Navarro 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
NANCY A. BERRYHILL, Acting
Commissioner of Social Security,
No. 16 C 2978
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 (“Commissioner”)
denying Plaintiff Angelo Navarro’s (“Plaintiff”) claim for Supplemental Security
Income (“SSI”) under Title XVI of the Social Security Act (“the Act”). 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 petition for summary
reversal or remand is granted in part and the Commissioner’s motion for summary
judgment [Doc. No. 23] is denied.
Plaintiff applied for SSI on December 2, 2011 alleging a disability onset date
of October 13, 2011 due to mental problems, delocated arm and shoulder, as well as
two holes in his heart.1 (R. 302, 324.) The claim was initially denied on March 23,
2012 and upon reconsideration on June 28, 2012. (R. 167–68.) Plaintiff filed a
written request for hearing on July 11, 2012, which was held on April 16, 2014. (R.
198.) Plaintiff appeared and testified at the hearing before Administrative Law
Judge (“ALJ”) Lovert F. Bassett. (R. 109–66.) Dr. Ronald A. Semerdjian, MD, a
medical expert, and Margaret H. Ford, a vocational expert, also appeared and
testified. (Id.) On August 9, 2014, the ALJ issued an unfavorable written decision,
finding Plaintiff is not disabled. (R. 15–40.) The Appeals Council (“AC”) denied
review on February 10, 2016, 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); Herron v.
Shalala, 19 F.3d 329, 332 (7th Cir. 1994); (R. 1–6.)
Plaintiff was born on December 6, 1965 and was forty-five years old as of his
alleged onset date. (R. 302.) His records reflect that he last worked as a laborer in a
spring factory for six months in 2008. (R. 318, 324.)
A. Medical Records
Although Plaintiff’s administrative record contains evidence related to both
his physical and mental impairments, the Court will only address those records
which are necessary to resolve the issues raised by the parties.
Claimant had previously filed an application for disability insurance benefits and
supplemental security income in July of 2010. (R. 172.) This application was rejected on
October 13, 2011. (R. 172–81.) Also in the record is the transcript of the hearing for this
determination, which took place on August 23, 2011. (R. 41–100.)
Well after his alleged onset date of October 13, 2011, Plaintiff presented to
Dr. Robert Prescott, Ph.D., at the behest of the Bureau of Disability Determination
Services for two separate formal mental evaluations. (R. 534, 1152.)
Plaintiff’s first exam with Dr. Prescott was on February 9, 2012. (R. 534.) To
begin, Dr. Prescott questioned Plaintiff about his educational, marital, criminal,
and vocational history. (R. 535.) Plaintiff, who served as the only informant on the
matters, stated that he had been placed in special education classes in high school,
but never graduated, had previously been married, and had no criminal history
other than a DUI in 2004. (Id.) He explained that he had last been employed at the
Garden Spring Company about two and half years prior to his exam date. (Id.) Dr.
Prescott also noted that Plaintiff interacted in a cooperative manner throughout the
examination and was well-articulated and understandable 90% of the time. (R. 536.)
During the latter half of the examination, Dr. Prescott focused on Plaintiff’s
mental status. (Id.). Plaintiff reported bouts of depression, and explained that he
was very irritable and often cried. (Id.) He additionally stated that he heard a voice
which instructed him to engage in “bad” behavior, such as stealing. (Id.) Dr.
Prescott diagnosed Plaintiff with a cognitive disorder not otherwise specified, mood
disorder not otherwise specified, and intermittent explosive disorder. (R. 538.)
Plaintiff’s second examination with Dr. Prescott was on May 9, 2014. (R.
1152.) Once again, Dr. Prescott asked Plaintiff several personal history questions,
to which Plaintiff was the only informant. (R. 1153.) Plaintiff stated that he had
attended high school, but did not know if he had been placed in special education
classes, had never been married, and had been to jail many times including as
recently at six years prior to the examination. (Id.) Moreover, he reported that he
had last worked at the Supreme Company over six years prior. (Id.) Dr. Prescott
deemed Plaintiff a poor historian because Plaintiff had provided several
contradictory statements between his two examinations, but nonetheless added
personality disorder with antisocial features to his list of diagnostic impressions. (R.
At the same appointment, Dr. Prescott completed a Medical Source
Statement of Ability to do Work-Related Activities (Mental). (R. 1158.) In it, he
determined that Plaintiff would have moderate impairments in his ability to:
understand, remember, and carry out simple instructions; make judgments on
simple work-related decisions; understand, remember, and carry out complex
instructions or make judgments on complex work-related decisions. (Id.) He further
opined that Plaintiff would have marked limitations in his ability to interact
appropriately with the public, supervisors, and co-workers and to respond
appropriately to usual work situations and to changes in a routine work setting. (R.
1159.) Dr. Prescott based this assessment on the fact that Plaintiff claims he
experiences “something” which makes him think others wish to harm him and he
wants to hurt them first, before they can hurt him. (Id.)
On August 9, 2014, the ALJ issued an unfavorable written determination
finding Plaintiff was not disabled between October 13, 2011, his alleged onset date,
and August 9, 2014, the date the decision was entered. (R. 15–40.) At step one, the
ALJ determined that Plaintiff had not engaged in substantial gainful activity since
December 2, 2011, his application date. (R. 20.) At step two, the ALJ found that the
Plaintiff had the following severe impairments: coronary artery disease/status post
remote stent placement, ureteral meatal stenosis, history of bladder/kidney stones,
right shoulder pain/contusion, left elbow pain with degenerative joint disease,
carpal tunnel syndrome, schizoaffective disorder, cognitive disorder, and personality
disorder with antisocial features.2 (Id.) At step three, the ALJ determined that
Plaintiff did not have an impairment or combination of impairments that meet or
medically equaled the severity of one of the listed impairments in 20 C.F.R. Part
404, Subpart P, Appendix 1 (416.920(d), 416.925, and 416.926). (Id.)
Before step four, the ALJ found that prior to August 9, 2014, Plaintiff had the
residual functional capacity (“RFC”) to perform light work except: occasional
handling; no fingering, no climbing of ladders, ropes, or scaffolds; can understand,
remember, and carry out simple job instructions; occasional interactions with
coworkers and supervisors but never the general public; and no collaborative joint
projects with fellow coworkers or supervisors. (R. 22.) At step four, the ALJ
concluded that Plaintiff was not capable of performing his past relevant work. (R.
Medical evidence regarding Plaintiff’s physical impairments has been omitted from this
31.) Finally, at step five, the ALJ found that prior to August 9, 2014, there were jobs
that existed in significant numbers in the national economy that Plaintiff could
have performed. (Id.) Specifically, the ALJ found that Plaintiff could have worked
as a bakery worker, a surveillance systems monitor, or as a wire preparer. (R. 32.)
Because of this determination, the ALJ found that Plaintiff had not been
disabled during the material period at issue.
Under the 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 plaintiff is disabled, the ALJ
considers the following five questions in order: (1) Is the plaintiff presently
unemployed? (2) Does the plaintiff 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 plaintiff unable to perform his former
occupation? and (5) Is the plaintiff unable to perform any other work? 20 C.F.R. §
An affirmative answer at either step three or step five leads to a finding that
the plaintiff is disabled. Young v. Sec’y of Health & Human Servs., 957 F.2d 386,
389 (7th Cir. 1992). A negative answer to any remaining question precludes a
finding of disability. Id. The plaintiff bears the burden of proof at steps one through
four. Id. Once the plaintiff shows an inability to perform past work, the burden then
shifts to the Commissioner to show the plaintiff’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 [his] decision to deny benefits.” Zurawski v. Halter, 245 F.3d 881, 889 (7th
Cir. 2001). In cases where the ALJ denies benefits to a plaintiff, “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.
We review the ALJ’s decision but we play an “extremely limited” role. Elder,
529 F.3d at 413. Where conflicting evidence would allow reasonable minds to differ,
the responsibility for determining whether a plaintiff 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).
Plaintiff alleges that the ALJ’s decision should be remanded because his
opinion: (1) erroneously rejected Dr. Prescott’s medical source statement and (2)
improperly assessed Plaintiff’s credibility. Because the Court finds that the ALJ
improperly discounted Dr. Prescott’s opinion, we need not address Plaintiff’s
credibility argument at this time.
A. The ALJ improperly discounted Dr. Prescott’s opinion
The ALJ’s first criticized Dr. Prescott’s medical source statement because it
appeared to be “largely based on the reports of [Plaintiff].” (R. 31.) While, the
requirement that medical reports not be based only on subjective complaints
extends to mental and physical impairments, almost all diagnoses—especially
mental health evaluations—require some consideration of the claimant’s subjective
symptoms. See McClinton v. Astrue, No. 09 C 4814, 2012 WL 401030, at *11 (N.D.
Ill. Feb. 6, 2012 (“Almost all diagnoses require some consideration of the patient’s
subjective reports, and certainly [the claimant’s] reports had to be factored into the
calculus that yielded the doctor’s opinion.”). Psychological and psychiatric conditions
are necessarily and largely diagnosed on the basis of subjective patient complaints,
Schickel v. Colvin, No. 14 C 5763, 2015 WL 8481964, at *11 (N.D. Ill. Dec. 10, 2015)
see Srab Zahedi, M.D., Diagnostic Review and Revision, in Oxford Textbook of
Correctional Psychiatry 102, 102 (Robert Trestman et al. eds., 2015) (“At its core,
psychiatric diagnosis relies on the subjective complaints of the patient and objective
signs noted on examination”), and doctors are permitted to rely on their patients’
descriptions of their conditions. See Brown v. Barnhart, 298 F. Supp. 2d 773, 792–
93 (E.D. Wis. 2004).
Here, Plaintiff’s subjective complaints were necessarily factored into Dr.
Prescott’s opinions, and the ALJ failed to point any evidence in the record that Dr.
Prescott relied more heavily on Plaintiff’s description of his condition than his own
clinical observations. In fact, Dr. Prescott examined Plaintiff on two occasions prior
to completing his Medical Source Statement and accounted for Plaintiff’s psychiatric
history when making his determinations. Thus the ALJ’s decision to dismiss Dr.
Prescott’s opinion because he relied too heavily on Plaintiff’s subjective statements,
without further explanation, was in error.
Next, the ALJ discounted Dr. Prescott’s finding that Plaintiff would have
marked limitations in social functioning because it appeared inconsistent with
Plaintiff’s overall record. While consistency is one element an ALJ must evaluate
before weighing a medical source opinion, an ALJ may not simply claim
inconsistency alone without explaining “how the evidence in the record contradicts”
the doctor’s diagnoses. Gudgel v. Barnhart, 345 F.3d 467, 470 (7th Cir. 2003)
(citation omitted). The ALJ points to evidence that Plaintiff was cooperative during
his mental status exams to support his own conclusion that Plaintiff demonstrated
only moderate limitations in social functioning; however, the ALJ’s cursory
statement does not amount to an explanation which satisfies the requisite logical
bridge between the evidence and his conclusions. The ALJ fails to explain how
Plaintiff’s ability to cooperate with Dr. Prescott during two forty-minute
examinations would translate into an ability to interact appropriately with the
public, supervisors, and co-workers and to respond appropriately to usual work
situations during a full work day or work week. Due to the ALJ’s lack of discussion,
the Court is precluded from effective review of his decision.
For the foregoing reasons, Plaintiff’s petition for summary reversal or
remand is granted in part and this case is remanded to the Commissioner for
further proceedings that are consistent with this order.
HON. MARIA VALDEZ
United States Magistrate Judge
November 29, 2017
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