May v. Saul

CourtDistrict Court, M.D. Pennsylvania
DecidedAugust 31, 2021
Docket3:20-cv-00577
StatusUnknown

This text of May v. Saul (May v. Saul) is published on Counsel Stack Legal Research, covering District Court, M.D. Pennsylvania primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
May v. Saul, (M.D. Pa. 2021).

Opinion

IN THE UNITED STATES DISTRICT COURT FOR THE MIDDLE DISTRICT OF PENNSYLVANIA

MARTHA JEAN MAY, : : Plaintiff, : No. 3:20-cv-00577 : v. : (Saporito, M.J.) : KILOLO KIJAKAZI1, Acting : Commissioner of Social : Security, : : Defendant. :

MEMORANDUM This is an action brought under 42 U.S.C. §405(g), seeking judicial review of the Commissioner of Social Security’s (“Commissioner”) final decision denying Martha Jean May’s (“May”) claim for supplemental security income under Title XVI of the Social Security Act. This matter has been referred to the undersigned United States Magistrate Judge on consent of the parties, pursuant to the provisions of 28 U.S.C. § 636(c)

1 Kilolo Kizakazi became the Acting Commissioner of Social Security on July 9, 2021. She has been automatically substituted in place of the original defendant, Andrew Saul. See Fed. R. Civ. P. 25(d); see also U.S.C. 405(g) (action survives regardless of change in the person occupying the office of Commissioner of Social Security). The caption in this case is amended to reflect this change and Rule 73 of the Federal Rules of Civil Procedure. (Doc. 9; Doc. 10; Doc.

12). For the reasons stated herein, we will vacate the Commissioner’s decision and remand the case for further consideration.

I. Background and Procedural History May is an adult individual born June 5, 1965, who was 51 years old at the time of her amended alleged onset date of disability and date of

application—May 8, 2017. (Tr. 71-72). May’s age at the onset date and date of application makes her an “individual approaching advanced age” under the Social Security Act. See 20 C.F.R. § 416.953. It is unclear from

the record whether May graduated from sixth, seventh or eighth grade, as there are conflicting reports and testimony. (Tr. 33, 505). Prior to her alleged onset date, May worked as a cleaner/maid. (Tr. 202).

On May 8, 2017, May protectively filed for supplemental security income pursuant to Title XVI of the Social Security Act. (Tr. 13). In her application, May alleged that she became disabled beginning February

17, 2017, as a result of posttraumatic stress disorder, mood swings, general anxiety, attention deficit disorder, social anxiety, and acid reflex. (Tr. 13, 173). May later amended her onset date to May 8, 2017, to coincide with her date of application. (Tr. 13) May’s claim was initially

denied on October 10, 2017. (Tr. 93-97). Thereafter, May filed a timely request for an administrative hearing on December 18, 2017, and it was granted. (Tr. 98-100, 101-115). May, represented by counsel, appeared

and testified before ALJ, Richard E. Guida (“ALJ”), on December 12, 2018, in Harrisburg, Pennsylvania. (Tr. 13, 28). In addition, an impartial vocational expert, Richard Anderson, appeared and testified during the

administrative hearing. (Tr. 30). At the time of this hearing, May was 54 years old and resided in Gettysburg, Pennsylvania, which is in the Middle District of Pennsylvania. (Tr. 32, 71). By a decision dated

February 20, 2019, the ALJ denied May’s application for benefits. (Tr. 10- 27). May sought further review of her claim by the Appeals Council of the Office of Disability Adjudication and Review, but her request was

denied for review on February 3, 2020. (Tr. 835). May subsequently filed an appeal to this court on April 6, 2020, arguing that the ALJ’s decision was not supported by substantial evidence. (Doc. 1). On September 15,

2020, the Commissioner filed his answer, in which he maintains that the ALJ’s decision is correct and in accordance with the law and regulations. (Doc. 13, at 3). This matter has been fully briefed by the parties and is ripe for decision. (Doc. 15; Doc. 16; Doc. 17; Doc. 19, Doc. 20).

May’s treatment records showed that, in the year preceding her application for SSI benefits, she was visiting Wellspan Behavioral Health for treatment of anxiety and depression. (Tr. 288-320). Her prescribed

treatment regimen was therapy and medication. (Tr. 288, 298). May reported worsening anxiety and depression in February 2017, three months before her application, and after her prior application for benefits

was denied. (Tr. 59-70, 293). The month after she applied, in June 2017, May had not been taking her prescribed medication due to cost, and she was irritable and

angry with her husband for not helping her financially. (Tr. 289). However, despite her abnormal mood and “loud” speech, her mental status was normal—her thought process was goal directed, her thought

content was intact, her cognition was within normal limits, and her insight and judgment were appropriate. (Tr. 289). May spoke with an interviewer over the telephone in an SSA field

office as part of her disability claim in July 2017. (Tr. 182-84). The interviewer did not observe any difficulty in May’s ability to understand, concentrate, talk, or answer questions. (Tr. 183). At a medication monitoring visit with her mental health provider,

Johar Shah, M.D., in August 2017, May reported stressors, noting issues with her husband, a previous denial of a social security disability claim, and worries about her physical health. (Tr. 498). Dr. Shah noted May’s

depression and anxious mood, and that she appeared poorly groomed and distracted; however, her speech was normal; her thought process was goal directed; her insight and judgment were appropriate; her memory

was appropriate; and her language and knowledge were not abnormal. (Tr. 498). Dr. Shah recommended an adjustment to her medication regimen, based on May’s reports that hydroxyzine was not helping, and

added gabapentin instead. (Tr. 498). May visited Christopher Gipe, MS a month later for a consultative examination as part of her disability claim. (Tr. 505-12). Mr. Gipe noted

that although her file indicated that May had an eighth-grade education “her test results suggests very poor educational background and intellectual level.” (Tr. 505). May alleged significant symptoms,

including difficulty interacting with others, difficulty concentrating, panic attacks, sleep disturbance, and issues with concentration and short-term memory. (Tr. 506-07). Mr. Gipe observed that May was cooperative and related adequately during the examination. (Tr. 507).

May’s speech was fluent and clear with adequate expressive and receptive language; her thought processes were coherent and goal directed. (Tr. 507). Her affect was anxious, depressed, and hopeless, and

she reported that her mood was nervous. (Tr. 507). In terms of attention and concentration and memory skills, Mr. Gipe noted that May was “[i]mpaired due to anxiety and limited intellectual functioning,” noting

that May counted, but could not do simple calculations or begin serial 7s; she remembered three objects immediately, but not after a delay; and she remembered four digits forward, but not backward. (Tr. 508). Mr. Gipe

listed unspecified bipolar and related disorder, depressive disorder, panic disorder, agoraphobia, anxiety disorder, and post-traumatic stress disorder under diagnoses, recommended that May continue her

treatment, and gave a fair to guarded prognosis. (Tr. 509). Mr.

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