Lockwood v. Commissioner of Social Security

Filing 24

ORDER: For the reasons contained in the attached Order, the Commissioner's final decision denying Plaintiff's application for social security disability benefits is REVERSED and REMANDED for rehearing and consideration of the evidence pursuant to sentence four of 42 U.S.C. § 405(g). Signed by Magistrate Judge Gilbert C. Sison on 9/24/2024.(kbh)

UNITED STATES DISTRICT COURT
FOR THE SOUTHERN DISTRICT OF ILLINOIS
LEA ANN L.,
Plaintiff,
vs.
COMMSSIONER OF SOCIAL
SECURITY,
Defendant.

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) Case No. 3:23-cv-01534-GCS
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MEMORANDUM & ORDER
SISON, Magistrate Judge:
In accordance with 42 U.S.C. § 405(g), Plaintiff seeks judicial review of the final
agency decision denying her application for Disability Insurance Benefits (“DIB”) and
Supplemental Income (“SSI”) pursuant to 42 U.S.C. § 423.
PROCEDURAL HISTORY
Plaintiff applied for DIB and SSI under Titles II and XVI of the Social Security Act
on July 1, 2010. (Tr. 224). She initially alleged that she became disabled on January 1, 2007.
(Tr. 190); (Tr. 192); (Tr. 216); (Tr.223); (Tr. 1824). Plaintiff’s case proceeded to a hearing
before Administrative Law Judge (“ALJ”) James E. Craig, who issued an unfavorable
decision on July 19, 2012. (Tr. 76-93). The Appeals Council (“AC”) remanded the claim
on September 16, 2013. (Tr. 94-98). ALJ Craig issued another unfavorable decision on June
23, 2014. (Tr. 681-702).
Plaintiff’s claim then proceeded to the District Court. The Commissioner moved
for remand on June 14, 2016, pursuant to 405(g). (Tr. 731). The District Court remanded
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the claim for rehearing by an order issued on July 20, 2016. (Tr. 736-739); (Tr. 733-735). In
the interim, Plaintiff filed an application for SSI benefits on August 27, 2015. (Tr. 759). The
AC consolidated Plaintiff’s new application with her application from 2010. (Tr. 745). ALJ
Matthias Onderak issued an unfavorable decision regarding these claims on September
12, 2017. (Tr. 571-614); (Tr. 1980-2023). The claims proceeded to the District Court once
again, and the parties jointly moved for remand, which was granted by court order on
August 6, 2018. (Tr. 2033); (Tr. 2034-2035). Thereafter, the AC issued a remand order with
specific directives to the ALJ upon rehearing. Following remand, an unfavorable decision
was issued by ALJ Onderak on July 1, 2019. (Tr. 1821-1869). The claim proceeded to the
District Court for the third time pursuant to 20 C.F.R. § 404.984.
On October 28, 2020, Magistrate Judge Mark Beatty issued an order for remand on
the basis that ALJ Onderak’s decision contained “significant errors.” (Tr. 2628).
Specifically, Judge Beatty found that the ALJ had erroneously weighed the opinions of
APRN Karaffa and Dr. Kalb. Id. The AC adopted the Court’s order and following remand,
a hearing was held on February 22, 2021, at which time Plaintiff amended her onset date
to January 1, 2010. (Tr. 2598-2599). A partially favorable decision was issued by ALJ
Scurry on March 31, 2021. (Tr. 2542-2590). ALJ Scurry found that Plaintiff’s disability
began on July 9, 2015. Id. Once again, the claim proceeded to the District Court pursuant
to 20 C.F.R. § 404.984.
On June 22, 2022, upon the Commissioner’s motion, District Judge David Dugan
reversed and remanded the decision of the Commissioner. (Tr. 3074–3075). In the
Commissioner’s Motion to Remand, the Commissioner argued that the decision, which
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resulted in a finding that Plaintiff was not disabled prior to July 9, 2015, did not consider
the opinion of Elizabeth Kalb, PhD., as to Plaintiff’s work-related functional limitations.
(Tr. 3074). Therefore, the Commissioner argued that the decision left open a question of
fact only the ALJ could resolve. Id. Plaintiff agreed that the case should be remanded for
rehearing and that a direct award of benefits would not be appropriate. Id. The AC
adopted the Court’s order and issued a Remand Order on August 10, 2022, pertaining to
Plaintiff’s disabled status for the period prior to July 9, 2015. (Tr. 3085-3091). A hearing
was held on January 10, 2023, following which the ALJ issued an unfavorable decision
on January 25, 2023. (Tr. 3031-3057). Pursuant to 20 C.F.R § 404.984(d), the ALJ’s decision
became final on March 27, 2023. Plaintiff then filed the present action on May 5, 2023.
(Doc. 1).
ISSUES RAISED BY PLAINTIFF
I.

The ALJ erred in his analysis of the medical opinions and medical evidence
contained within the record.
APPLICABLE LEGAL STANDARDS
To qualify for DIB and SSI, a claimant must be disabled within the meaning of the

applicable statutes. Under the Social Security Act, a person is disabled if he or she 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).
To determine whether a plaintiff is disabled, the ALJ considers the following five
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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 or her former occupation? and (5) Is the plaintiff unable to perform any other work?
See 20 C.F.R. § 404.1520.
An affirmative answer at either step three or step five leads to a finding that the
plaintiff is disabled. A negative answer at any step, other than at step three, precludes a
finding of disability. The plaintiff bears the burden of proof at steps one through four.
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. See Zurawski v. Halter, 245 F.3d 881, 886 (7th
Cir. 2001).
The scope of judicial review is limited. “The 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). Thus, this Court must determine not whether plaintiff was, in fact,
disabled at the relevant time, but whether the ALJ’s findings were supported by
substantial evidence and whether any errors of law were made. See Lopez ex rel. Lopez v.
Barnhart, 336 F.3d 535, 539 (7th Cir. 2003). The Supreme Court defines substantial
evidence as “such relevant evidence as a reasonable mind might accept as adequate to
support a conclusion.” Biestek v. Berryhill, 139 S. Ct. 1148, 1154 (2019) (internal citations
omitted).
In reviewing for “substantial evidence,” the entire administrative record is taken
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into consideration, but this Court does not reweigh evidence, resolve conflicts, decide
questions of credibility, or substitute its own judgment for that of the ALJ. See Burmester
v. Berryhill, 920 F.3d 507, 510 (7th Cir. 2019). While judicial review is deferential, it is not
abject; this Court does not act as a rubber stamp for the Commissioner. See Parker v.
Astrue, 597 F.3d 920, 921 (7th Cir. 2010).
THE DECISION OF THE ALJ
The ALJ followed the five-step analysis detailed above. He determined that
Plaintiff had not worked at a level of substantial gainful activity since January 1, 2010, the
amended alleged onset date, to July 9, 2015. (Tr. 3039). The ALJ found that Plaintiff had
the following severe impairments: schizoaffective disorder; dysthymic disorder; panic
disorder with agoraphobia; and alcohol dependence. Id. The ALJ also determined that
beginning on January 1, 2012, Plaintiff no longer had the severe impairment of alcohol
dependence.1 (Tr. 3040). Additionally, the ALJ found that beginning on or about August
27, 2015, the Plaintiff had the added severe impairments of hepatitis C; chronic
obstructive pulmonary disease (“COPD”); and hypertension. Id. Lastly, beginning on or
about February 11, 2019, the ALJ found that Plaintiff had the severe impairment of
diabetes mellitus. Id.
In determining Plaintiff’s residual functional capacity (“RFC”), the ALJ found that

Following January 1, 2012, when the Plaintiff stopped substance use, the remaining severe
impairments were found to have caused more than minimal impact on the claimant’s ability to
perform basic work activities. Therefore, the Plaintiff continued to have a severe impairment or
combination of severe impairments. Plaintiff’s severe physical impairments, which began on or
around May 7, 2013, were also found to have caused more than a minimum impact on Plaintiff’s
ability to perform basic work activities. (Tr. 3040).

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Plaintiff could:
. . . perform medium work as defined in 20 CFR 404.1567(c) and 416.967(c)
except she needed to avoid concentrated exposure to extreme cold, heat,
and humidity. She needed to avoid even moderate exposure to extreme
amounts of fumes, odors, dust, gases, and areas of poor ventilation. In other
words, she needed to work in environments with levels of respiratory
irritants similar to those found in business offices, retail establishments,
public areas such as a post office or library, or a clean industrial setting. She
needed to avoid exposure to unprotected heights and avoid operating
dangerous or hazardous moving machinery and equipment. In addition,
she could learn and engage in rote tasks that required the exercise of little
independent judgment or decision-making and could be learned from a
short demonstration within 30 days. She needed to work in a stable setting
with minimal change in terms of the tools used, the processes employed, or
the setting itself, and change, where necessary, is introduced gradually. The
individual needed to refrain from work in an environment that is
stringently production or quota-based and she could not perform fastpaced, assembly line type of work. She could meet production
requirements that allowed her to sustain a flexible and goal-oriented pace.
She could not engage in work-related interaction with the general public.
She could not work jobs that require close coordination with coworkers. She
could have only occasional task-focused interaction with her coworkers.
The individual could tolerate task-focused interaction with her supervisor.
She could be given direction and could be re-directed when necessary.
However, she was not able to work a job that requires constant oversight
and interaction with her supervisor.
(Tr. 3040-3041). As such, the ALJ denied Plaintiff at step five and determined that she
would have been able to perform the requirements of representative occupations, like
warehouse worker, Dictionary of Occupational Titles (“DOT”) number 922.687-058, of
which there are about 170,000 positions in the national labor market; a cleaner in a
healthcare setting, DOT number 323.687-010, of which there are about 440,000 positions
in the national labor market; and a laundry worker, DOT number 361.685-018, of which
there are about 39,000 positions in the national labor market. (Tr. 1881, 3042).
In the decision, ALJ Scurry incorporated his partially favorable decision on
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Plaintiff’s claim from March 31, 2021. (Tr. 3039-3041). The jurisdiction and procedural
section of ALJ Scurry’s opinion is the only place where he conducts a fresh analysis of
Plaintiff’s medical records – focusing on those from Dr. Elizabeth Kalb, PhD. and Melissa
Karaffa, APRN. (Tr. 3035-3037). ALJ Scurry believed that both Kalb’s assessment of
Plaintiff’s medical records as well as Karaffa’s mental functional capacity report
supported an onset date of July 9, 2015, with limitations of 2-3 absences per month. (Tr.
3036).
THE EVIDENTIARY RECORD
The Court has reviewed and considered the entire evidentiary record in
formulating this Memorandum and Order. The following summary of the record is
directed to the points raised by Plaintiff.
A.

Evidentiary Hearing
During the Oral Hearing held on January 10, 2023, Plaintiff rested on the testimony

from her previous hearings before an ALJ. (Tr. 3066). Plaintiff’s counsel noted that this
was Plaintiff’s fifth hearing before an ALJ, and expressed his belief that nothing further
would be gained from additional testimony from Plaintiff. (Tr. 3065). The ALJ inquired if
Plaintiff’s Counsel had any further questions for Plaintiff, counsel indicated that he did
not, and the ALJ concluded the hearing. (Tr. 3066–3067).
B.

Mental Functional Capacity Report Submitted by Melissa Karaffa, APRN
Melissa Karaffa, APRN, submitted a Mental Functional Capacity Report on behalf

of Plaintiff on July 14, 2016. (Tr. 1643-1646). Karaffa reported that she last examined
Plaintiff on April 29, 2016. (Tr. 1644). She listed Plaintiff’s impairment/diagnosis as
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follows: “schizoaffective disorder, depressed type. episodic alcohol use. stimulant use
disorder in remission. She has heard voices since 2000. The voices are disturbing and ‘riot’
in her head. She is paranoid and cannot go into public places without significant anxiety.
Depressed include[s] low mood, crying, sleep disturbance, passive suicidal thoughts,
variable appetite, and isolative behavior.” (Tr. 1644).
Considering these mental impairments, Karaffa found that Plaintiff had no
functional limitations completing activities of daily living. (Tr. 1644). However, Karaffa
found that Plaintiff had marked limitations in social functioning. Id. With respect to
Plaintiff’s ability to maintain concentration, persistence, or pace, Karaffa believed that
Plaintiff only experienced moderate limitations2 five or more days per month. (Tr. 16441645). When recounting Plaintiff’s episodes of decompensation in the last twelve months,
Karaffa recounted one to two episodes. (Tr. 1645). She believed that these indicated that
Plaintiff needed to increase treatment and be in less stressful situations. Id. Karaffa
identified from her treatment records that Plaintiff’s dates of decompensation during the
past year, had occurred on July 9, 2015, August 12, 2015, and November 9, 2015. (Tr. 1646).
Karaffa anticipated that Plaintiff’s impairments or treatment would require her to
be absent from work two to three times per month. (Tr. 1646). She also expressed her
belief that Plaintiff’s use of alcohol or substance abuse was due, at least in part, to her

“A moderate limitation with respect to concentration, persistence, or pace is demonstrated
when an individual is, in aggregate, off task 10%-20% of the workday during periods they are
supposed to be on task.” (Tr. 1645). In contrast, “a marked limitation with respect to
concentration, persistence, or pace is demonstrated when an individual cannot complete tasks
without extra supervision or assistance or in accordance with quality and accuracy standards or
at a consistent pace without an unreasonable number and length of rest periods (20% of the
workday or greater) or without undue interruptions or distractions.” (Tr. 1645).

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mental impairments. Id. However, Karaffa noted that she would not change her
assessments regarding Plaintiff’s activities of daily living, social functioning, and
concentration, persistence, or pace, if Plaintiff ceased using alcohol or other substances.
Id. Karaffa concluded her report by noting that she had commenced treating Plaintiff
sometime in 2000 and that her condition was “chronic.” Id.
C.

Medical Interrogatory-Mental Impairments by Elizabeth Kalb, PhD.
On October 2, 2018, ALJ Onderak requested Dr. Kalb’s professional opinion in

connection with Plaintiff’s claim for Social Security disability. (Tr. 2221). Dr. Kalb
completed the enclosed assessment on October 10, 2018. (Tr. 2233-2244). She was asked
to review the evidence considering Plaintiff’s proposed onset date of January 1, 2007. (Tr.
2233).
Ultimately, Kalb reasoned that Plaintiff’s mental disorders did not meet the criteria
for any of the listing of impairments provided for by the social security administration.
(Tr. 2235). Dr. Kalb found that the evidence within the record established that Plaintiff
suffers from “Schizophrenia spectrum and other psychotic disorders/Depressive, bipolar
and related disorders: Schizoaffective Disorder, Depressed type.”3 (Tr. 2242). In reaching
this determination, Kalb reviewed Plaintiff’s medical history – which began in June 2010
when she first presented to an ER reporting auditory hallucinations. Id. As such, Kalb felt

However, Dr. Kalb did not find that the medical record evidence supported Plaintiff’s
diagnosis of generalized anxiety disorder and panic disorder with agoraphobia. (Tr. 2242). She
also believed that Plaintiff’s depressive symptoms did not meet the diagnostic criteria for major
depressive disorder and dysthymic disorder. (Tr. 2243). Rather, Kalb opined that Plaintiff’s
depressive symptoms and social anxiety fell under and were a product of her schizoaffective
disorder. Id.

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that Plaintiff’s medical records only supported an onset date of June 2010 and not January
2007. Id. In her analysis of Plaintiff’s medical records, Kalb specifically highlighted
Plaintiff’s treatment from Dr. Spyropoulos (July 2010), Dr. Klug (May 2011 and
November 2013), St. Mary’s Good Samaritan Behavioral Health Treatment Program (2011
and 2012), and Nurse Karaffa, APRN (2013 through 2017). Id. As Plaintiff’s schizoaffective
disorder was co-morbid with substance abuse, Kalb expressed her opinion that Plaintiff’s
January 2016 consultative exam would be an adequate assessment of her current
functioning. Id.
Regarding Plaintiff’s functioning, Dr. Kalb found Plaintiff to have moderate
impairments in the areas of understanding, remembering, or applying information;
interacting with others; concentrating, persisting, or maintaining pace; and adapting or
managing oneself. (Tr. 2234). Dr. Kalb went on to assess Plaintiff’s ability to “do work
related activities on a sustained basis.” (Tr. 2239-2241). She determined that Plaintiff’s
ability to understand remember and carry out instructions was impacted by her mental
illness. (Tr. 2239). Specifically, she found that Plaintiff’s condition caused a mild
impairment to her ability to understand and remember simple instructions, carry out
simple instructions, and make judgments on simple, work-related decisions. Id. She also
found that Plaintiff had a moderate impairment to her ability to understand and
remember complex instructions, carry out complex instructions, and make judgments on
complex, work-related decisions. Id. As such, she recommended that Plaintiff be “limited
to 1 to 3 step, rote/over learned tasks.” Id. Dr. Kalb also determined that Plaintiff’s ability
to interact appropriately with supervisors, co-workers, and the public, as well as respond
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to changes in the routine work setting, were impacted by her mental illness. (Tr. 2240).
She found that Plaintiff’s ability to interact appropriately with the public, interact
appropriately with a supervisor, interact appropriately with co-workers, and respond
appropriately to usual work situations and to changes in a routine work setting were
moderately impaired. Id.
Lastly, Dr. Kalb recommended that Plaintiff “avoid tasks with speed, pacing or
quotas” and noted that she “agreed with 40F (Karaffa’s Mental Functioning Capacity
Report) that given presentation in treatment with ups and downs while completing that,
could be absent 2-3x a month.” (Tr. 2240). She also noted, that based on her review of
Plaintiff’s records that she had determined “within a reasonable degree of medical or
psychological probability” that Plaintiff’s limitations were first present around June 2010.
Id.
DISCUSSION
Plaintiff asserts that the ALJ’s determination of her disability onset date is flawed
because the ALJ misconstrued Dr. Kalb’s medical opinion through his misunderstanding
of Melissa Karaffa’s 2016 mental functioning report. (Doc. 17, p. 27-28). While Plaintiff
does not dispute the ALJ’s reliance on Kalb’s report, which favorably considered
Karaffa’s assessment and treatment records, Plaintiff suggests that the ALJ determined
Plaintiff’s disability onset date with the understanding that Karaffa’s mental functioning
report reflected her assessment of Plaintiff’s entire mental health history. However,
Plaintiff points out that the mental health functioning report questionnaire Karaffa
responded to only asked her to reflect on Plaintiff’s episodes of decompensation for the
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past twelve months. Thus, Karaffa only included decompensation dates from 2015 – the
first being July 9, 2015 – which is the disability onset date set by ALJ Scurry. Defendant
disagrees with Plaintiff’s characterization of the ALJ’s opinion and believes that Plaintiff
only wants the ALJ to reweigh Karaffa’s report “more favorably.” (Doc. 22, p. 11). Upon
review of the record, the Court agrees with Plaintiff that the ALJ misinterpreted Karafa’s
report, and as this was the basis for the July 9, 2015, disability onset date, the Court must
remand the case once again for reconsideration.
In his January 25, 2023, opinion, ALJ Scurry reflected on the medical opinion of
Dr. Kalb, by stating the following:
Dr. Kalb indicated the claimant’s documented mental health impairments
cause moderate limitations in the ability to understand, remember, and
carry out instructions; moderate limitations in interacting appropriately
with others; and deficits in the ability to concentrate, persist, and maintain
pace as well as in the ability to adapt or manage oneself resulting in the
claimant being absent 2-3 times a month, in agreement with Exhibit 40F. It should
be noted that in Exhibit 40F, Melissa Karaffa, APRN, stated that the episodes of
decompensation were supported beginning as of July 9, 2015, and that Ms. Karaffa
had been treating the claimant prior to July 2013. Exhibit B22A states that Ms.
Karaffa saw the claimant for the first time in November 2012, as supported
by Exhibit B23F.
(Tr. 3036) (emphasis added). ALJ Scurry went on to determine that “based on the report
of [Plaintiff’s] treating nurse Ms. Karaffa, that was relied on and referenced by medical
expert Dr. Kalb” that the “record does not support a finding of disabled until July 9,
2015.” Id. Given this conclusion drawn by ALJ Scurry, it appears that Scurry based
Plaintiff’s onset of disability date on Karaffa’s mental residual functioning capacity
report. However, the plain language of the questionnaire limited Karaffa’s reporting to
only one year of decompensation episodes; Karaffa was not required to report anything
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prior to that point. Furthermore, ALJ Scurry notes that Kalb relied on and referenced
Karaffa’s report, but Kalb believed the disability onset date was much earlier in June 2010.
Thus, the Court is concerned that ALJ Scurry improperly determined Plaintiff’s onset of
disability date.
Question five of the mental health functioning report submitted by Melissa Karaffa
asked Karaffa to report Plaintiff’s “episodes of decompensation in the last twelve months.”
(Tr. 1645). (emphasis added). Karaffa reported that Plaintiff had experienced one to two
decompensation episodes during this period. Id. The form then asked Karaffa to “identify
the dates this is supported by your treatment notes” (Tr. 1646). In response, Karaffa listed
July 9, 2015, August 12, 2015, and November 9, 2015, as Plaintiff’s dates of
decompensation. Id. However, Karaffa noted that Plaintiff’s limitations commenced
sometime in the year 2000 and that she had been treating Plaintiff since July 2013. Id. She
also expressed her belief that Plaintiff’s mental health conditions were “chronic.” Id.
As ALJ Scurry correctly indicated, Dr. Kalb heavily referenced Karaffa’s report in
her own expert opinion. Kalb reported that Plaintiff’s medical records revealed that
Plaintiff had been seen for medication management by Ms. Karaffa in 2013 and 2014. (Tr.
2242). Kalb found that Karaffa had diagnosed Plaintiff with “chronic schizoaffective
disorder, depressed.” Id. Kalb’s review of Plaintiff’s medical records further revealed that
Plaintiff continued her mental health treatment with Karaffa from 2014 to 2017, where
she carried the diagnosis of “schizoaffective disorder, depressive, episodic alcohol abuse,
and stimulant/methamphetamine abuse, in remission.” Id. Kalb concluded that “[t]aking
the MER (medical evidence record) as a whole, [Plaintiff’s] reported symptoms best fit
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the diagnosis of schizoaffective disorder.” Id. While Kalb also stated that she agreed with
“40F (Karaffa’s mental function report)” regarding her absenteeism “2-3x a month”, Kalb
reported that she believed Plaintiff’s limitations began in June 2010. (Tr. 2240). Nowhere
did Kalb express an opinion that Plaintiff’s onset date began in 2015.
Based on the Court’s review of these two pieces of evidence, the Court believes
ALJ Scurry’s misinterpreted both Kalb’s medical expert opinion and Karaffa’s mental
health functioning report. Thus, the Court remands for reconsideration on the ground
that ALJ Scurry did not support his determination of Plaintiff’s onset of disability with
substantial evidence. As the Court has found that the ALJ committed error regarding the
evidence of disability within the record, the Court need not address Plaintiff’s remaining
arguments. The Court wishes to stress that this Memorandum and Order should not be
construed as an indication that the Court believes Plaintiff was disabled during the
relevant period or that she should be awarded benefits. On the contrary, the Court has
not formed any opinions in that regard and leaves those issues to be determined by the
Commissioner after further proceedings.
CONCLUSION
The Commissioner’s final decision denying Plaintiff’s application for social
security disability benefits is REVERSED and REMANDED for rehearing and
consideration of the evidence, pursuant to sentence four of 42 U.S.C. § 405(g).
IT IS SO ORDERED.
DATED: September 24, 2024.

Digitally signed by
Judge Sison
Date: 2024.09.24
12:02:53 -05'00'
___________________________________

GILBERT C. SISON
United States Magistrate Judge
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