Fredericks v. Colvin
MEMORANDUM Opinion and Order Signed by the Honorable Maria Valdez on 11/29/2017:Mailed notice(lp, )
IN THE UNITED STATES DISTRICT COURT
FOR THE NORTHERN DISTRICT OF ILLINOIS
DONALD E. FREDERICKS,
NANCY A. BERRYHILL, Acting
Commissioner of Social Security,1
No. 16 C 2696
MEMORANDUM OPINION AND ORDER
This action was brought under 42 U.S.C. § 405(g) to review the final decision
of the Commissioner of the Social Security Administration (the “Commissioner”)
denying Plaintiff Donald Fredericks’s (“Plaintiff”) claim for Disability Insurance
Benefits (“DIB”). The parties have consented to the jurisdiction of the United States
Magistrate Judge pursuant to 28 U.S.C. § 636(c). For the reasons that follow,
Plaintiff’s motion for summary judgment [Doc. No. 14] is granted in part. The case
is remanded for further proceedings consistent with this Opinion.
On July 16, 2012, Plaintiff filed a claim for DIB, alleging disability since June
8, 2010. (R. 20, 213–18.) The claim was denied initially and upon reconsideration,
after which Plaintiff timely requested a hearing before an Administrative Law
Nancy A. Berryhill is substituted for her predecessor, Carolyn W. Colvin, pursuant to
Federal Rule of Civil Procedure 25(d).
Judge (“ALJ”). (R. 20.) On May 7, 2014, Plaintiff, represented by counsel, appeared
and testified by video before ALJ Karen Sayon. (R. 35–76.) Vocational expert (“VE”)
Jacqueline Bethell also testified. (Id.)
On June 10, 2014, the ALJ denied Plaintiff’s claim for DIB, finding him not
disabled under the Social Security Act. (R. 20–29.) The Social Security
Administration Appeals Council denied Plaintiff’s request for review, leaving the
ALJ’s decision as the final decision of the Commissioner and, therefore, reviewable
by the District Court under 42 U.S.C. § 405(g). See Haynes v. Barnhart, 416 F.3d
621, 626 (7th Cir. 2005).
The ALJ found at step one that Plaintiff had not engaged in substantial
gainful activity from his alleged onset date of June 8, 2010. (R. 22.) At step two, the
ALJ concluded that Plaintiff had the severe impairments of lumbar degenerative
disc disease, cervical degenerative disc disease, and obesity. (Id.) The ALJ indicated
at step three that Plaintiff did not have an impairment or combination of
impairments that met or medically equaled the severity of one of the listed
impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1. (R. 23.) The ALJ then
assessed Plaintiff’s residual functional capacity (“RFC”) and determined that
Plaintiff retained the capacity to perform light work, except that he could not climb
ladders, ropes, or scaffolds, and was limited to occasional balancing, stooping,
kneeling, crouching, crawling, and climbing of ramps and ladders. (R. 24.) At step
four, the ALJ concluded that Plaintiff was unable to perform any past relevant
work. (R. 28.) Finally, at step five, the ALJ found that there were jobs that existed
in significant numbers in the national economy that Plaintiff could perform, such as
counter clerk, housekeeper, or laundry aide. (R. 29.). Because of this determination,
the ALJ found that Plaintiff was not disabled under the Act. (Id.)
ALJ LEGAL STANDARD
Under the Social Security Act, a person is disabled if he has an “inability to
engage in any substantial gainful activity by reason of any medically determinable
physical or mental impairment which can be expected to result in death or which
has lasted or can be expected to last for a continuous period of not less than twelve
months.” 42 U.S.C. § 423(d)(1)(a). In order to determine whether a claimant suffers
from a disability, the ALJ considers the following five questions in order: (1) Is the
claimant presently unemployed? (2) Does the claimant have a severe impairment?
(3) Does the impairment meet or medically equal one of a list of specific
impairments enumerated in the regulations? (4) Is the claimant unable to perform
his former occupation? and (5) Is the claimant unable to perform any other work?
20 C.F.R. § 416.920(a)(4).
An affirmative answer at either step three or step five leads to a finding that
the claimant is disabled. Young v. Sec’y of Health & Human Servs., 957 F.2d 386,
389 (7th Cir. 1992). A negative answer at any step, other than at step three,
precludes a finding of disability. Id. The claimant bears the burden of proof at steps
one through four. Id. Once the claimant shows an inability to perform past work,
the burden then shifts to the Commissioner to show the claimant’s ability to engage
in other work existing in significant numbers in the national economy. Id.
Section 405(g) provides in relevant part that “[t]he 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). Judicial review of the ALJ’s decision is
limited to determining whether the ALJ’s findings are supported by substantial
evidence or based upon legal error. Clifford v. Apfel, 227 F.3d 863, 869 (7th Cir.
2000); Stevenson v. Chater, 105 F.3d 1151, 1153 (7th Cir. 1997). Substantial
evidence is “such relevant evidence as a reasonable mind might accept as adequate
to support a conclusion.” Richardson v. Perales, 402 U.S. 389, 401 (1971); Skinner v.
Astrue, 478 F.3d 836, 841 (7th Cir. 2007). This Court may not substitute its
judgment for that of the Commissioner by reevaluating facts, reweighing evidence,
resolving conflicts in evidence, or deciding questions of credibility. Skinner, 478 F.3d
at 841; see also Elder v. Astrue, 529 F.3d 408, 413 (7th Cir. 2008) (holding that the
ALJ’s decision must be affirmed even if “‘reasonable minds could differ’” as long as
“the decision is adequately supported”) (internal citation omitted).
The ALJ is not required to address “every piece of evidence or testimony in
the record, [but] the ALJ’s analysis must provide some glimpse into the reasoning
behind her decision to deny benefits.” Zurawski v. Halter, 245 F.3d 881, 889 (7th
Cir. 2001). In cases where the ALJ denies benefits to a claimant, “he must build an
accurate and logical bridge from the evidence to his conclusion.” Clifford, 227 F.3d
at 872. The ALJ must at least minimally articulate the “analysis of the evidence
with enough detail and clarity to permit meaningful appellate review.” Briscoe ex
rel. Taylor v. Barnhart, 425 F.3d 345, 351 (7th Cir. 2005); Murphy v. Astrue, 496
F.3d 630, 634 (7th Cir. 2007) (“An ALJ has a duty to fully develop the record before
drawing any conclusions . . . and must adequately articulate his analysis so that we
can follow his reasoning . . . .”); see Boiles v. Barnhart, 395 F.3d 421, 425 (7th Cir.
Where conflicting evidence would allow reasonable minds to differ, the
responsibility for determining whether a claimant is disabled falls upon the
Commissioner, not the court. See Herr v. Sullivan, 912 F.2d 178, 181 (7th Cir.
1990). However, an ALJ may not “select and discuss only that evidence that favors
his ultimate conclusion,” but must instead consider all relevant evidence. Herron v.
Shalala, 19 F.3d 329, 333 (7th Cir. 1994); see Scrogham v. Colvin, 765 F.3d 685, 698
(7th Cir. 2014) (“This ‘sound-bite’ approach to record evaluation is an impermissible
methodology for evaluating the evidence.”).
Plaintiff asserts the following errors on appeal: (1) the ALJ improperly
assessed the opinion of his treating physician; (2) the ALJ’s RFC determination was
erroneous and not supported by substantial evidence; and (3) the ALJ erred in
assessing Plaintiff’s subjective allegations and credibility. [Doc. No. 15, at 7–16.]
For the reasons that follow, this matter is remanded for further proceedings
consistent with this Opinion.
A. The ALJ Did Not Properly Evaluate the Medical Opinion Evidence
In evaluating a claim of disability, an ALJ “must consider all medical
opinions in the record.” Roddy v. Astrue, 705 F.3d 631, 636 (7th Cir. 2013); see 20
C.F.R. § 404.1527(b). The opinion of a treating physician is afforded controlling
weight if it is both “well-supported” by clinical and diagnostic evidence and “not
inconsistent with the other substantial evidence” in the case record. 20 C.F.R. §
404.1527(c)(2); see Scott v. Astrue, 647 F.3d 734, 739 (7th Cir. 2011).2 Because of a
treating doctor’s “greater familiarity with the claimant’s condition and
circumstances,” Gudgel v. Barnhart, 345 F.3d 467, 470 (7th Cir. 2003), an ALJ must
“offer good reasons for discounting a treating physician’s opinion.” Campbell v.
Astrue, 627 F.3d 299, 306 (7th Cir. 2010) (citations omitted); see also See Stage v.
Colvin, 812 F.3d 1121, 1126 (7th Cir. 2016). Those reasons must be “supported by
substantial evidence in the record; a contrary opinion of a non-examining source
does not, by itself, suffice.” Campbell, 627 F.3d at 306.
Even where a treater’s opinion is not given controlling weight, an ALJ must
still determine what value the assessment does merit. Scott, 647 F.3d at 740;
Campbell, 627 F.3d at 308. In making that determination, the regulations require
the ALJ to consider a variety of factors, including: (1) the nature and duration of the
examining relationship; (2) the length and extent of the treatment relationship; (3)
the extent to which medical evidence supports the opinion; (4) the degree to which
The SSA recently adopted new rules for agency review of disability claims involving the
treating physician rule. See 82 Fed. Reg. 5844-01, 2017 WL 168819, at *5844 (Jan. 18,
2017). Because the new rules apply only to disability applications filed on or after March
27, 2017, they are not applicable in this case. (Id.)
the opinion is consistent with the entire record; (5) the physician’s specialization if
applicable; and (6) other factors which validate or contradict the opinion. 20 C.F.R.
§ 404.1527(c). The ALJ must then provide a “sound explanation” for that decision.
Punzio v. Astrue, 630 F.3d 704, 710 (7th Cir. 2011).
In a letter dated April 22, 2014, Plaintiff’s treating physician, Sanjay
Chatrath, D.O., briefly detailed Plaintiff’s history of chronic neck and back pain
with radiculopathy in his arms, and opined that the worsening of these conditions
caused him to be unable to work as of June 2010. (R. 384.) Dr. Chatrath stated that
Plaintiff’s current diagnoses included chronic pain, chronic lumbar radiculopathy
and cervical radiculopathy due to a back injury and degenerative disc disease and
bulging discs. (Id.) Since Dr. Chatrath began treating Plaintiff in August 2012,
Plaintiff had been taking Norco six to eight times a day, and Flexeril and
Gabapentin three times a day in order to cope with his pain and radiculopathy
symptoms. (Id.) Dr. Chatrath indicated that Plaintiff could not sit, stand, or walk
for long periods of time, his pain woke him up at night, and that his activities of
daily living were hard to complete or manage. (Id.) Dr. Chatrath noted that a July
30, 2013 MRI of the lumbar spine revealed moderate to severe degenerative disc
disease of L1-S1, with L5-S1 being the worst. (R. 365–66, 384.) An MRI of the
cervical spine performed the same day revealed moderate to severe degenerative
disc disease of C6-C7 with bilateral nerve impingement. (R. 363–64, 384.) Dr.
Chatrath opined that these MRI results “all coincide with [Plaintiff’s] symptoms.”
(R. 384.) Additionally, Dr. Chatrath opined that Plaintiff needed to see a spine
specialist as soon as possible to prevent permanent nerve damage, and that
Plaintiff’s quality of life would “greatly benefit from cervical and lumbar surgery as
soon as possible.” (Id.) Dr. Chatrath invited the reader to contact his office if further
documentation would be needed, and noted that Plaintiff was in possession of his
prior medical records. (Id.) The letter was co-signed by Karie Prokop, PA-C. (Id.)
The Court concludes that the ALJ improperly discounted the opinions of Dr.
Chatrath. It is undisputed that Dr. Chatrath is Plaintiff’s treating physician and
has been treating Plaintiff since August 2012. However, the ALJ gave insufficient
reasons to reject Dr. Chatrath’s opinion as a treating physician. The ALJ gave “no
weight” to the medical opinion of Dr. Chatrath because: (1) the opinion was based
upon Plaintiff’s subjective allegations, as Dr. Chatrath did not begin treating
Plaintiff until August 2012; and (2) the opinion was “a conclusory opinion on
disability, which is a determination to be made by the Commissioner.” (R. 27–28.)
There are several flaws in the ALJ’s analysis.
First, the ALJ did not substantiate her assertion that Dr. Chatrath’s opinion
was inappropriately based on Plaintiff’s subjective complaints. The Seventh Circuit
has found that “if the treating physician’s opinion is . . . based solely on the patient’s
subjective complaints, the ALJ may discount it.” Ketelboeter v. Astrue, 550 F.3d 620,
625 (7th Cir. 2008) (emphasis added). However, the Seventh Circuit recently noted
that it was “illogical to dismiss the professional opinion of an examining [physician]
simply because that opinion draws from the claimant’s reported symptoms.” Aurand
v. Colvin, 654 F. App’x 831, 837 (7th Cir. 2016) (unpublished opinion). “Almost all
diagnoses require some consideration of the patient’s subjective reports, and
certainly [Plaintiff’s] reports had to be factored into the calculus that yielded the
doctor’s opinion.” McClinton v. Astrue, 2012 WL 401030, at *11 (N.D. Ill. Feb. 6,
In this case, Dr. Chatrath’s medical opinions do not “amount merely to a
recitation of [Plaintiff’s] complaints.” Rice v. Barnhart, 384 F.3d 363, 371 (7th Cir.
2004). Dr. Chatrath had the opportunity to examine Plaintiff on six separate
occasions in addition to reviewing the MRI evidence and Plaintiff’s prior medical
records. And there is nothing in the record to suggest that Dr. Chatrath disbelieved
Plaintiff’s description of his symptoms, or that Dr. Chatrath relied more heavily on
Plaintiff’s descriptions than his own clinical observations and interpretation of the
objective MRI evidence in concluding that Plaintiff was seriously impaired. See
Davis v. Astrue, 2012 WL 983696, at *19 (N.D. Ill. March 21, 2012) (“The ALJ fails
to point to anything that suggests that the weight [Plaintiff’s treating physician]
accorded Plaintiff's reports was out of the ordinary or unnecessary, much less
questionable or unreliable.”); see also Ryan v. Comm’r, 528 F.3d 1194, 1199–200
(9th Cir. 2008) (“[A]n ALJ does not provide clear and convincing reasons for
rejecting an examining physician’s opinion by questioning the credibility of the
patient’s complaints where the doctor does not discredit those complaints and
supports his ultimate opinion with his own observations.”). As such, the ALJ did not
“build an accurate and logical bridge” from the evidence to her conclusion. Beardsley
v. Colvin, 758 F.3d 834, 836 (7th Cir. 2014). Moreover, neither the ALJ nor the
Commissioner cite to any evidence that Dr. Chatrath based his entire opinion solely
on Plaintiff’s subjective complaints, and, therefore, this reason for denying weight to
his opinion is unavailing.
Next, while the Court agrees with the ALJ that the ultimate issue of
disability is a legal decision reserved for the Commissioner, the ALJ cannot
disregard medical evidence as a whole from the treating physician. Scrogham, 765
F.3d at 697. Thus, although it is true that the ALJ was not bound by Dr. Chatrath’s
assertions that Plaintiff was too disabled to work, see Garcia v. Colvin, 741 F. 3d
758, 760 (7th Cir. 2013), Plaintiff’s physical and mental ability to work full time “is
something to which medical testimony is relevant and if presented can’t be ignored.”
(Id.) (citing Bjornson v. Astrue, 671 F.3d 640, 647–48 (7th Cir. 2012)).
Further, although the ALJ is not required to give Dr. Chatrath’s opinion
controlling weight, she still must address the factors listed in 20 C.F.R. § 404.1527
to determine what weight to give the opinion. Social Security Ruling (“SSR”)3 96-2p.
SSR 92-2p states that treating source medical opinions like Dr. Chatrath’s “are still
entitled to deference and must be weighed using all of the factors provided in 20
C.F.R. § 404.1527.” Id. (emphasis added). Here, the ALJ afforded Dr. Chatrath’s
opinion no weight, but failed to adequately address or otherwise demonstrate
consideration of many of the enumerated factors provided in 20 C.F.R. § 404.1527.
SSRs “are interpretive rules intended to offer guidance to agency adjudicators. While
they do not have the force of law or properly promulgated notice and comment regulations,
the agency makes SSRs binding on all components of the Social Security Administration.”
Nelson v. Apfel, 201 F.3d 799, 803 (7th Cir. 2000); see 20 C.F.R. § 402.35(b)(1). While the
court is “not invariably bound by an agency’s policy statements, the Court “generally
defer[s] to an agency’s interpretations of the legal regime it is charged with
administrating.” Liskowitz v. Astrue, 556 F.3d 736, 744 (7th Cir. 2009).
Specifically, the ALJ did not analyze the nature and extent of the treatment
relationship, the frequency of examination, the supportability of the decision, the
consistency of the opinion with the record as a whole, or whether Dr. Chatrath had
a relevant specialty. The ALJ is required to “sufficiently account [ ] for the factors in
20 C.F.R. § 404.1527.” Schreiber v. Colvin, 519 F. App’x 951, 959 (7th Cir. 2013)
(unpublished decision). The ALJ’s failure to do so prevents this Court from
determining the reasonableness of the ALJ’s decision in light of the factors outlined
in 20 C.F.R. § 404.1527.
For the reasons described herein, the ALJ did not offer substantial evidence
for rejecting the Dr. Chatrath’s opinion, which is an error requiring remand.
B. Remaining Arguments
Because remand is required for errors in the ALJ’s weighing of the opinion
evidence of Dr. Chatrath, the Court need not address Plaintiff’s remaining
arguments at this time. The Court expresses no opinion about the decision to be
made on remand but encourages the Commissioner to use all necessary efforts to
build a logical bridge between the evidence in the record and her ultimate
conclusions, whatever those conclusions may be. See, e.g., Myles v. Astrue, 582 F.3d
at 678 (“On remand, the ALJ should consider all of the evidence in the record, and,
if necessary, give the parties the opportunity to expand the record so that he may
build a ‘logical bridge’ between the evidence and his conclusions”); Smith v. Apfel,
231 F.3d 433, 437 (7th Cir. 2000); Luna v. Shalala, 22 F.3d 687, 693 (7th Cir. 1994).
Further, the ALJ is advised to consider Plaintiff’s testimony in light of the recent
guidance provided by SSR 16-3p and focus on Plaintiff’s asserted symptoms. See
Cole v. Colvin, 831 F.3d 411, 412 (7th Cir. 2016). The Commissioner should not
assume that any other claimed errors not discussed in this Order have been
adjudicated in her favor. On remand, the Commissioner therefore must carefully
articulate her findings as to every step.
For the foregoing reasons, Plaintiff’s motion for summary judgment [Doc. No.
14] is granted in part. The Court finds that this matter should be remanded to the
Commissioner for further proceedings consistent with this Order.
DATE: November 29, 2017
HON. MARIA VALDEZ
United States Magistrate Judge
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