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Goforth v. Berryhill

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

May 9, 2017

NANCY A. BERRYHILL, Acting Commissioner of Social Security, [1]Defendant.


          JOHN M. BODENHAUSEN United States Magistrate Judge.

         Edward Goforth ("Plaintiff) appeals the final decision of the Acting Commissioner of Social Security ("Defendant") denying his application for supplemental security income ("SSI") benefits under Title XVI of the Social Security Act ("Act"). See 42 U.S.C. §§ 401, et seq. Substantial evidence does not support Defendant's decision, and it is therefore REVERSED and REMANDED for further proceedings consistent with this opinion.

         I. Procedural History & Summary of Memorandum Decision

         Plaintiff applied for SSI benefits on October 15, 2013, alleging that he became disabled on July 1, 2005, due to bipolar manic depression, anxiety, a pinched nerve in his shoulder, panic attacks, insomnia, trouble concentrating, stress, and eczema. (Tr. 115)[3] The Social Security Administration initially denied Plaintiff s application on November 27, 2013. (Tr. 55-58) Plaintiff requested a hearing before an administrative law judge ("ALJ"), and that hearing took place on October 8, 2014, with Plaintiffs counsel present. (Tr. 59, 25-44) Plaintiff and Theresa Wolford, a Vocational Expert ("VE"), testified at the hearing. (Tr. 42-44) In a decision dated October 24, 2014, the ALJ found that Plaintiff was not disabled under the Act. (Tr. 9-21) The Social Security Administration Appeals Council denied Plaintiffs request for review, leaving the ALJ's decision as the final decision of the Commissioner in this matter. (Tr. 1-3) Plaintiff filed the instant action on August 4, 2016 and the matter is properly before this Court. (ECF No. 15); see42U.S.C. § 405(g).

         II. Evidence Before the ALJ

         The ALJ conducted a hearing on October 8, 2014. (Tr. 27) Plaintiffs attorney did not request any additional examinations or to seek expand or clarify the record. (Tr. 43)

         A. Hearing Testimony

         1) Plaintiffs Testimony (Tr. 26-44)

         At the hearing, Plaintiff explained that he had trouble standing on his feet for long periods of time, that he could not sleep at night, that he felt trapped on a time clock or in a work environment, and that he could not stand to be around crowds of people. (Tr. 32-34) To address his physical symptoms, Plaintiff sought treatment with Dr. Karl Killion, a primary care physician who had treated Plaintiff for fifteen or twenty years. (Tr. 35) At the time of the hearing, Plaintiff had a prescription for Percocet from Dr. Killion. (Tr. 35) According to Plaintiff, Dr. Killion first prescribed Percocet eight or ten years earlier. (Id.)

         Despite the psychiatric issues Plaintiff described, at the time of his hearing Plaintiff had no current mental healthcare provider and had stopped taking psychiatric medicines prescribed to him by his previous counselor at Resolutions Behavioral Health ("RBH") roughly a year before. (Tr. 33-34, 150) Plaintiff testified that he did not agree with his treatment plan because a nurse practitioner treated him rather than a doctor and because the medicines prescribed did not work. (Tr. 34) Plaintiff also testified that he lost Medicaid "right after" seeing the nurse practitioner at RBH. (Id.) Plaintiffs medical records do not clarify his reasons for ceasing treatment. Notes from his last appointment, on April 17, 2013, recommend another appointment in four weeks and contain no reference to closing his file. (Tr. 152)

         Plaintiff stated that because he had no insurance at the time of the hearing, no psychiatrist would treat him (Tr. 34) Additionally, Plaintiff represented that he had been approved for Medicaid coverage recently but that every psychiatrist he spoke with had a two month wait until their first available appointment. (Id.) Plaintiff offered no documentation of psychiatrists' refusal to treat him without insurance, his search for a psychiatrist, or the waiting period to see a psychiatrist.

         At the time of the hearing, Plaintiff lived in a house with his wife and his mentally disabled daughter. (Tr. 35) Plaintiff testified that during the day, he watches TV or tries to keep active by visiting his mother or his daughter. (Tr. 36) Plaintiff testified that he performs no yard work and "hardly any" household chores, but that he shops at the store when he has to, accompanied by his wife or son. (Tr. 36, 40)

         2) Vocational Expert's Testimony (Tr. 40-43)

         Theresa Wolford testified as a vocational expert ("VE") at the hearing. The ALT asked the VE to consider a hypothetical person of Plaintiff s age, education, and work experience who could work at the light exertion level. (Tr. 42) This hypothetical person should avoid concentrated exposure to vibration, could occasionally climb ramps and stairs, stoop and crouch, but could never climb ladders, ropes, or scaffolds. (Id.) This person could perform simple routine tasks in a low stress work environment. (Id.) The ALJ defined a low stress work environment as one with "only occasional workplaces change" and one with occasional contact with supervisors, coworkers or the general public. (Id.)

         The VE testified that this hypothetical person could perform several jobs, including: (1) housekeeping; (2) routing clerk; and (3) assembler production. (Tr. 42) If the hypothetical person with the same limitations was also off task in excess of 20 percent of the day, the VE testified that no jobs would exist for them in the economy. (Tr. 43)

         B. Plaintiffs Work History and Function Reports (Tr. 30, 32, 100-110, 128-137)

         Plaintiff has work experience as a building maintenance worker. (Tr. 30, 32, 110) In the function report he filled out, Plaintiff indicates that he does not need special reminders to take care of personal needs and grooming, and that he shops for groceries about once a month. (Tr. 130, 131) The report also indicates that Plaintiff needs reminders to take medicine, does not prepare his own meals, and does not perform house or yard work because he has no energy and because he experiences heightened pain when he stands for a long time. (Id.) Plaintiff also reported that he has trouble getting along with other people because he "can't stand to be around a lot of people or sometimes just one" and that he does not handle changes in routine well. (Tr. 133, 134) Finally, Plaintiff indicated that he can pay attention for "not long, " that he can follow written instructions "somewhat, " and that he can follow spoken instructions "some." (Tr. 133)

         C. Other Evidence

         1) Medical Records

         The record before this Court does not include medical records from the time of Plaintiff s alleged onset date of July 1, 2005, through January 23, 2013. On January 23, 2013, Plaintiff began treatment at Rehabilitative Behavior Health ("RBH") with Nancy McNail, a psychiatric-mental health nurse practitioner. He reported anxiety, decreased sleep (two hours per night), and at times not wanting to be around others. (Tr. 157, 158) Treatment notes from that visit indicate that Plaintiff had not taken any psychological medication for several years prior to his initial visit. (Tr. 157) Ms. McNail diagnosed Plaintiff with bipolar affective disorder and prescribed Depakote and counseling. (Tr. 158) Ms. ...

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