Long v. Commissioner of Social Security

Filing 24

OPINION AND ORDER: The Plaintiff's request contained in her Opening Brief is GRANTED. The Administrative Law Judge's decision is REVERSED and this matter is REMANDED to the Commissioner of Social Security for further proceedings consistent with this Opinion and Order. Signed by Magistrate Judge John E Martin on 3/28/17. (cer)

UNITED STATES DISTRICT COURT
NORTHERN DISTRICT OF INDIANA
HAMMOND DIVISION
NICOLE E. LONG,
Plaintiff,
v.
COMMISSIONER OF SOCIAL
SECURITY, sued as Carolyn W. Colvin,
Defendant.

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CAUSE NO. 2:15-CV-408-JEM

OPINION AND ORDER
This matter is before the Court on a Complaint [DE 1], filed by Plaintiff on November 2,
2015, and on Plaintiff’s Opening Brief in a Social Security Matter [DE 16], filed by Plaintiff on
March 23, 2016. The Commissioner filed a response to Plaintiff’s brief on June 29, 2016, and
Plaintiff filed a reply on July 13, 2016.
I.

Procedural Background
In May 2012, Plaintiff applied for disability insurance benefits with the United States Social

Security Administration (“SSA”), alleging that she had become disabled as of April 2, 2010.
Plaintiff later amended her onset date to January 14, 2012. Plaintiff’s claim was denied initially and
on reconsideration. On March 18, 2014, Administrative Law Judge (“ALJ”) Christa Zamora held
a hearing at which Plaintiff, represented by counsel, and a vocational expert (“VE”) testified. On
April 8, 2014, the ALJ issued a decision denying Plaintiff benefits on the ground that Plaintiff was
not disabled.
In the opinion, the ALJ made the following findings under the required five-step analysis:
1.

The claimant meets the insured status requirements of the Social Security Act
through December 31, 2017.

2.

The claimant had not engaged in substantial gainful activity since January 14, 2012,
the alleged onset date.

3.

The claimant had the following severe impairments: lupus; carpal tunnel
syndrome; arthritis; degenerative disc disease; hyperthyroidism; rheumatoid
arthritis; deppresive disorder; anxiety disorder; and somatoform disorder.

4.

The claimant did not have an impairment or combination of impairments that
met or medically equaled any of the listed impairments in 20 CFR 404,
Subpart P, Appendix 1.

5.

The claimant had the residual functional capacity (“RFC”) to perform light
work, except that she is limited to the performance of simple routine tasks
and simple work related decisions.

6.

The claimant was unable to perform any past relevant work.

7.

As of the alleged disability onset date, the claimant was 40 years old, which
is defined as a younger individual.

8.

The clamant has at least a high school education and is able to communicate
in English.

9.

Transferability of job skills was immaterial to the disability determination
because Plaintiff was “not disabled” under the Medical-Vocational rules
irrespective of whether she had transferable job skills.

10.

Considering the claimant’s age, education, work experience, and residual
functional capacity, there are jobs that exist in significant numbers in the
national economy that the claimant can perform.

11.

The claimant was not under a disability, as defined in the Social Security
Act, from January 14, 2012, through the date of the ALJ’s decision.

On July 29, 2015, the Appeals Council denied Plaintiff’s request for review, leaving the
ALJ’s decision as the final decision of the Commissioner. On November 2, 2015, Plaintiff filed the
underlying Complaint seeking reversal of the adverse SSA determination.
The parties consented to have this case assigned to a United States Magistrate Judge to
conduct all further proceedings and to order the entry of a final judgment in this case. Therefore, this
Court has jurisdiction to decide this case pursuant to 28 U.S.C. § 636(c) and 42 U.S.C. § 405(g).

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II.

Standard of Review
The Social Security Act authorizes judicial review of the final decision of the SSA and

indicates that the Commissioner’s factual findings must be accepted as conclusive if supported by
substantial evidence. 42 U.S.C. § 405(g). Thus, a court reviewing the findings of an ALJ will
reverse only if the findings are not supported by substantial evidence or if the ALJ has applied an
erroneous legal standard. See Briscoe v. Barnhart, 425 F.3d 345, 351 (7th Cir. 2005). Substantial
evidence consists of “such relevant evidence as a reasonable mind might accept as adequate to
support a conclusion.” Schmidt v. Barnhart, 395 F.3d 737, 744 (7th Cir. 2005) (quoting Gudgel v.
Barnhart, 345 F.3d 467, 470 (7th Cir. 2003)).
A court reviews the entire administrative record but does not reconsider facts, re-weigh the
evidence, resolve conflicts in evidence, decide questions of credibility, or substitute its judgment
for that of the ALJ. See Boiles v. Barnhart, 395 F.3d 421, 425 (7th Cir. 2005); Clifford v. Apfel, 227
F.3d 863, 869 (7th Cir. 2000); Butera v. Apfel, 173 F.3d 1049, 1055 (7th Cir. 1999). Thus, the
question upon judicial review of an ALJ’s finding that a claimant is not disabled within the meaning
of the Social Security Act is not whether the claimant is, in fact, disabled, but whether the ALJ
“uses the correct legal standards and the decision is supported by substantial evidence.” Roddy v.
Astrue, 705 F.3d 631, 636 (7th Cir. 2013) (citing O’Connor-Spinner v. Astrue, 627 F.3d 614, 618
(7th Cir. 2010); Prochaska v. Barnhart, 454 F.3d 731, 734-35 (7th Cir. 2006); Barnett v. Barnhart,
381 F.3d 664, 668 (7th Cir. 2004)). “A reversal and remand may be required, however, if the ALJ
committed an error of law or if the ALJ based the decision on serious factual mistakes or omissions.”
Beardsley v. Colvin, 758 F.3d 834, 837 (7th Cir. 2014) (citations omitted).
At a minimum, an ALJ must articulate her analysis of the evidence in order to allow the
reviewing court to trace the path of her reasoning and to be assured that the ALJ considered the
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important evidence. See Scott v. Barnhart, 297 F.3d 589, 595 (7th Cir. 2002); Diaz v. Chater, 55
F.3d 300, 307 (7th Cir. 1995); Green v. Shalala, 51 F.3d 96, 101 (7th Cir. 1995). An ALJ must
“‘build an accurate and logical bridge from the evidence to [the] conclusion’ so that, as a reviewing
court, we may assess the validity of the agency’s final decision and afford [a claimant] meaningful
review.” Giles v. Astrue, 483 F.3d 483, 487 (7th Cir. 2007) (quoting Scott, 297 F.3d at 595)); see
also O’Connor-Spinner, 627 F.3d at 618 (“An ALJ need not specifically address every piece of
evidence, but must provide a ‘logical bridge’ between the evidence and his conclusions.”); Zurawski
v. Halter, 245 F.3d 881, 889 (7th Cir. 2001) (“[T]he ALJ’s analysis must provide some glimpse into
the reasoning behind [the] decision to deny benefits.”).
III.

Analysis
Plaintiff argues that the ALJ failed to properly consider treating physician testimony and

improperly assessed Plaintiff’s RFC. The Commissioner contends that the ALJ’s opinion was
supported by substantial evidence.
A.

Medical Opinions

Plaintiff contends that the ALJ failed to give proper weight to the medical findings made by
her treating physicians, Dr. Fadi Alzeidan and Dr. Vinay Reddy. Both doctors opined that Plaintiff
has or would likely have significant work-related limitations. The Commissioner argues that the
ALJ’s decision to discredit the treating physicians’ testimony in favor of state agency consultants’
opinions was proper and supported by the evidence.
“A treating physician’s opinion regarding the nature and severity of a medical condition is
entitled to controlling weight if it is well supported by medical findings and not inconsistent with
other substantial evidence in the record.” Gudgel, 345 F.3d at 470 (citing 20 C.F.R. §

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404.1527(d)(2)); see also Schmidt v. Astrue, 496 F.3d 833, 842 (7th Cir. 2007). Being “not
inconsistent” does not require that the opinion be supported directly by all of the other evidence “as
long as there is no other substantial evidence in the case record that contradicts or conflicts with the
opinion.” S.S.R. 96–2p, 1996 WL 374188, at *3 (July 2, 1996). To be “substantial,” conflicting
evidence “need only be such relevant evidence as a reasonable mind might accept as adequate to
support a conclusion.” Id.; see also Schmidt, 395 F.3d at 744.
In particular, an ALJ may not simply ignore an opinion that addresses a plaintiff’s ability to
work, but must “evaluate all the evidence in the case record to determine the extent to which the
opinion is supported by the record.” S.S.R. 96–5p, 1996 WL 374183, at *3, *5 (July 2, 1996); see
also Hamilton v. Colvin, 525 F. App’x 433, 439 (7th Cir. 2013) (“While the ALJ is right that the
ultimate question of disability is reserved to the Commissioner, a treating physician’s opinion that
a claimant is disabled ‘must not be disregarded.’”) (quoting S.S.R. 96–5p) (citing 20 C.F.R. §
416.927(e)(2)); Roddy, 705 F.3d at 636 (“Even though the ALJ was not required to give [the treating
physician]’s opinion [that the claimant could not handle a full-time job] controlling weight, he was
required to provide a sound explanation for his decision to reject it.”).
In this case, the ALJ opined that Dr. Alzeidan was unjustified in concluding that Plaintiff
would “never be able to work a productive job” because he would have needed to follow up with
Plaintiff over an extensive period of time to make that determination. AR 32. The ALJ also noted
that Dr. Alzeidan’s conclusions that Plaintiff could lift less than five pounds for approximately 5%
of the workday and that Plaintiff could sit for four hours and stand and walk for two hours in an
eight-hour work day were inconsistent with medical and psychiatric consultative medical
examinations. AR 32. The ALJ noted “that [Plaintiff’s] detailed medical and psychiatric consultative

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examinations were conspicuously without indicia as to significant symptomology as to focal motor,
neurological, or psychiatric deficits that would support [Dr. Alzeidan’s findings of] significant
limitations.” AR 32. Accordingly, the ALJ afforded “little to no weight to Dr. Alzeidan’s opinions.”
AR 32.
Similarly, the ALJ discounted Dr. Reddy’s opinion because the consultative examiner’s
evaluations revealed different findings than those contained in Dr. Reddy’s medical statement. AR
33. Specifically, the ALJ noted that the consultative examiner’s observation of Plaintiff’s hand
functioning was normal contradicted Dr. Reddy’s opinion that Plaintiff could not use either hand
for fine or gross manipulation. AR 33. The ALJ gave “little to no weight [to] the opinion evidence
submitted by Dr. Reddy.” AR 33.
The ALJ improperly discounted Dr. Alzeidan’s and Dr. Reddy’s opinions. The ALJ
discounted both opinions in their entirety based on limited inconsistencies with the consultative
examiners’ reports and Plaintiff’s testimony about her ability to maintain her personal hygiene.
However, the ALJ did not explain how the doctors’ other findings, which also suggested significant
work-related limitations, were controverted by either the consultative examiners’ opinions or some
other evidence in the record. For example, Dr. Alzeidan and Dr. Reddy opined that Plaintiff would
need to take unscheduled breaks, that pain and stress would interfere with her attention and
concentration, and that she would likely miss more than 4-5 days of work per month. AR 816-18,
886-89. The ALJ did not mention these limitations or explain why she rejected those findings. See
Roddy, 705 F.3d at 636 (“Even though the ALJ was not required to give [the treating physician]’s
opinion controlling weight . . . he was required to provide a sound explanation for his decision to
reject it.”).

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Furthermore, even if an ALJ declines to give a treating source’s opinion controlling weight,
she must still determine what weight to give it according to the following factors: the length, nature,
and extent of the physician’s treatment relationship with the claimant; whether the physician’s
opinions were sufficiently supported; how consistent the opinion is with the record as a whole;
whether the physician specializes in the medical conditions at issue; and other factors, such as the
amount of understanding of the disability programs and their evidentiary requirements or the extent
to which an acceptable medical source is familiar with other information in the claimant’s case. 20
C.F.R. §§ 404.1527(c)(2)(i)-(ii), (c)(3)-(6); see also 20 C.F.R. § 404.1527(a)(2)(c)(2)(ii)(5) (an ALJ
is required to grant more weight to a treating specialists when the medical issue is related to their
area of expertise); 20 C.F.R. § 404.1527(c)(2)(ii)(5) (an ALJ is required to consider the length,
nature, and extent of a treating providers relationship with the plaintiff and the frequency of his
examinations).
In this case, in weighing Dr. Alzeidan and Dr. Reddy’s opinion evidence, the ALJ failed to
address many of these required factors, such as the doctors’ respective specialities; the length,
nature, and extent of their relationships with Plaintiff; or the frequency of the physicians
examinations. See 20 C.F.R. §§ 404.1527(a)(2)(c)(2)(ii)(5) and 404.1527(c)(2)(ii)(5). The ALJ was
required to provide this explanation. Punzio v. Astrue, 630 F.3d 704, 710 (7th Cir. 2011). While the
ALJ states that she “considered opinion evidence in accordance with the requirements of 20 CFR
404.1527 and 416.927 and SSRs 96-2p, 96-5p, 96-6p and 06-3p,” this statement is not enough. AR
27. “[W]henever an ALJ . . . reject[s] a treating source’s opinion, a sound explanation must be given
for that decision.” Punzio, 630 F.3d at 710. The ALJ failed to explain why she considered the
consultants’ opinions more credible than the treating physicians’ despite their history with Plaintiff

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and their areas of expertise.
On remand, the ALJ is directed to reconsider the weight afforded to the opinion of Plaintiff’s
treating physicians, Dr. Reddy and Dr. Alzeidan, specifically the weight given to their conclusions
concerning her physical limitations.
B.

RFC Evidence

Plaintiff also argues that the ALJ’s RFC was not supported by the evidence and was, at
times, contrary to the weight of the evidence. The Commissioner argues that the ALJ’s RFC analysis
was appropriately supported and appropriately addressed the record.
The RFC is an assessment of what work-related activities the claimant can perform despite
her limitations. Young v. Barnhart, 362 F.3d 995, 1000 (7th Cir. 2004); see also 20 C.F.R. §§
404.1545(a)(1); 416.1545(a)(1). In evaluating a claimant’s RFC, an ALJ is expected to take into
consideration all of the relevant evidence, including both medical and non-medical evidence. See
20 C.F.R. §§ 404.1545(a)(3); 416.945(a)(3). Although an ALJ is not required to discuss every piece
of evidence, she must consider all of the evidence that is relevant to the disability determination and
provide enough analysis in her decision to permit meaningful judicial review. Clifford, 227 F.3d
at 870; Young, 362 F.3d at 1002. In other words, the ALJ must build an “accurate and logical bridge
from the evidence to his conclusion.” Scott, 297 F.3d at 595 (quoting Steele v. Barnhart, 290 F.3d
936, 941 (7th Cir. 2002)).
Plaintiff contends that the ALJ “consistently addresses only such evidence as supports her
conclusion that Plaintiff is not disabled.” Pl. Br. at 14 [DE 16]. “An ALJ cannot rely only on the
evidence that supports her opinion.” Yurt v. Colvin, 758 F.3d 850, 859 (7th Cir. 2014) (quoting
Bates v. Colvin, 736 F.3d 1093, 1099 (7th Cir. 2013)); see also Scrogham v. Colvin, 765 F.3d 685,

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698 (7th Cir. 2014) (“[T]he ALJ identified pieces of evidence in the record that supported her
conclusion that [the plaintiff] was not disabled, but she ignored related evidence that undermined
her conclusion. This ‘sound-bite’ approach to record evaluation is an impermissible methodology
for evaluating the evidence.”); Denton v. Astrue, 596 F.3d 419, 425 (7th Cir. 2010) (“An ALJ has
the obligation to consider all relevant medical evidence and cannot simply cherry-pick facts that
support a finding of non-disability while ignoring evidence that points to a disability finding.”).
Although medical evidence “may be discounted if it is internally inconsistent or inconsistent with
other evidence,” Knight, 55 F.3d at 314 (citing 20 C.F.R. § 404.1527(c)) (other citations omitted),
the ALJ “must provide a ‘logical bridge’ between the evidence and h[er] conclusions.” O’ConnorSpinner, 627 F.3d at 618.
In this case, the ALJ failed to adequately explain how she arrived at her RFC conclusion. For
example, the ALJ concluded that Plaintiff’s carpal tunnel qualified as a severe impairment but did
not address how Plaintiff’s carpal tunnel affected Plaintiff’s RFC. AR 23. The Commissioner now
argues that the ALJ “found that Plaintiff could only lift or carry up to 20 pounds occasionally and
up to 10 pounds frequently,” which demonstrates a “clear nexus to her impairment of carpal tunnel
syndrome.” Def. Br. at 19-20 [DE 22]. However, the ALJ did not provide that connection in her
opinion, which does not contain an assessment of what effect, if any, Plaintiff’s carpal tunnel had
on her RFC. SEC v. Chenery Corp., 318 U.S. 80, 87 (1943) (“The grounds upon which an
administrative order must be judged are those upon which the record discloses that its action was
based.”). Similarly, the ALJ noted that Plaintiff’s lupus is a severe impairment, AR 23, but then cited
evidence questioning whether lupus was an appropriate diagnosis at all. AR 29. Consequently, the
Court cannot find the “logical bridge” between the ALJ’s cited evidence and her conclusions

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concerning Plaintiff’s RFC. See O’Connor-Spinner, 627 F.3d at 618.
Furthermore, the ALJ concluded that Plaintiff suffered from the severe impairment of
somatoform disorder, AR 23, which is “a mental condition that causes a person to experience
physical symptoms of a purely psychological origin.” Simila v Astrue, 573 F.3d 503, 510 (7th Cir.
2009). However, the ALJ later wrote that “most, if not all, of the claimant’s alleged symptomology
is psycho-somatic in origin and thereby fails to result in specific physical limitations.” AR 30.
Consequently, Plaintiff contends that the ALJ improperly incorporated her somatic disorder into the
RFC.
An ALJ commits legal error when she fails “to appreciate the psychological nature of the
claimant’s somatoform disorder and relie[s] primarily on the lack of objective medical data to
support [her] conclusions.” Simila, 573 F.3d at 517 (citing Carridine v. Barnhart, 573 F.3d 751,
754-55 (7th Cir. 2004)). As the Seventh Circuit has written:
If pain is disabling, the fact that its source is purely psychological
does not disentitle the applicant to benefits. Pain is always subjective
in the sense of being experienced by the brain. The question of
whether the experience is more acute because of a psychiatric
condition is different from the question of whether the applicant is
pretending to experience pain, or more pain than she actually feels.
The pain is genuine in the first, the psychiatric case, though
fabricated in the second. The cases involving somatization recognize
this.
Carradine, 360 F.3d at 754.
In this case, the ALJ wrote:
[M]ost, if not all, of the claimant’s alleged symptomology is psychosomatic in origin and thereby fails to result in specific physical
limitation . . . . The record does mention the claimant’s “quite
significant low pain threshold” . . . . Nevertheless, the claimant’s
subjective complaints alone are not enough to substantiate
limitations; moreover, said low pain threshold likely relates to her
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somatic disorder. Consequently, the undersigned finds that the lack
of documented focal deficit in the clinical record fails to support
greater limitations than those assessed herein.
AR 29-30. This reasoning fails to acknowledge that Plaintiff’s pain – which could be purely
psychological – might not manifest itself physically or have a physical cause. She simply might feel
pain, possibly limiting her ability to work. See Caradine, 360 F.3d at 754-55.
Furthermore, while an ALJ may “consider the lack of objective evidence in rejecting a
claimant’s subjective complaints,” the ALJ cannot deny disability “solely because the available
objective medical evidence does not substantiate” the claimant’s pain statements. Simila, 573 F.3d
at 519. The ALJ’s language quoted above demonstrates that she discredited Plaintiff’s pain
statements for lack of objective evidence. Because the ALJ appears to have misunderstood the
psychological nature of Plaintiff’s pain and improperly discounted plaintiff’s pain statements for
lack of objective evidence, remand is appropriate. See Beardsley v. Colvin, 758 F.3d 834, 837 (7th
Cir. 2014) (“A reversal and remand may be required . . . if the ALJ committed an error of law or if
the ALJ based the decision on serious factual mistakes or omissions.”).
Accordingly, the Court is remanding for additional proceedings consistent with this Opinion.
The ALJ is instructed to consider how Plaintiff’s severe impairments, including her somatic
disorder, affected her RFC to the extent supported by the record.
IV.

Conclusion

For the foregoing reasons, the Court hereby GRANTS the request contained in Plaintiff’s
Opening Brief in a Social Security Matter [DE 16], REVERSES the Administrative Law Judge’s
decision, and REMANDS this matter to the Commissioner for further proceedings consistent with
this Opinion.

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So ORDERED this 28th day of March, 2017.
s/ John E. Martin
MAGISTRATE JUDGE JOHN E. MARTIN
UNITED STATES DISTRICT COURT
cc:

All counsel of record

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