earnings every quarter between 1978 and the alleged onset date in 2011. She last worked as a supervisor in a photo finishing department at a major drugstore chain, and was fired for illness-related absences.

         As part of her disability application, Singleton completed a Function Report on March 27, 2012, a disability report on April 17, 2012, and a second disability report on February 19, 2013. In these reports, Singleton alleged that she suffers from physical impairments including migraines, a bleeding ulcer, back and knee pain, depression, and leg weakness. She testified that she suffers from fibromyalgia, that she is in constant pain at a level “7” or “8”, especially in her entire back and legs, and that her medications, Neurontin and Tramadol, only help her a little. She also asserted that she has balance problems, that she is often dizzy, that she has fallen down twice, that she is not able to bend for more than 15 seconds at a time, that she has difficulty seeing because she does not have bifocals, that she is able to walk just one block at a time, that she is able to stand for just 15 minutes at a time, that she is able to sit for just 45 minutes at a time, and that she is able to lift just 5 pounds.

         She added that she has difficulty pushing and pulling, that she has trouble reaching out and overhead, that 2 fingers on her left hand are numb so she has difficulty gripping objects, that she has trouble climbing stairs, that she uses a special bar to get into and out of the shower, that she takes frequent breaks while doing household chores, and that she lies down 4 or 5 times during the day. She stated that she takes Sumatriptan for her migraines, which occu r 3 or 4 times per week and lasting 30 minutes to several hours. She reported that she used a walker at home about once a week, and that she has been using a cane for a couple of years.

         Singleton also referenced mental impairments when she stated that she cannot work around loud and repetitive noises due to stress and depression, that it takes her forever to move from one place to another due to depression, that she is not able to follow a story line in books or on television, and that she has crying spells every other day which last for 30 minutes.

         In a Third-Party Function Report dated May 23, 2012, Singleton's sister, Patricia Angel, stated Singleton was unsteady on her feet, that she was depressed, and that she often did not follow advice from her family, friends, or doctors. Angel also alleged that Singleton no longer participated in family get-togethers, that she was only able to lift light objects, that she suffered from dizzy spells, that she used a walker, that she did not handle stress like she used to, that she was unsociable, and that she had difficulty bending and climbing stairs.

         B. Medical Evidence

         1. Singleton's Medical Treatment History

         Singleton's medical record before the Court begins in March 2010, about one year before her alleged onset date and while she was still working. At that time, Singleton sought treatment through the Lutheran Medical Group for hypertension and migraines. In the summer of 2010, Singleton experienced regular vomiting that ultimately led to surgical removal of her gall bladder. Despite the surgery, however, Singleton continued to suffer from vomiting and other gastric issues into January 2011.

         In June 2011, Singleton was admitted to the hospital with ongoing gastric issues plus hypertension and depression. At that time, she refused a referral to a behavioral health professional. She continued treatment without much success through August 2011. In September 2011, she was diagnosed with neuropathy and in October 2011, she was admitted to the hospital for a second time for alcoholic hepatitis and major depression. Singleton was also seen in mid-October 2011 for issues related to falls, pain, and needing a walker to ambulate. In December 2011, she was hospitalized for the third time for hypotension[1] and dehydration during which time she once again declined a referral to a behavioral health professional.

         The record suggests that financial concerns limited Singleton's medical treatments throughout this time. However, the record includes no opinions about Singleton's ability to work from any of the medical professionals she saw from 2010 through July 2012 at the Lutheran Medical Group before she started treating at HOPE 85, a free clinic where she saw Dr. Rose Wenrich. Through 2013, Singleton visited HOPE 85 and Dr. Wenrich for treatment of many of the same symptoms, but also for a wide range of symptoms including a new diagnosis of fibromyalgia as well as depression.

         On August 13, 2013, Singleton was admitted to the Bowen Center for a 72-hour emergency detention after attempting suicide by overdosing on pills. When she arrived at the Bowen Center, Singleton was assessed with a Global Assessment of Function (“GAF”) score of 20-25[2]. During a psychiatric evaluation while she was detained, Singleton stated that “she did not want to go on any more and be homeless . . . .” [DE 10 at 450]. She reported that she had been on antidepressants for a year prescribed by a free clinic. Reports on discharge, however, show that Singleton appeared cooperative, made good eye contact, and denied being suicidal or homicidal. In addition, her discharge report indicated that her mood was better, her affect was appropriate, her stream of thought was linear and goal directed, her insight was limited to fair, and her GAF score had improved to 50[3].

         Before Singleton's emergency detention, her primary care physician, Dr. Wenrich, completed a Medical Source Statement Concerning the Nature and Severity of an Individual's Physical Impairment on July 11, 2013. In her Statement, Dr. Wenrich opined about Singleton based on having treated her at HOPE 85 for a year. Dr. Wenrich's Statement detailed Singleton's diagnoses of fibromyalgia, tachycardia, migraines, depression, chronic pain, ulcers, insomnia, hypothyroidism, and low vitamin D with a “poor” prognosis. Dr. Wenrich also opined that Singleton's primary symptoms were pain in her back, legs and arms, which resulted in an inability to stand for more than 30 or 40 minutes. Dr. Wenrich stated that Singleton's headaches were another of her primary symptoms. She detailed that Singleton has deep muscle pain with severe head pain and that she cannot bend over for more than 15 seconds because she becomes light-headed. She opined that Singleton experiences fatigue at a level of 9 out of 10, and that her pain has not been resolved with medication without unacceptable side effects.

         Dr. Wenrich also opined that Singleton would be limited to 2 or less hours of sitting and standing/walking in a workday on a sustained basis, and that it would be necessary for Singleton to avoid sitting continuously in a work setting. Dr. Wenrich further opined that Singleton was limited to rarely carrying less than 10 pounds and never carrying more than 10 pounds, and that she had significant limitations doing repetitive reaching, handling, fingering and lifting due to numbness in her left hand. In addition, Dr. Wenrich reported that Singleton required the use of a cane or another assistive device to stand/walk and that her poor balance would interfere with her ability to keep her neck in a constant position. She opined that Singleton's impairments lasted and could be expected to last at least 12 months, that she could not do a full time competitive job that requires activity on a sustained basis, and that she had further limitations including psychological limitations, limited vision, inability to stoop, push, kneel, pull, and bend, and the need to avoid heights.

         Dr. Wenrich detailed that Singleton was taking numerous medications for her impairments, that emotional factors contributed to the severity of her symptoms, and that she could only tolerate low-stress work. Dr. Wenrich explicitly found that Singleton is not a malingerer, noting that “[w]hen she was well, enjoyed challenging workplace - now physically unable to work.” [Id. at 399]. Dr. Wenrich opined that Singleton's impairments would cause her to be absent from work more than 3 times per month.

         2. State Agency ...

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