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Clark v. Berryhill

United States District Court, W.D. Wisconsin

August 29, 2019

NANCY A. BERRYHILL, Acting Commissioner of Social Security Administration, Defendant.



         Pursuant to 42 U.S.C. § 405(g), claimant Roberta Clark seeks judicial review of the Commissioner of Social Security's determination that she is ineligible for Supplemental Security Income under Title XVI of the Social Security Act. Clark, who filed her claim pro se but is now represented by counsel on appeal, argues that remand is necessary because the ALJ failed to develop the administrative record adequately in support of his findings. Because the ALJ had a “heightened duty” to develop a record fully on behalf of a pro se claimant, the court agrees and will remand for further proceedings. See, e.g., Thompson v. Sullivan, 933 F.2d 581, 585-86 (7th Cir. 1991).


         A. Procedural History

         Clark filed an application for supplemental security income (SSI) on January 28, 2013, alleging a disability onset date of November 30, 2008. (AR 17.) Her application was denied on May 14, 2013, and was denied again on reconsideration on October 2, 2013. (Id.) On March 4, 2015, she appeared pro se at a hearing before Administrative Law Judge Brent C. Bedwell (“ALJ Bedwell” or “ALJ”). (See AR 163-80.) The hearing itself lasted only twenty-four minutes. (See AR 165, 180.) On March 20, 2015, ALJ Bedwell issued an unfavorable decision. (AR 14.)

         After claimant appealed (AR 45), the Appeals Council initially remanded in April, 2016, for a new hearing because it could not find the administrative record. (AR 9-10.) Once the record was located in August 2017, however, the Appeals Council vacated its prior order, then upheld ALJ Bedwell's decision on September 20, 2017. (AR 3.) Claimant sought judicial review from this court. (See Compl. (dkt. #3).)

         B. Claimant's Medical Records

         The medical records considered by ALJ Bedwell are fairly sparse. For example, while claimant's alleged onset date is November 30, 2008, her medical records do not begin until 2012. Likewise, numerous medical records that claimant informed the ALJ existed are missing from the administrative record. Indeed, claimant specifically informed the ALJ that she received a CT scan of her head at Aspirus Grandview Hospital on September 9, 2013 (see AR 112-13), but the accompanying medical records are nowhere to be found in the record. Claimant also informed the ALJ that she visited Dr. Wes Frisbie[1] at Iron Wood Hospital on August 4, 2014, and that he diagnosed her with depression, high blood pressure, stress, migraines, and a concussion, as well acute visual impairments (AR 123). Any record of this visit is also missing.

         The few medical records reviewed by the ALJ reveal that claimant was treated for anxiety, stress, sleep deprivation, colds, bronchitis, hypertension, dyslipidemia, Carpal Tunnel Syndrome (“CTS”) and rail styloid tenosynovitis in her left hand. (AR 127-131, 140, 147.) Clark apparently received a brace for her CTS, although her medical records do not indicate who prescribed it for her. (AR 21.) In her written request for appeal, Clark wrote that she wore a brace on her right and left hands, and she could not lift more than five pounds. (AR 12.) Clark also claimed that she had difficulty performing basic tasks, like writing. (Id.) At her hearing, Clark stated that an orthopedist named “Zergaball”[2] had ordered the braces, but there is again no documentation of this order in the administrative record. (AR 172-73.) Clark said that the brace was “helping” and that she did not frequently have to take medication for the pain. (AR 173-74.)[3]

         Clark was prescribed amoxicillin, Atenol, Bonzepril and Ventolin for her sinus issues, hypertension, anxiety and lung problems respectively. (AR 88, 129.) At her hearing, Clark testified that the medication for her hypertension had been “very helpful.” (AR 176.) Clark's doctor also prescribed her Citalopram for her depression in October 2012, and followed up with her in January and February 2013. (AR 156-62.) However, Clark's notice of appeal indicates that she still suffers from depressive symptoms. (AR 13.) Clark further believed that she had received the wrong medication for her depression. (See id.). At the hearing, she referenced “bad side effects” of the medication (although she did not elaborate), and she said that the medication gave her “bad dreams.” (AR 171.) Clark reported seeing a doctor for her depression about “every three months.” (AR 174.) Finally, Clark wrote on her disability report form that she was taking baby aspirin for “strokes, ” but there is no other mention of this condition in the record. (AR 113.)[4]

         C. ALJ's Decision

         On March 20, 2015, ALJ Bedwell issued a decision concluding that claimant was not disabled because she “did not have an impairment or combination of impairments that has significantly limited (or is expected to significantly limit) the ability to perform basic work-related activities for 12 consecutive months.” (ALJ Decision (dkt. #10-1) 5.) First, the ALJ considered her physical impairments, noting that claimant continued to perform daily activities despite her bronchitis. (AR 21.) The ALJ also found no indication of a diagnosis or report of CTS before February 25, 2015, and insufficient evidence to support a finding of severe impairment. (Id.) He also found no evidence that claimant's hypertension caused any significant limitations or end organ damage. (Id.)

         Second, ALJ Bedwell determined that claimant's depression constituted a “medically determinable mental impairment, ” but found that this impairment was only “mild.” (AR 22-23.) The ALJ further found that the claimant's statements concerning the limiting effects of her depression on her intensity, persistence and pace were neither entirely credible, nor supported by medical evidence in the record, plus that this impairment created only a “mild” limitation in activities of daily living, social functioning, and concentration, persistence or pace, and there were no episodes of decompensation. (AR 22.)

         Ultimately, the ALJ concluded that the claimant's physical and mental impairments, whether considered independently and in combination, did not significantly limit her ability to perform basic work activities. (Id.) On this basis, the ...

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