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Maynard v. Commissioner of Social Security

United States District Court, S.D. Ohio, Eastern Division

July 25, 2019


          George C. Smith Judge.



         Plaintiff, Kimberly J. Maynard, brings this action under 42 U.S.C. § 405(g) seeking review of a final decision of the Commissioner of Social Security (“Commissioner”) denying her application for Disability Insurance Benefits (“DIB”) and Supplemental Security Income (“SSI”). For the reasons set forth below, it is RECOMMENDED that the Court REVERSE the Commissioner's non-disability finding and REMAND this case to the Commissioner and Administrative Law Judge under Sentence Four of § 405(g).

         I. BACKGROUND

         Plaintiff filed her first application for DIB and SSI in December 2010, which was denied by Administrative Law Judge Rita Eppler on December 10, 2013. (Doc. 8-3, Tr. 99-117).

         ALJ Eppler made the following residual functional capacity (“RFC”) finding:

. . . the claimant has the residual functional capacity to perform a full range of work at all exertional levels but with the following nonexertional limitations: she is able to understand, remember and carry out simple routine repetitive tasks and is able to frequently interact with supervisors, coworkers and the public. She is limited to low stress work, which in this case is defined as having no strict production or time pressures.

(Tr. 109).

         Plaintiff filed another application for DIB and SSI on April 7, 2015, alleging that she was disabled beginning December 13, 2013. (Doc. 8, Tr. 296). After her application was denied initially and on reconsideration, ALJ Irma Flottman (the “ALJ”) held a hearing on August 7, 2017. (Tr. 69-97). On December 14, 2017, the ALJ issued a decision denying Plaintiff's application for benefits. (Tr. 10-28). The Appeals Council denied Plaintiff's request for review, making the ALJ's decision the final decision of the Commissioner. (Tr. 1-6).

         Plaintiff filed the instant case seeking a review of the Commissioner's decision on August 27, 2018 (Doc. 1), and the Commissioner filed the administrative record on November 9, 2018 (Doc. 8). Plaintiff filed her Statement of Errors (Doc. 9), Defendant filed an Opposition (Doc. 11), and Plaintiff filed a Reply (Doc. 12). In accordance with the Court's directive, the parties also filed supplemental briefs on the issue of res judicata. (See Docs. 13, 14, 15). Thus, this matter is now ripe for consideration.

         A. Relevant Medical Background

         Plaintiff's Statement of errors pertains to her mental health so the Court limits its discussion of her medical records to the same.

         On May 4, 2012, Plaintiff underwent a psychiatric evaluation at North Community Counseling Center. (Tr. 531-34). She reported fighting depression for several years and described symptoms of insomnia, fatigue, crying spells, and decreased appetite. (Tr. 531). She also reported a history of suicidal ideation. (Id.). Records from her mental status examination indicate that she was well-groomed with average demeanor, eye contact, and activity. (Tr. 532). She had clear speech and no delusions, thoughts of self-abuse, aggression, or hallucinations. (Id.). Her thought processes were “circumstantial, ” and her mood was moderately depressed, anxious and angry. (Tr. 533). She had a “full” affect and was cooperative. (Id.). Plaintiff was diagnosed with PTSD and prescribed medication for her symptoms. (Id.).

         Plaintiff continued to receive treatment at North Community Counseling Center throughout 2012 and 2013. On September 17, 2013, she reported a history of situational stressors, including constant threats of violence from neighbors and having a 16-year-old son with impulse control problems. (Tr. 436). On November 19, 2013, she reported that she was not doing well, as she was under “incredible stress.” (Tr. 440). She also reported that she was having trouble with her kids and was experiencing financial difficulties. (Id.). Further, she stated that her medication had not improved her anxiety or sleep. (Id.).

         On January 29, 2014, Plaintiff again reported situational stressors, including financial problems, demanding children, and difficulties with sleep. (Tr. 443). However, on March 18, 2014, she reported that she was sleeping better on Ambien. (Tr. 449). Further, she reported that family turmoil continued, although her son's behavior had improved. (Id.). Plaintiff did not receive treatment again until June 27, 2014, and had been off her medications due to missed appointments. (Tr. 452). According to exam notes, she had a dysphoric mood, and was easily agitated and frustrated. (Id.). She described multiple environmental stressors, primarily financial hardships. (Id.).

         On July 17, 2014, Plaintiff reported that she was still struggling with dysphoria, anxiety, and feeling agitated. (Tr. 455). She stated that she experienced anxiety to the point of having nausea. (Id.). She continued to report financial stressors, including owing back rent. (Id.). Plaintiff explained that she had stopped taking Latuda because of its side effects. (Id.). Records from her mental status examination showed her to be dysphoric, overwhelmed, stressed, anxious, and irritable. (Id.). She had slow, hesitant speech. (Id.). She maintained good eye contact and exhibited an organized thought processes but had poor insight and judgment and indicated non-compliance with her medications. (Id.).

         Records from November 6, 2014, show that Plaintiff had not taken Latuda for approximately four weeks because of rescheduled appointments. (Tr. 462). She reported feeling stressed, overwhelmed, depressed, and agitated. (Id.). She described ongoing environmental stressors, including financial troubles. (Id.). On November 20, 2014, she described her mood as depressed and tearful. (Tr. 466). She indicated recent suicidal ideation with hopeless thoughts but had no intent or plan. (Id.). Mental status examination records show that she was depressed, tearful, irritable, and overwhelmed. (Id.). She displayed an organized thought process but had poor insight and judgment. (Id.).

         On January 22, 2015, Plaintiff reported that her mood was improving. (Tr. 470). She described remaining hopeful about her future. (Id.). She rated her mood a five on a ten-point scale. (Id.). She used coping skills to deal with ongoing environmental stressors related to financial hardship and awaiting approval for disability benefits. (Id.). As for her medications, she had been taking her Latuda consistently and could see the improvement in her mood. (Id.). Her mood was dysphoric, but she was less tearful. (Id.) She remained anxious, stressed, and overwhelmed. (Id.). Exam records show that her speech was within normal limits and that she had good eye contact. (Id.).

         On February 12, 2015, Plaintiff reported missing doses of Latuda. (Tr. 474). On March 26, 2015, she reported being more tolerant of stressful situations. (Tr. 482). She also reported that her mood had improved overall. (Id.).

         Plaintiff continued to receive treatment at North Community Counseling Center in 2016. On June 15, 2016, she reported that she had stopped taking all medications three weeks prior. (Tr. 737). She was agitated, frustrated, anxious, and stressed. (Id.). She reported ongoing stressors stemming from her family, particularly issues with her daughter. (Id.). She denied thoughts of ...

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