Trigg Fields v. Commissioner of Social Security

Filing 25

OPINION AND ORDER: The relief requested by Plaintiff Vicky Trigg Fields in her Opening Brief (DE 16 ) is GRANTED. This matter is REMANDED for further proceedings consistent with this Opinion and Order. Signed by Magistrate Judge John E Martin on 3/21/17. (cer)

UNITED STATES DISTRICT COURT
NORTHERN DISTRICT OF INDIANA
HAMMOND DIVISION
VICKY TRIGG FIELDS,
Plaintiff,

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v.
NANCY A. BERRYHILL,
Acting Commissioner of the
Social Security Administration,
Defendant.

CAUSE NO.: 2:16-CV-24-JEM

OPINION AND ORDER
This matter is before the Court on a Complaint [DE 1], filed by Plaintiff Vicky Trigg Fields
on January 20, 2016, and Plaintiff’s Opening Brief [DE 16], filed by Plaintiff on July 15, 2016.
Plaintiff requests that the decision of the Administrative Law Judge be reversed and remanded for
further proceedings. On October 21, 2016, the Commissioner filed a response, and on November
18, 2016, Plaintiff filed a reply. For the following reasons, the Court grants Plaintiff’s request for
remand.
I.

Background
On June 24, 2013, Plaintiff filed an application for benefits alleging that she became disabled

on March 17, 2010. Plaintiff’s application was denied initially and upon reconsideration. On May
15, 2015, Administrative Law Judge (“ALJ”) Margaret Carey held a hearing at which Plaintiff, with
an attorney, and a vocational expert (“VE”) testified. On June 26, 2015, the ALJ issued a decision
finding that Plaintiff was not disabled.
The ALJ made the following findings under the required five-step analysis:
1.

The claimant has not engaged in substantial gainful activity since the
application date.

2.

The claimant has severe impairments: osteoarthritis of the neck, obesity,

chronic cystitis, degenerative joint disease of the shoulder, hip, knee, and
degenerative disc disease of the spine.
3.

The claimant does not have an impairment or combination of impairments
that meets or medically equals the severity of one the listed impairments in
20 CFR 404, Subpart P, Appendix 1.

4.

The claimant has the residual functional capacity to lift and carry up to 20
pounds occasionally, 10 pounds frequently, stand and/or walk about 6 hours
in an 8-hour workday, and sit about 6 hours in an 8-hour workday with
normal breaks. The claimant must never climb ladders, ropes, or scaffolds
but may occasionally climb ramps and stairs, balance, stoop, kneel, crouch,
or crawl. She is limited to work that is only occasionally exposed to
unprotected heights, moving mechanical parts, and operation of a motor
vehicle, and she can only work occasionally in environments of slippery or
uneven surfaces. As a result of the claimant’s bladder issues, she must be
allowed 5-minute breaks every two hours which can be accommodated by
routine breaks, for the use of the restroom. The claimant must be allowed a
sit/stand option such that after 1 hour of standing the claimant could sit but
not be off task and then sit for an hour and stand back up. She is limited to
only occasional overhead reaching with the left upper extremity. Finally, the
claimant is limited to simple, routine, and repetitive work in low-stress
environments with only occasional decision-making.

5.

The claimant is unable to perform any of her past relevant work.

6.

The claimant was a younger individual age 18-49 on the date the application
was filed.

7.

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

8.

Transferability of job skills is not material to the determiation of disability
because using the Medical-Vocational Rules as a framework supports a
finding that the claimant is “not disabled,” whether or not she has
transferable job skills.

9.

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.

10.

The claimant has not been under a disability, as defined in the Social Security
Act, since the date the application was filed.

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On November 16, 2015, the Appeals Council denied Plaintiff’s request for review, leaving
the ALJ’s decision the final decision of the Commissioner.
The parties filed forms of consent 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).
II.

Standard or Review
The Social Security Act authorizes judicial review of the final decision of the agency 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.

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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)). “[I]f the Commissioner commits an error of law,” the Court may
reverse the decision “without regard to the volume of evidence in support of the factual findings.”
White v. Apfel, 167 F.3d 369, 373 (7th Cir. 1999) (citing Binion v. Chater, 108 F.3d 780, 782 (7th
Cir. 1997)).
At a minimum, an ALJ must articulate his or 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
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 erred in determining the credibility of Plaintiff, did not

according appropriate weight to the opinions of Plaintiff’s treating physician, and failed to
adequately address some of Plaintiff’s impairments. The Commissioner argues that the ALJ’s
findings are supported by substantial evidence.

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A.

Credibility and Mental Health

Plaintiff argues that the ALJ made an improper credibility determination. An ALJ is not
required to give full credit to every statement of pain made by the claimant or to find a disability
each time a claimant states he or she is unable to work, but “must ‘consider the entire case record
and give specific reasons for the weight given to the individual's statements.’” Shideler v. Astrue,
688 F.3d 306, 311 (7th Cir. 2012) (quoting Simila v. Astrue, 573 F.3d 503, 517 (7th Cir. 2009)). The
ALJ referred to “a number of issues that call into question” Plaintiff’s credibility, but the only one
she specifically identifies is “claimant’s limited compliance with treatment.” AR 42. The
Commissioner argues that the ALJ had other reasons to consider Plaintiff less than credible and
points out inconsistencies in her statements. However, these inconsistencies do not form the basis
of the ALJ’s credibility determination and the ALJ did not ask Plaintiff about her perceived noncompliance with treatment. “Although a history of sporadic treatment or the failure to follow a
treatment plan can undermine a claimant’s credibility, an ALJ must first explore the claimant’s
reasons for the lack of medical care before drawing a negative inference.” Shauger v. Astrue, 675
F.3d 690, 696 (7th Cir. 2012); see also Craft v. Astrue, 539 F.3d 668, 679 (7th Cir. 2008) (“[T]he
ALJ must not draw any inferences about a claimant’s condition from this failure [to follow a
treatment plan] unless the ALJ has explored the claimant’s explanations as to the lack of medical
care.”) (quotation omitted).
This is particularly concerning given Plaintiff’s record of mental health difficulties. The ALJ
mentioned that Plaintiff sought treatment for depression, but concluded that her “poor compliance
detracts from the claimant’s allegations” so that “the degree to which these impose limitations on
her functional abilities is minimal.” AR 32. The ALJ failed to address Plaintiff’s diagnoses of

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major depression, panic disorder, and post-traumatic stress disorder. However, “[a] diagnosis of
‘major depression’ means, by definition, that an individual’s ‘symptoms cause clinically significant
distress or impairment in social, occupational, or other important areas of functioning.’” O’ConnorSpinner v. Colvin, 832 F.3d 690, 693 (7th Cir. 2016) (quoting AM. PSYCHIATRIC ASS’N,
DIAGNOSTIC & STATISTICAL MANUAL OF MENTAL DISORDERS 356 (4th ed. text revision
2000)). It appears, however, that the ALJ ignored the diagnoses and disregarded any limitations
caused Plaintiff’s mental health disorders on the basis of Plaintiff’s supposed noncompliance with
treatment. Not only did she fail to ask Plaintiff about her noncompliance, as discussed above, but
she failed to recognize that failure to comply with treatment may be a sign of mental disorder rather
than a reason to discount its severity. As the Seventh Circuit has emphasized, “mental illness . . .
may prevent the sufferer from taking her prescribed medicines or otherwise submitting to treatment.”
Kangail v. Barnhart, 454 F.3d 627, 630 (7th Cir. 2006); see also Martinez v. Astrue, 630 F.3d 693,
697 (7th Cir. 2011) (“[P]eople with serious psychiatric problems are often incapable of taking their
prescribed medications consistently.”); Jelinek v. Astrue, 662 F.3d 805, 814 (7th Cir. 2011) (listing
cases). In short, the ALJ erred in her treatment of Plaintiff’s mental health disorders, and failed to
draw a logical bridge from Plaintiff’s diagnosed disorders to the conclusion that they would not
affect her ability to work.
B.

Treating Physician

The ALJ also used Plaintiff’s perceived noncompliance with treatment as a reason to reject
the opinion of her treating physician, Dr. Sheriff. The Commissioner argues that the ALJ’s reasons
for rejecting his opinion were well-supported.
“A treating physician’s opinion regarding the nature and severity of a medical condition is

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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. §

404.1527(d)(2)); see also Schmidt v. Astrue, 496 F.3d 833, 842 (7th Cir. 2007). Being “not
inconsistent” does not require that 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.” SSR 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 v. Barnhart, 395 F.3d at 744. If the 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). “If
the ALJ discounts the [treating] physician’s opinion after considering these factors, [the Court] must
allow that decision to stand so long as the ALJ ‘minimally articulated’ his reasons.” Elder v. Astrue,
529 F.3d 408, 415 (7th Cir. 2008) (quoting Berger v. Astrue, 516 F.3d 539, 545 (7th Cir. 2008)); see
also Punzio v. Astrue, 630 F.3d 704, 710 (7th Cir. 2011) (“[W]henever an ALJ does reject a treating
source’s opinion, a sound explanation must be given for that decision.”); Schmidt v. Astrue, 496 F.3d
at 842 (“An ALJ thus may discount a treating physician’s medical opinion if it . . . ‘is inconsistent
with the opinion of a consulting physician or when the treating physician’s opinion is internally

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inconsistent, as long as he minimally articulates his reasons for crediting or rejecting evidence of
disability.’”) (quoting Skarbek v. Barnhart, 390 F.3d 500, 503 (7th Cir. 2004)).
In this case, Dr. Sheriff began treating Plaintiff in 2013 and completed a Physical Residual
Functional Capacity Questionnaire on March 13, 2015, outlining significant physical limitations in
Plaintiff’s ability to do work. The ALJ gave his opinion “little weight” as inconsistent with
Plaintiff’s testimony at the hearing and with treatment notes from Dr. Sheriff and other
contemporaneous appointments. The ALJ does not describe or identify any inconsistencies except
to say that “[t]he internal inconsistencies of the claimant reporting steadied improvement with
missed appointments prevalent throughout the records of Dr. Sheriff detract from his opinions.” AR
41. The ALJ appears to conclude that Plaintiff’s failure to fully comply with treatment makes the
treating doctor’s notes about the treatment she did undergo less than credible. Not only is this
logically inconsistent, but, as described above, the ALJ failed to ask Plaintiff about her perceived
failure to seek treatment. A vague description of “inconsistencies” does not rise to the level of
substantial conflicting evidence, and is an insufficient articulation of the reasons for discounting
his opinion, particularly since the ALJ failed to address Dr. Sheriff’s treating relationship with
Plaintiff, his specialization, or any other factors that should be considered in determining the weight
given a treating physician’s opinion.
On remand, the ALJ is reminded of the directive to give controlling weight to the opinion
of a treating physician or to explain the reason not to.
C.

Other Impairments

Plaintiff argues that the ALJ also failed to explain how, if at all, Plaintiff’s bladder condition
and abdominal pain were incorporated into the RFC.

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“Although [] impairments may not on their own be disabling, that would only justify
discounting their severity, not ignoring them altogether. Moreover, . . . an ALJ must consider the
combined effects of all of the claimant’s impairments, even those that would not be considered
severe in isolation.” Terry v. Astrue, 580 F.3d 471, 477 (7th Cir. 2009); see also Martinez, 630 F.3d
at 698 (“Even if each problem assessed separately were less serious than the evidence indicates, the
combination of them might be disabling.”); Getch v. Astrue, 539 F.3d 473, 483 (7th Cir. 2008)
(“[A]n ALJ is required to consider the aggregate effects of a claimant’s impairments, including
impairments that, in isolation, are not severe.”) (citing 20 C.F.R. § 404.1523; Golembiewski v.
Barnhart, 322 F.3d 912, 918 (7th Cir. 2003)).
The ALJ did include a bathroom break requirement in the RFC, but does not explain how
she arrived at this particular restriction, particularly since it does not correspond with any limitation
as described by a physician or by Plaintiff herself. The ALJ failed to draw a logical bridge from the
evidence to her conclusions about the number and frequency of Plaintiff’s bathroom breaks. See
Scott, 297 F.3d at 595 (reminding that the ALJ must build an “accurate and logical bridge from the
evidence to his conclusion”) (quoting Steele v. Barnhart, 290 F.3d 936, 941 (7th Cir. 2002)).
Although the ALJ need not specifically include every limitation alleged by Plaintiff in the
RFC, she must consider the combination of impairments, and explain how she incorporated all of
symptoms and limitations into the RFC. “In determining an individual’s RFC, the ALJ must
evaluate all limitations that arise from medically determinable impairments, even those that are not
severe, and may not dismiss a line of evidence contrary to the ruling.” Villano v. Astrue, 556 F.3d
558, 563 (7th Cir. 2009) (citing SSR 96-8p, 1996 WL 374184 (Jul. 2, 1996)); Golembiewski, 322
F.3d at 917). This the ALJ failed to do, and this case must be remanded for a new RFC that

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incorporates all of Plaintiff’s limitations, including an explanation of how the limitations from each
of her impairments (particularly her severe impairments, but also those that are not severe), alone
and in combination, are taken into account in the RFC.
On remand, the ALJ is instructed to fully review all of the medical evidence in the record
and to obtainupdated information as needed. See, e.g., Barnett, 381 F.3d at 669 (“An ALJ has a duty
to solicit additional information to flesh out an opinion for which the medical support is not readily
discernable.”) (citing 20 C.F.R. § 404.1527(c)(3); SSR 96-2p at *4; 20 C.F.R. §§ 404.1512(d)(1),
416.919(b)); see also Nelms v. Astrue, 553 F.3d 1093, 1098 (7th Cir. 2009) (citing 20 C.F.R. §§
416.912(d)-(f), 416.919, 416.927(c)(3)) (other citations omitted).
D.

VE Testimony

Plaintiff also argues that the ALJ erred by basing her analysis on unreliable VE testimony.
To determine whether jobs exist in the economy for a claimant’s RFC at Step Five, the ALJ will
look to job information available from government publications like the DOT. 20 C.F.R. §
404.1566(d). An ALJ may also use a VE to determine which occupations, if any, are compatible
with a claimant’s RFC. 20 C.F.R. § 404.1566(e). If using a VE, an ALJ has an “affirmative
responsibility” to ask whether a vocational expert’s testimony conflicts with the DOT and to elicit
a “reasonable explanation” for any conflict. S.S.R. 00-4p, 2000 WL 1898704, at *4 (Dec. 4, 2000);
Overman v. Astrue, 546 F.3d 456, 462-63 (7th Cir. 2008); Prochaska, 454 F.3d at 735. If the VE
responds that a conflict exists or if a conflict is apparent, an ALJ may rely on the VE’s testimony
as substantial evidence to support a determination of non-disability only if she resolves the conflict
in favor of the VE’s testimony and explains why. S.S.R. 00-4p, 2000 WL 1898704, at *4; Overman,
546 F.3d at 463.

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Plaintiff argues that there was a discrepancy between the DOT number given by the VE and
the job title he referred to, making it impossible to determine which job he was claiming Plaintiff
could do. Furthermore, Plaintiff argues, the VE failed to state the source of his testimony regarding
the occupational statistics he cited, statistics that are not contained in the DOT.
In this case, new VE testimony will likely be required after the credibility and RFC
determinations are corrected as described above. Particularly relevant in this case is the Seventh
Circuit Court of Appeals’ questioning of relying on “job descriptions used by the Social Security
Administration come from a 23-year-old edition of the Dictionary of Occupational Titles, which is
no longer published, and mainly moreover from information from 1977 – 37 years ago,” as “[n]o
doubt many of the jobs have changed and some have disappeared.” Browning v. Colvin, 766 F.3d
702, 709 (7th Cir. 2014). The Browning court also expressed concern that “[t]here is no official
source of number of jobs for each job classification in the Dictionary of Occupational Titles . . .
[a]nd many of the[ VEs] estimate the number of jobs of a type the applicant for benefits can perform
by the unacceptably crude method of dividing the number of jobs in some large category (which may
be the only available data) by the number of job classifications in the category.” Id.
The case is being remanded for other reasons described above, and new VE testimony will
likely need to be obtained based on the appropriate RFC findings. The ALJ is cautioned that she
must incorporate all relevant limitations in her questioning of the VE. In addition, the Court
recommends that the ALJ specifically ascertain the source of the VE’s opinion that the jobs
identified as able to be performed by Plaintiff do, in fact, actually exist in adequate numbers.

IV.

Conclusion

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For the foregoing reasons, the Court hereby GRANTS the relief requested in Plaintiff’s
Opening Brief [DE 16] and REMANDS this matter for further proceedings consistent with this
opinion.
SO ORDERED this 21st 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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