Zinda, Neal v. Saul, Andrew

CourtDistrict Court, W.D. Wisconsin
DecidedSeptember 18, 2020
Docket3:19-cv-00931
StatusUnknown

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

Bluebook
Zinda, Neal v. Saul, Andrew, (W.D. Wis. 2020).

Opinion

IN THE UNITED STATES DISTRICT COURT FOR THE WESTERN DISTRICT OF WISCONSIN - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - NEAL P. ZINDA, OPINION AND ORDER Plaintiff, 19-cv-931-bbc v. ANDREW SAUL, Commissioner of Social Security, Defendant. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Plaintiff Neal P. Zinda is seeking review of a final decision denying his claim for disability insurance benefits and supplemental security income under the Social Security Act. 42 U.S.C. § 405(g). The administrative law judge found that plaintiff had several severe mental and physical impairments, but that he could still perform work in the national economy despite his impairments. Plaintiff contends that the administrative law judge erred in several ways. As explained below, the administrative law judge failed to provide good reasons to support her decision to weigh the opinions of non-examining agency psychologists over those of plaintiff’s treating and examining medical providers. In addition, the administrative law judge failed to provide sufficient basis for her assessment of plaintiff’s mental and physical limitations and plaintiff’s subjective symptoms. As a result, I conclude that the administrative law judge’s assessment of plaintiff’s residual functional capacity is not supported by substantial evidence. This case will be remanded for further proceedings. 1 The following facts are drawn from the administrative record (AR).

FACTS

A. Social Security Application and Background Plaintiff Neal Zinda was born in 1970, making him 45 years old at the time he filed for disability insurance benefits and supplemental security income in May 2016. Plaintiff is a former firefighter, and claims to have been disabled since August 2015 by post-traumatic stress disorder, bipolar disorder, anxiety and a bulging disk. AR 268. He later asserted that he was also disabled by right shoulder pain. His application was denied initially and on

reconsideration, and plaintiff requested a hearing before an administrative law judge. After the hearing, the administrative law judge issued a written decision concluding that plaintiff was not disabled. AR 13-24. In September 2019, the appeals council denied plaintiff’s request for review, AR 1-3, making the administrative law judge’s decision the final decision of the commissioner. Plaintiff then filed this lawsuit under 42 U.S.C. § 405(g).

B. Overview of Medical Problems and Treatment 1. Mental health Plaintiff has a long history of mental health problems, and his treating providers have diagnosed bipolar disorder, post-traumatic stress disorder, depression with anxiety, attention

deficit disorder and insomnia. AR 429, 671. He was given a diagnosis of bipolar disorder 2 in 2008, and had several psychiatric hospitalizations after that, although none after his alleged disability onset date in 2015. AR 372, 376. He has difficulty controlling his anger and aggressiveness toward others, and his anger has made it difficult for him to hold a job.

AR 48, 315, 430. He was terminated from his assistant fire chief position a few months after receiving a bipolar diagnosis in 2008. AR 376. He takes several medications for his mental health problems, including Seroquel, Depakote, Prozac, Wellbutrin, Xanax and Adderall. AR 559. For more than 15 years, plaintiff’s primary medical provider has been Teresa Grimes, a physician assistant. Grimes diagnosed bipolar disorder and anxiety, and manages

plaintiff’s psychiatric medications. AR 446-450, 552-554. During appointments with Grimes in 2016, plaintiff sometimes reported feeling depressed, anxious and agitated, AR 446-448, 583, while at other times, he reported that he was able to manage his depression and anxiety. AR 552. In July 2016, plaintiff reported to Grimes that he had had a panic attack while attending his child’s sporting event, and Grimes noted that plaintiff had a flat mood and affect and that his anxiety was apparent. AR 553. Grimes also noted that

plaintiff had not been able to work full-time because he kept being fired from jobs. Id. In September 2016, plaintiff asked Grimes whether she could adjust his medications because they were causing hand weakness and tremors. AR 552. Plaintiff has received psychotherapy from several licensed professional counselors. He saw Lynn Flannery, MS, LPC-SA, NCC, from Jefferson County Human Services, on a

weekly basis for psychotherapy from August 2014 to June 2016. AR 472-547. Flannery 3 worked with plaintiff on anger management and other coping skills. Flannery’s treatment notes report that plaintiff had several periods during which his mood and anxiety were stable and under control, AR 467, 475, 477-78, 484-91, 502, and other times during which he

needed extra counseling about PTSD triggers and anxiety. AR 495-499. Between December 2015 and March 2016, plaintiff had an increase in his depressive and anxious symptoms and reported that he had had angry outbursts and was unable to work, check his mail, email or voicemail, or care of himself properly. AR 503-09. During this period, he sent angry and threatening emails to a supervisor and was put on administrative leave from his part-time job as a peer-support specialist. AR 511, 518. He later resigned from the job because he was

frustrated. AR 513. In April 2016, plaintiff reported feeling stable again. AR 504-20, 24. In June 2016, plaintiff was assigned to a different therapist, Krista Doerr, MS, LPC- SA, NCC. AR 526. Doerr met with plaintiff for a couple of sessions, and noted that he was depressed but stable. AR 593. In September 2016, plaintiff starting seeing Jennifer Wendt, MA, LPC-SA, NCC for psychotherapy. AR 600. Between September and November 2016, Wendt noted that plaintiff’s moods were depressed, but stable. AR 600-604. In December

2016, plaintiff became very angry during a session with Wendt and stated that he wanted to throw a chair. AR 607.

2. Shoulder pain Plaintiff first sought treatment for right shoulder pain in May 2016. AR 560. An

exam showed that his right shoulder had a normal range of motion and strength, but that 4 the shoulder caused him pain during examination, was tender, and that there was some crepitus with backward movements. AR 563. An x-ray showed no fracture or dislocation. AR 566.

Plaintiff sought treatment again for shoulder pain in January 2017. AR 638. Upon examination, plaintiff felt pain in his shoulder when he raised it more than 50 degrees and during backward extension, and crepitus over his rotator cuff was noted. AR 641. Plaintiff was also experiencing numbness and tingling in his right middle finger and the thumb of his right hand. AR 638. Plaintiff was instructed to use heat and ibuprofen, and he was referred to orthopedics. AR 641.

Plaintiff was seen at an orthopedic clinic in April 2017. AR 725. The orthopedist assessed a partial tear in plaintiff’s right rotator cuff, a tear in the superior labrum and right shoulder pain. Id. Orthopedic testing showed that plaintiff’s shoulder was positive for impingement, and that plaintiff experienced pain during several other tests. AR 729. The orthopedist recommended surgical repair, AR 731, but plaintiff chose to continue with conservative care, including physical therapy and pain medication, because he was concerned

about the recovery period and lack of support during the postoperative period. AR 845. Plaintiff received cortisone injections that provided him temporary relief. AR 733. In April 2018, plaintiff sought treatment again because his shoulder pain had increased. AR 845.

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Zinda, Neal v. Saul, Andrew, Counsel Stack Legal Research, https://law.counselstack.com/opinion/zinda-neal-v-saul-andrew-wiwd-2020.