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Wells v. Colvin

United States District Court, E.D. Missouri, Northern Division

September 27, 2016

SHEILA P. WELLS, Plaintiff,
CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant.



         This is an action under 42 U.S.C. § 405(g) for judicial review of the final decision of Defendant Carolyn W. Colvin, the Acting Commissioner of Social Security, denying in part the application of Plaintiff Sheila P. Wells (“Plaintiff”) for Disability Insurance Benefits (“DIB”) under Title II of the Social Security Act, 42 U.S.C. §§ 401 et seq. (the “Act”). The parties consented to the jurisdiction of the undersigned magistrate judge pursuant to 28 U.S.C. § 636(c). (Doc. 13). Because I find the decision denying benefits was supported by substantial evidence, I will affirm the Commissioner's denial of Plaintiff's application.

         I. Factual Background [1]

         Plaintiff was born April 20, 1959. (Tr. 37). On April 22, 2015, Plaintiff testified at a hearing before the ALJ. (Tr. 37-56). On November 10, 2012, at the age of 53, Plaintiff suffered a stroke. (Tr. 37). Since then, she has had headaches a couple of times a week that involve extreme pressure, lasting between a couple of hours and over a day. (Tr. 40-41). She has also had memory problems since the stroke; she will put something on the stove and walk away and forget it, and she has trouble remembering conversations and instructions. (Tr. 41). A few months after the stroke, she developed weakness and pain in both of her arms and shoulders. (Tr. 41-42). She has trouble sleeping because of the pain. (Tr. 43). She has had physical therapy that made her shoulder pain worse, and injections that helped somewhat. (Tr. 44). She took narcotic pain medications, but stopped because she was getting immune to them. (Tr. 45). She uses ice and heat on her shoulder several times a week. (Tr. 46). She can lift about the weight of a gallon of milk in each hand. (Tr. 44-45). Plaintiff also has had problems with her left leg since a “botched” vein surgery. (Tr. 46-47). Her leg burns every day, and it swells up when she is on her feet for less than an hour. (Tr. 47-48). She has carpal tunnel syndrome in her left hand and still has numbness two or three times a day. (Tr. 48-49). She has a lot of pain in her lower back, especially when bending or squatting. (Tr. 50).

         Since her stroke, Plaintiff has had weekly therapy sessions. (Tr. 50). She also sees a psychiatrist every two months. (Tr. 55). She gets overwhelmed very easily, and when she cannot remember or understand something, she has anxiety attacks, gets depressed, and starts crying. The crying has improved with medication and occurs four times a week. (Tr. 51-52). Plaintiff has depression and anxiety and takes medications for them. (Tr. 52). She fears drowning when taking a bath and fears accidents when in a car. (Tr. 53). She gets confused easily and does not like being in crowds. (Tr. 56).

         Plaintiff's medical records show that on November 11, 2012, Plaintiff suffered a subarachnoid hemorrhage and spent nine days in the hospital. (Tr. 353-54). In the eighteen months following her stroke, Plaintiff frequently sought treatment for a number of physical and mental problems, including anxiety, fear of having another stroke, depression, crying episodes, problems sleeping, balance problems, headaches, carpal tunnel syndrome, lower extremity weakness, and bilateral shoulder and arm pain. In addition to seeing her primary care physician, a neurologist, a psychiatrist, and a physical therapist, she has had weekly therapy sessions with a counselor, Betty Bockhorst, M.A., L.P.C.

         The record contains opinion evidence from two sources. On September 18, 2013, state agency consulting psychologist Mark Altomari, Ph.D., completed a mental residual functional capacity assessment. (Tr. 76-78). Dr. Altomari found that Plaintiff had the ability to understand, remember, and carry out simple instructions; could relate appropriately to coworkers and supervisors; could adapt to most changes in a competitive work setting; and could make simple work-related decisions. (Tr. 78).

         On January 16, 2015, Plaintiff's counselor, Betty Bockhorst, completed a Medical Source Statement of Ability to Do Work-Related Activities (Mental) for Plaintiff. Ms. Bockhorst opined that Plaintiff had extreme limitations in the ability to understand and remember complex instructions; moderate limitations in the ability to understand and remember simple instructions, carry out complex instructions, make judgments on complex work decisions, interact appropriately with the public, and respond appropriately to usual work situations and to changes in a routine work setting; and mild or no limitations in the ability to carry out simple instructions, make judgments on simple work-related decisions, and interact appropriately with supervisors and co-workers. (Tr. 108-09). Ms. Bockhorst noted that she had to write down any suggestions given to Plaintiff and that if Plaintiff did not have a suggestion written down, she would not remember it. (Tr. 109). Ms. Bockhorst also opined that Plaintiff would be off-task 25% of the time or more; would miss work more than four days per month; and would need to take unscheduled breaks three to four times a day. (Tr. 109-10). She noted that the symptoms causing a need for breaks were panic attacks, crying spells, anxiety, and depression. (Tr. 110). She opined that Plaintiff's disability began November 10, 2012. (Tr. 110).

         II. Procedural Background

         On January 10, 2013, Plaintiff applied for DIB, alleging that she had been unable to work since November 10, 2012 due to depression, anxiety, a subarachnoid brain hemorrhage, left leg nerve damage, hyperglycemia, memory loss, and fatigue. (Tr. 200-01, 215). Plaintiff's claim was initially denied. (Tr. 85-89). On May 18, 2015, following a hearing, the ALJ issued a partially favorable decision finding Plaintiff was not disabled prior to April 19, 2014, but was disabled after that date. (Tr. 25). On August 20, 2015, the Social Security Administration's Appeals Council denied Plaintiff's request for review. (Tr. 1-6). Plaintiff has exhausted all administrative remedies, and the decision of the ALJ stands as the final decision of the Commissioner of the Social Security Administration.

         III. Standard for Determining Disability Under the Act

         To be eligible for benefits under the Social Security Act, a claimant must prove he or she is disabled. Pearsall v. Massanari, 274 F.3d 1211, 1217 (8th Cir. 2001); Baker v. Sec'y of Health & Human Servs., 955 F.2d 552, 555 (8th Cir. 1992). The Social Security Act defines as disabled a person who is unable “to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than twelve months.” 42 U.S.C. § 423(d)(1)(A); see also Hurd v. Astrue, 621 F.3d 734, 738 (8th Cir. 2010). The impairment must be “of such severity that [the claimant] is not only unable to do his previous work but cannot, considering his age, education, and work experience, engage in any other kind of substantial gainful work which exists in the national economy, regardless of whether such work exists in the immediate area in which he lives, or whether a specific job vacancy exists for him, or whether he would be hired if he applied for work.” 42 U.S.C. § 423(d)(2)(A).

         To determine whether a claimant is disabled, the Commissioner engages in a five-step evaluation process. 20 C.F.R. § 404.1520(a); see also McCoy v. Astrue, 648 F.3d 605, 611 (8th Cir. 2011) (discussing the five-step process). At Step One, the Commissioner determines whether the claimant is currently engaging in “substantial gainful activity”; if so, then he is not disabled. 20 C.F.R. § 404.1520(a)(4)(i); McCoy, 648 F.3d at 611. At Step Two, the Commissioner determines whether the claimant has a severe impairment, which is “any impairment or combination of impairments which significantly limits [the claimant's] physical or mental ability to do basic work activities”; if the claimant does not have a severe impairment, he is not disabled. 20 C.F.R. §§ 404.1520(a)(4)(ii), 404.1520(c); McCoy, 648 F.3d at 611. At Step Three, the Commissioner evaluates whether the claimant's impairment meets or equals one of the impairments listed in 20 C.F.R. Part 404, Subpart P, Appendix 1 (the “listings”). 20 C.F.R. § 404.1520(a)(4)(iii); McCoy, 648 F.3d at 611. If the claimant has such an impairment, the Commissioner will find the claimant disabled; if not, the Commissioner proceeds with the rest of the five-step process. 20 C.F.R. §§ 404.1520(d); McCoy, 648 F.3d at 611.

         Prior to Step Four, the Commissioner must assess the claimant's “residual functional capacity” (“RFC”), which is “the most a claimant can do despite [his or her] limitations.” Moore v. Astrue, 572 F.3d 520, 523 (8th Cir. 2009) (citing 20 C.F.R. § 404.1545(a)(1)); see also 20 C.F.R. § 404.1520(e). At Step Four, the Commissioner determines whether the claimant can return to his past relevant work, by comparing the claimant's RFC with the physical and mental demands of the claimant's past relevant work. 20 C.F.R. §§ 404.1520(a)(4)(iv), 404.1520(f); McCoy, 648 F.3d at 611. If the claimant can perform his past relevant work, he is not disabled; if the claimant cannot, the analysis proceeds to the next step. Id. At Step Five, the Commissioner considers the claimant's RFC, age, education, and work experience to determine ...

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