Jones v. Commissioner of Social Security

Filing 17

OPINION entered by Judge Richard Mills on 9/27/2019. The Motion of Plaintiff Jennifer Jones for Summary Judgment, d/e 11 is ALLOWED in part. The Motion of Defendant Commissioner of Social Security for Summary Judgment, d/e 13 is DENIED. The C ommissioner's Decision is Reversed under sentence four of 42 U.S.C. § 405 and the action is remanded to the Commissioner, in order to give appropriate weight to Dr. Lin's opinion, and if necessary, revise the Plaintiff's residual functional capacity assessment. Pursuant to Federal Rule of Civil Procedure 25(d), the Clerk will substitute Andrew Saul, Commissioner of the Social Security Administration, as the proper Defendant. The Clerk will enter Judgment and terminate this case. (SEE WRITTEN OPINION) (MAS, ilcd)

E-FILED

Monday, 30 September, 2019 04:11:37 PM
Clerk, U.S. District Court, ILCD

IN THE UNITED STATES DISTRICT COURT
FOR THE CENTRAL DISTRICT OF ILLINOIS
SPRINGFIELD DIVISION

JENNIFER JONES,

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Plaintiff,
v.
ANDREW SAUL,
Commissioner of Social Security,
Defendant.

Case No. 18-3011

OPINION
RICHARD MILLS, United States District Judge:
Pursuant to 42 U.S.C. § 405(g), Plaintiff Jennifer Jones seeks judicial review
of an adverse decision on her claim for disability insurance benefits under Sections
216(I) and 223 of the Social Security Act.
Pending are the Plaintiff’s motion for summary judgment and Defendant’s
motion for summary affirmance.
I.

BACKGROUND

Plaintiff Jennifer Jones alleges disability since May 13, 2010, when she was
35-years old. The Plaintiff, who has an eighth-grade education, has a combination
of medical problems including Chiari malformation resulting in chronic headaches,
depression and memory loss. Her last long-term job was as a CNA at the Illinois
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Veterans Home, a position she held from 1999 to 2010. None of her jobs after that
lasted more than a couple of weeks.
On July 21, 2016, following the parties’ joint motion to remand, this Court
remanded the action to the Social Security Administration in order for the
Administrative Law Judge (ALJ) to proceed through the sequential disability
evaluation process as appropriate and issue a new decision. On October 11, 2017,
Administrative Law Judge Kelly Wingate Campbell issued a Decision denying the
Plaintiff’s applications for disability insurance benefits and supplemental security
income pursuant to Titles II and XVI of the Social Security Act, respectively.
The ALJ found that the Plaintiff has the following severe impairments: a
history of surgery for Chiari malformation, headaches/dizziness, cervical
degenerative disc disease, bilateral carpal tunnel, neuropathy, hypertension, obesity,
depression/adjustment/mood disorder, generalized anxiety, a borderline personality
disorder and a posttraumatic stress disorder.

However, no impairment or

combination of impairments meets or medically equals the severity of one of the
listed impairments in 20 CFR Part 404, Subpart P, Appendix 1.
The ALJ’s Decision found the Plaintiff was “not disabled” at step five of the
sequential evaluation process. Vocational expert Bob Hammond testified that
Plaintiff’s past work included CNA (DOT 355.674-014 classified as medium,
performed at heavy SVP 4) and cook (DOT 313.361-014, medium SVP 7). The ALJ
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presented the following hypothetical: whether an individual of Plaintiff’s age,
education and work experience limited to medium work, never climb ladders, ropes
or scaffolds or be exposed to unprotected heights or hazardous work environments,
but could occasionally climb stairs or ramps; could frequently balance, occasionally
stoop, kneel, crouch or crawl and could frequently handle or finger; avoid no more
than occasional reaching overhead with the right upper extremity; avoid
concentrated exposure to noise and bright flashing lights or flickering lights, as well
as vibrations, fumes, dust or pulmonary irritants; would be limited to simple work
related decisions and could have frequent contact with supervisors and coworkers,
but only occasional contact with the public and would be off task 10% of the work
day.
The vocational expert testified past work is eliminated but the hypothetical
person could perform the following jobs: kitchen helper (DOT 318.687-010,
164,000 jobs nationally); cleaner I (DOT 310.687-014, 121,000 jobs nationally);
both are medium SVP 2. At the light level, such a person could perform these jobs:
injection molder (DOT 556.685-038, 121,000 jobs nationally); press operator (DOT
614.685-014, 127,000 jobs nationally); both are SVP 2. If an individual were off
task 20%, it would eliminate all jobs as would missing two or more days of work a
month. These jobs would not allow a person to lie down during any point of the

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shift. Anything more than two additional breaks of more than six minutes each
would eliminate all jobs.
The ALJ relied on the testimony of the vocational expert that a person of
Plaintiff’s age, education, vocational profile and residual functional capacity could
adjust to occupations such as molder and press operator.
Because the Plaintiff did not seek further review, the ALJ’s Decision became
the final Decision of the Commissioner.

See 20 C.F.R. § 404.955, 404.984,

416.1455, 416.1484.
On appeal, the Plaintiff contends that the ALJ failed to give proper weight to
the opinion of treating neurosurgeon, Dr. Julian Lin. She also alleges the ALJ failed
to give proper weight to consider a proper residual functional capacity.
The Commissioner contends that the ALJ reasonably evaluated the medical
opinion evidence and reasonably evaluated the Plaintiff’s alleged symptoms.
Moreover, substantial evidence supports the ALJ’s residual functional capacity.
II.

STANDARD OF REVIEW

When, as here, the Appeals Council denies review, the ALJ=s decision stands
as the final decision of the Commissioner. See Schaaf v. Astrue, 602 F.3d 869, 874
(7th Cir. 2010). The Act specifies that Athe findings of the Commissioner of Social
Security as to any fact, if supported by substantial evidence, shall be conclusive.@
42 U.S.C. ' 405(g). ASubstantial evidence@ is defined as Asuch relevant evidence as
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a reasonable mind might accept as adequate to support a conclusion.@ Yurt v. Colvin,
758 F.3d 850, 856 (7th Cir. 2014) (citations omitted). Although the task of a court
is not to re-weigh evidence or substitute its judgment for that of the ALJ, the ALJ=s
decision Amust provide enough discussion for [the Court] to afford [the Plaintiff]
meaningful judicial review and assess the validity of the agency=s ultimate
conclusion.@ Id. at 856-57. The ALJ Amust build a logical bridge from the evidence
to his conclusion, but he need not provide a complete written evaluation of every
piece of testimony and evidence.@ Schmidt v. Barnhart, 395 F.3d 737, 744 (7th Cir.
2005) (internal citations and quotation marks omitted).
III.

DISCUSSION

ALJ’s evaluation of medical evidence
The Plaintiff alleges the ALJ failed to give controlling weight to the opinion
of Dr. Lin. While treating physicians are “usually entitled to controlling weight, see
20 C.F.R. § 404.1527(c)(2); SSR 96-2p, 1 an ALJ may discredit the opinion if it is
inconsistent with the record.” Winsted v. Berryhill, 923 F.3d 472, 478 (7th Cir.
2019). An ALJ must provide “good reasons” for discounting the opinion of a
treating physician. Scott v. Astrue, 647 F.3d 734, 739 (7th Cir. 2011). When not
entitled to controlling weight, an ALJ assigns a medical opinion appropriate weight
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The treating-physician rule was eliminated for claims filed after March 27, 2017, see 20 C.F.R. §
404.1520c (2017), but still applies to the Plaintiff’s claim.
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after considering relevant factors, such as the length of the treatment relationship
and frequency of examination; the nature and extent of the treatment relationship;
the supportability of the opinion, including medical signs and laboratory findings;
whether the opinion was consistent with the record as a whole, and the specialization
of the treating relationship. See 20 C.F.R. § 404.1527(c).
The Plaintiff notes that on September 12, 2012, Dr. Julian Lin completed a
medical source statement which indicated that Plaintiff has limitations preventing
her from lifting/carrying less than ten pounds, standing or walking less than two
hours in an 8-hour workday or sitting less than six hours in an 8-hour workday. The
Plaintiff notes the first ALJ gave no weight to Dr. Lin’s opinion and alleges that the
second ALJ makes the same error.
Regarding the Plaintiff’s postural limitations, Dr. Lin’s medical source
statement indicated that Plaintiff is able to do the following frequently, or one-third
to two-thirds of an 8-hour workday: climbing—ramps/stairs/ladder/rope/scaffold,
balancing, kneeling, crouching, crawling, stooping.
Dr. Lin found that Plaintiff has impairments that limited her sight, hearing and
speaking but noted no environmental limitation.
On December 23, 2011, after seeing the Plaintiff for a follow-up after Chiari
decompression, Dr. Lin noted “[s]he has effort related weakness in her grips, biceps
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and triceps.” TR 587. On January 17, 2012, as part of the Plaintiff’s physical exam,
Dr. Lin noted “[p]atient has no focal motor weakness or sensory loss and that her
gait is unremarkable.” TR 582.
The ALJ’s Decision addresses why she affords no weight to Dr. Lin’s opinion:
The undersigned gives no weight to the opinion of treating neurosurgeon
Julian Lin, M.D. Exhibit 28. Though a treating source is generally given
controlling weight, his opinion is internally inconsistent. For example, he
opined that the claimant can lift and carry less than 10 pounds, stand/walk less
than 2 hours and sit more than 6 hours in an 8-hour workday yet he also opined
that she could frequently climb ramps, stairs, scaffolds, and ropes and balance,
kneel, crouch, crawl, and stoop. Dr. Lin further opined that the claimant had
impairments that affected her sight, hearing, and speaking but noted no
environmental limitations. Additionally, his statement is inconsistent with his
own treatment notes. For example, his records show that the claimant’s
speech is clear that she has no focal motor weakness or sensory loss and that
her gait is unremarkable. . . . He also noted that the claimant had “effort
related” weakness in her grips, biceps, and triceps.
TR 905-06.
The Plaintiff notes that the ALJ does not discuss a number of the relevant
factors. Moreover, the opinion comes from the treating neurosurgeon, not merely a
family doctor, that performed the Chiari malformation repair on Plaintiff as well as
carpal tunnel surgery. The Plaintiff notes he has treated her since before July 2011.
Dr. Lin has seen her for follow-up of her surgery and ongoing issues post-surgery.
In September 2013, Dr. Lin noted that Plaintiff complained of a “persistent headache
with some dizziness and shoulder pain,” describing the headache as “unstoppable,
holocranial.” TR 774. The CT scan did not show any acute findings. Dr. Lin
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thought that Plaintiff’s persistent headache could be related to her high blood
pressure and recommends continued treatment with a neurologist.
The Plaintiff claims the record as a whole included documentation of her
headaches. On August 14, 2012, the Plaintiff visited the ER complaining of nausea,
vomiting, weakness and headache. In October 2013, the Plaintiff received an
occipital nerve block for headaches with only mild improvement. On January 7,
2014, the Plaintiff complained of headaches that were described as classic migraines.
On April 5, 2014, the Plaintiff visited the ER with another migraine.
In 2015 and 2016, the Plaintiff complained of extensive headaches and neck
pain, sometimes with high blood pressure. In November 2015, neurologist Dr.
Douglas Sullivant noted “Occipital nuchal origin of her headaches is not surprising.
She has a Chiari malformation status post decompression.” TR 1619.
The Plaintiff notes that Dr. Lin was not contacted to clarify any portion of his
opinion that the ALJ believed to be inconsistent. Like the first ALJ, the second ALJ
gives “partial weight” to non-treating Dr. Mitra’s report of November 2010, and Dr.
Mack’s report of February 2012, neither of whom had Dr. Lin’s opinion to review.
The Plaintiff contends it is error to give any weight to those reports and none to the
treating neurosurgeon.

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The Court agrees with the Plaintiff that the ALJ’s articulated reason for
discounting Dr. Lin’s opinion is insufficient. The ALJ’s Decision does not address
some of the factors noted in the applicable regulation. There is no discussion of
length of treatment, frequency of examination, the nature and extent of treatment
relationship and or specialization of the treating physician. Even though the ALJ
found certain internal inconsistencies within Dr. Lin’s medical source statement, that
is not a sufficient basis to discount the treating physician’s opinion without at least
touching on some of the other factors. This is particularly true if Dr. Lin’s treatment
records otherwise provide support for his opinion. “If an ALJ does not give a
treating physician’s opinion controlling weight, the regulations require the ALJ to
consider the length, nature, and extent of the treatment relationship, frequency of
examination, the physician’s specialty, the types of tests performed, and the
consistency and supportability of the physician’s opinion.” Moss v. Astrue, 555 F.3d
556, 561 (7th Cir. 2009). Because the ALJ did not consider most of those factors,
the Court will remand the matter so that the appropriate factors can be considered in
order to appropriately weigh Dr. Lin’s opinion.
Ergo, the Motion of Plaintiff Jennifer Jones for Summary Judgment [d/e 11]
is ALLOWED in part.
The Motion of Defendant Commissioner of Social Security for Summary
Judgment [d/e 13] is DENIED.
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The Commissioner’s Decision is Reversed under sentence four of 42 U.S.C.
§ 405 and the action is remanded to the Commissioner, in order to give appropriate
weight to Dr. Lin’s opinion, and if necessary, revise the Plaintiff’s residual
functional capacity assessment.
Pursuant to Federal Rule of Civil Procedure 25(d), the Clerk will substitute
Andrew Saul, Commissioner of the Social Security Administration, as the proper
Defendant.
The Clerk will enter Judgment and terminate this case.
ENTER: September 27, 2019

FOR THE COURT:
/s/ Richard Mills
Richard Mills
United States District Judge

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