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Sudler v. Berryhill

United States District Court, D. Delaware

March 30, 2017

ROGER L. SUDLER, Plaintiff,
v.
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.[1]

          Angela Pinto Ross, DOROSHOW, PASQUALE, KRAWITZ & BHAYA, Wilmington, DE Attorney for Plaintiff.

          David C. Weiss, Acting United States Attorney, and Heather Benderson, Special Assistant United States Attorney, United States Attorney's Office, Wilmington, DE

          Nora Koch and Robert S. Drum, Office of the General Counsel, Social Security Administration, Philadelphia, PA Attorneys for Defendant.

          MEMORANDUM OPINION

          STARK, U.S. District Judge:

         I. INTRODUCTION

         Plaintiff Roger L. Sudler appeals a final decision of the Acting Commissioner of Social Security, Nancy A. Berryhill ("Commissioner" or "Defendant"), denying Plaintiffs application for disability insurance benefits and supplemental security income, under Title n, 42 U.S.C. §§ 401-434, and Title XVI, 42 U.S.C. §§ 1381-1383, of the Social Security Act. The Court has jurisdiction under 42 U.S.C. §§ 405(g) and 1383(c)(3).

         Pending before the Court are cross-motions for summary judgment filed by Sudler and the Commissioner. (See D.I. 10, 14) Sudler requests that the Court remand to the ALJ for further proceedings. (See D.I. 11 at 20-21) The Commissioner requests that the Court affirm the decision denying Plaintiffs application for benefits. (See D.I. 15 at 16) For the reasons set forth below, the Court will grant in part and deny in part the motions for summary judgment and remand for further proceedings.

         II. BACKGROUND

         A. Procedural History

         On April 18, 2012, Sudler protectively filed an application for supplemental security income benefits, alleging disability with an onset date of April 1, 2012, due to HIV, bipolar disorder, depression, mood disorder, and chronic asthma. (See D.I. 7 at 287-297 ("Tr.")) Sudler also filed an application for disability insurance benefits on May 2, 2012. (See id.) The claims were initially denied on August 8, 2012, and again upon reconsideration on April 19, 2013. (See Id . at 28) After a hearing before an Administrative Law Judge ("ALJ") on July 17, 2014, the ALJ issued a decision on October 1, 2014, finding that Plaintiff did not have a disability within the meaning of the Social Security Act. (See Id . at 28-44) Plaintiff filed a request for review of the ALJ's decision, which was denied on June 25, 2015, resulting in a final decision of the Commissioner of Social Security. (See Id . at 1)

         On August 24, 2015, Sudler filed a complaint in the District of Delaware, seeking judicial review of the ALJ's decision. (See D.I. 2) Sudler moved for summary judgment on April 8, 2016 (see D.I. 10), and the Commissioner filed a cross-motion for summary judgment on June 9, 2016 (see D.I. 14).

         B. Factual Background

         1. Plaintiff's testimony

         Sudler was born on May 26, 1978, and lives in Dover, Delaware. (See Tr. at 55-56) Plaintiff has a high school diploma and enrolled in some college courses at Delaware State University, although he never received any degrees or certificates. (See Id . at 57) Sudler has past work experience as a card services manager, a group home caretaker, a cashier, and a certified nurse's assistant. (See Id . at 71-73) Plaintiff also received on-the-job training as a mechanic. (See Id . at 59) Plaintiff testified that in 2007, he was convicted in Delaware of identity theft for making a purchase at a Target with a stolen credit card. (See Id . at 59-60) Plaintiff is also a father and sees his daughter about every other weekend. (See Id . at 56)

         Plaintiff stopped working in April 2012, after leaving his full-time employment as a mechanic at a flame retardant file cabinet manufacturer, where he had worked for three years. (See Id . at 58-59, 74-75) Plaintiff testified to having had a "meltdown" in 2012, which resulted in frustration, lowered attendance, and difficulty handling his job duties. (Id.) Plaintiff testified that he took time off, began counseling at Kent Wellness Clinic, and - at the advice of his therapist - stopped working altogether. (See Id . at 59)

         Plaintiff testified that he had no physical limitations until about three months before the hearing and continued to drive. (See Id . at 63) Plaintiff testified that his medications make him feel sedated, and that he stays in bed most of the time. (See Id . at 64) Plaintiff stated that he tried to go to places like the library, the gym, or the mall but that he felt too lethargic to go and stopped trying. (See Id . at 64-65)

         2. Plaintiffs Medical History

         a. Voluntary Hospitalizations '

         Plaintiff voluntarily submitted to hospitalization for psychiatric reasons four times between April 2012 and May 2013. (See Id . at 32) Sudler was first hospitalized for about a week in April 2012 for depression and suicidal thoughts. (See Id . at 394-95) During that stay, he was diagnosed with major depressive disorder, and his symptoms improved, in part due to being prescribed medications to treat that disorder. (See id.) Sudler was hospitalized again, for nearly two weeks, in August 2012, for depression and suicidal ideation, and again saw some improvement. Sudler was diagnosed with bipolar I disorder and depression, and prescribed three different medications. (See Id . at 761-65) Plaintiffs third hospitalization, again the result of depression and suicidal thoughts, lasted one week in March 2013. (See Id . at 535) During his stay, Plaintiff was prescribed a number of medications to treat his mental-health disorders. (See Id . at 538) Finally, Sudler was hospitalized for a week in May 2013 after running out of his medications. (See Id . at 772) Sudler again showed improvement during the course of his stay, during which his medications were adjusted and he was referred to out-patient treatment. (See Id . at 775) Sudler does not report any hospital stays after May 2013.

         b. Out-patient Treatment

         Sudler was seen by multiple doctors and therapists starting around April 2012. (See Id . at 35-39) Of most importance here are Sudler's ongoing treatments with therapist Henriette Morris and psychiatrist Berjees Mukhtar. Following his August 2012 hospitalization, Sudler was referred for out-patient therapy to Ms. Morris, a licensed clinical social worker. (See Id . at 620-21) Ms. Morris' progress notes indicate that Plaintiff suffered from bipolar I disorder and insomnia. (See, e.g., Id . at 466, 476) Her notes suggest that Plaintiff improved on medication and that his attention and concentration were intact despite the effects of depression and anxiety. (See, e.g., Id . at 478, 500) For example, on May 23, 2013, Ms. Morris indicated that Sudler was "feeling much better" on medication, but was sometimes experiencing periods of hypersomnia. (Id. at 570) She also noted that Sudler's medications "can be sedative" as a side effect. (Id.)

         After his May 2013 hospital stay, Plaintiff also began to see Dr. Mukhtar, who noted that Plaintiff has bipolar disorder. (See Id . at 737-39) On several occasions, Dr. Mukhtar's notes indicate that Plaintiff reported prolonged periods of sleeping or sleep disturbances. (See, e.g., Id . at 709, 730, 734) In February 2014, Dr. Mukhtar recommended that Plaintiff undergo electroconvulsive therapy, as Dr. Mukhtar thought Sudler showed signs of medication resistance. (See Id . at 695) Dr. Mukhtar's notes from June 2014 indicate that Sudler had not been cleared for electroconvulsive therapy for cardiac reasons. (See Id . at 689)

         c. Cardiology Testing

         As a result of Dr. Mukhtar's referral for electroconvulsive therapy, Sudler underwent a cardiac exam. Plaintiffs cardiologist, Dr. Horjinder Grewal, performed a echocardiogram on May 19, 2014, which showed severely reduced systolic function with an ejection fraction of 30%, a reversed E/A ratio, and severe global hypokinesis of the left ventricle. (See Id . at 748) Dr. Grewal then performed additional testing - left and right heart catheterizations, selective coronary angiography, left ventriculography, and right lower leg angiography - on June 13, 2014, which also showed "severely reduced left ventricular systolic function with an ejection of 30 percent." (Id. at 744-45) At the hearing before the ALJ, Sudler's counsel stated that additional follow-up was needed on these tests. (See Id . at 54)

         3. Medical Opinion Evidence

         Plaintiff submitted two opinions from treating providers: cardiologist Dr. Grewal and therapist Ms. Morris. (See Id . at 541, 740-43) Sudler was also assessed by several non-treating medical and psychiatric consultants. (See Id . at 39-41)

         a. Treating Providers' Opinions

         In a letter dated November 8, 2013, Ms. Morris wrote that she had been working with Plaintiff since May of 2012 for bipolar I disorder with episodic depression, anxiety, and trauma. (See Id . at 541) Ms. Morris stated that Plaintiff incurred four hospitalizations, each lasting at least two weeks, and she described his current mental health as "very unpredictable." (Id.) She opined that "active gainful employment with stringent attendance requirement[s] as well as increased stress may prove to be counterproductive in his strive for symptomatic control." (Id.)

         In a physical residual functional capacity questionnaire filled out on July 7, 2014, Dr. Grewal identified Sudler as having idiopathic cardiomyopathy causing fatigue with impairment lasting or expected to last in excess of 12 months. (See Id . at 740) Dr. Grewal stated that Plaintiff needs a life vest and beta blockers and that Plaintiffs depression contributes to his condition. (See id.) Dr. Grewal did not estimate Sudler's functional limitations but stated that Plaintiff is "disabled." (See Id . at 741-42) Dr. Grewal concluded that Sudler is incapable of performing even low-stress work and that he would be absent "everyday." (Id. at 741, 743)

         b. Consultations with ...


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