Wills v. Saul

          OPINION AND ORDER

          JON E. DEGUILIO JUDGE.

         Trina Wills filed a complaint seeking review of the final decision of the Commissioner of Social Security denying her application for social security disability benefits. [DE 1]. The matter is fully briefed and ripe for decision. [DEs 15-18]. For the reasons stated below, the Court remands this matter to the Commissioner for further proceedings.

         I. FACTS

         Wills first filed applications for disability insurance benefits and supplemental security income on January 27, 2014. Her claims were denied initially and upon reconsideration. On January 19, 2016, the first ALJ who reviewed Wills' case issued a decision denying her disability benefits and concluded that Wills was not disabled under the Social Security Act because she was able to perform other work in the economy. On February 8, 2016, Wills again applied for disability benefits this time alleging that her disability began on January 15, 2016. Her claims were denied initially and upon reconsideration.

         Wills contends that she is unable to work primarily because she suffers from left shoulder pain, degenerative joint disease in her left knee following an ACL tear and repair, degenerative disc disease of the lumbar spine and S3 fracture, left elbow dislocation, migraine headaches, asthma, chronic obstructive pulmonary disease, emphysema, depression, anxiety, attention deficit hyperactive disorder, problems with her right eye, and loss of vision in her left eye due to glaucoma and cataracts. Wills stated that her vision problems have ruined her life, that vision and gait issues have caused her to fall five times as of February 2016, and that her depth perception issues caused her to fall more recently.^[1] In fact, many of her current ailments are the result of these previous and more recent falls.

         The record shows that Wills has a long history of problems with her left eye and she has undergone numerous surgical procedures to correct them-none of which were successful. (R. 90).^[2] As of January 2014, the best corrected visual acuity in her left eye was 20/200 and therefore she is permanently legally blind in that eye. Id. At several points throughout the record, Wills states that she is having problems with her right eye despite several exams demonstrating her to have 20/20 vision in it.^[3] In the Disability Report from February 23, 2016, her interviewer observed that “she is blind in [her] left eye and having problems with her R[ight] eye.” (R. 278). In the Medical Conditions section of the Disability Report, Wills listed problems with her right eye as one of six conditions that limit her ability to work. (R. 281). On March 3, 2016, Wills had an appointment with her ophthalmologist, Bruce H. Schwartz MD, where she stated that her right eye had been bothering her and she felt like her vision was going bad. (R. 583). She also noted that her glasses were not helping her or did not seem strong enough and that she was seeing starbursts from headlights while driving, even during the day. Id. The ophthalmologist recorded the current problem in that appointment to be gradual decreasing vision in her right eye. Id.

         On April 12, 2016, at the request of the Social Security Administration, Wills attended a consultative exam performed by R. Gupta MD in which he noted that Wills had no sight out of her left eye and that she had an antalgic gait.^[4] (R. 597). Less than two weeks later, Wills went to the emergency room after falling while trying to get down from standing on a kitchen chair. Wills stated that when she was stepping down from the chair, she misjudged the distance to the floor and fell. (R. 608). X-rays suggested a sacral fracture and a CT examination in May 2016 showed a suspected fracture at ¶ 3 with degenerative changes most pronounced in L5-S1. (R. 24). She also noted to the ER doctor that she has chronic balance problems. (R. 608).

         On June 4, 2016, Wills went to the emergency room a second time after falling down the stairs. She stated that she injured her left arm, left knee, and hit her head in the fall. (R. 642). Wills reported that she fell “as a result of a miss-step due to ‘blind spots' in her vision.” Id. She was diagnosed with an open left elbow dislocation and was admitted for surgical reduction and repair of the medial collateral ligament. (R. 24, Ex. B12F1-8). Wills had been drinking that evening, but she told the ALJ in the hearing that she did not believe alcohol to be a factor in the fall. (R. 67). According to laboratory results from that evening, Wills' blood alcohol level was 134 mg/dL. (R. 645). Two weeks after completing the surgery on her left arm, Wills again returned to the hospital after slipping and falling in a kiddie pool filled with river water, which resulted in her arm cast getting wet. (R. 795).

         On November 9, 2017, at her hearing before the ALJ, Wills testified that the recurring issues with her eyes caused her to have depth perception and balancing problems, which resulted in her not being steady on her feet and running into walls a lot. (R. 41). In fact, Wills' history with injuries resulting from falls goes back to December 2013, when she tripped over a pallet at work and injured her left knee. (R. 50-51). She testified that, at the time, she was working for a manufacturing company and she tripped over a pallet. (R. 50). She told the ALJ that she fell the day before her 50^th birthday “and then they fired me and ever since it's been one problem after another.” (R. 49). An MRI completed in June 2014 showed a complete tear of her ACL and a lateral meniscus tear in her left knee. (R. 90). It was not until August of 2014 that Wills underwent surgery to repair her ACL tear and remove her torn meniscus. Id. Wills reported that following the surgery her left leg never regained its full mobility. (R. 23, Ex. B8f).

         During the hearing, the ALJ noted the multiple falls in Wills' record and asked whether it was due to her depth perception issues and Wills confirmed that it was. (R. 64). Wills stated that she normally wears bifocal glasses, but that they were broken in one of the falls and her insurance would not cover another pair for five years. (R. 46). She testified that she stopped driving six months prior to the hearing because she was scared following an incident where she drove into her neighbor's yard while turning left onto her driveway. Id. Wills also explained to the ALJ that her right eye gets tired from over-compensating for her blind left eye, how she has light sensitivity problems in her right eye, and she is unable to read due to her vision issues. (R. 62, 65).

         A vocational expert (“VE”) testified during the hearing and his testimony was based strictly on the hypothetical posed to him, which offered an assigned residual functional capacity (“RFC”)^[5] of light work with normal breaks and additional exertional and environmental limitations. The hypothetical individual had no left eye vision but could avoid hazards in the workplace such as doors ajar, boxes on the floor, and the individual could read 12 point font or greater. (R. 73). Per the VE, that individual would be able to perform representative work such as a garment sorter, an office helper, or merchandise marker. (R. 74). Wills' attorney then asked the VE if such an individual was limited to only an occasional near acuity whether those three jobs would be eliminated and the VE confirmed that to be true. (R. 76). The VE also indicated that there would not be any other types of light jobs that could be done by the hypothetical individual with only an occasional near acuity. Id.

         The ALJ issued a decision on March 29, 2018, denying Wills disability benefits and concluding that Wills was not disabled under the Social Security Act because she was able to perform other work in the economy. On September 28, 2018 the Appeals Council then denied Wills' request for review which made the ALJ's decision the final determination of the Commissioner. Schomas v. Colvin, 732 F.3d 702, 707 (7th Cir. 2013). Wills seeks review of the Commissioner's decision, invoking this Court's jurisdiction under 42 U.S.C. §§ 405(g) and 1383(c)(3).

         II. STANDARD OF REVIEW

         This Court will affirm the Commissioner's findings of fact and denial of disability benefits if they are 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). This evidence 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 “reasonable minds could differ” about the disability ...