United States District Court, N.D. Indiana, South Bend Division
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 50th 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 ...