Hinojosa v. Commissioner of Social Security

Filing 21

OPINION AND ORDER: The Court hereby GRANTS the relief requested in Plaintiff's Brief in Support of Reversing the Decision of the Commissioner of Social Security 16 and REMANDS this matter for further proceedings consistent with this opinion. Signed by Magistrate Judge John E Martin on 9/28/2017. (jss)

UNITED STATES DISTRICT COURT
NORTHERN DISTRICT OF INDIANA
HAMMOND DIVISION
JACQUELINE M. HINOJOSA,
Plaintiff,

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

CAUSE NO.: 2:16-CV-202-JEM

OPINION AND ORDER
This matter is before the Court on a Complaint [DE 1], filed by Plaintiff on June 3, 2016, and
Plaintiff’s Brief in Support of Reversing the Decision of the Commissioner of Social Security [DE
16], filed on November 14, 2016. Plaintiff requests that the decision of the Administrative Law
Judge be reversed and remanded for further proceedings. On January 18, 2017, the Commissioner
filed a response, and on February 7, 2017, Plaintiff filed a reply. For the following reasons, the Court
grants Plaintiff’s request for remand.
I.

Procedural Background
On October 9, 2012, Plaintiff filed an application for benefits alleging that she became

disabled on June 21, 2006. Plaintiff’s application was denied initially and upon reconsideration.
On May 22, 2014, Administrative Law Judge (“ALJ”) Rebecca LaRiccia held a video hearing at
which Plaintiff, with an attorney representative, a medical expert, and a vocational expert (“VE”)
testified. On October 24, 2014, the ALJ issued a decision finding that Plaintiff was not disabled.
The Appeals Council denied Plaintiff’s request for review, leaving the ALJ’s decision the final
decision of the Commissioner.
The ALJ made the following findings under the required five-step analysis:

1.

The claimant has not engaged in substantial gainful activity since October 9,
2012, the application date.

2.

The claimant has the following severe impairments: possible systemic lupus
erythematosus and gastroparesis.

3.

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

4.

The claimant has the residual functional capacity to perform sedentary work
with exceptions: the claimant is able to lift 10 pounds occasionally and up to
10 pounds frequently, stand and/or walk for up to 2 hours in an 8-hour work
period and sit up to 6 hours in an 8-hour work day. The claimant is capable
of frequent, but not constant overhead reaching. She can occasionally climb
ramps and stairs, but never ladders, ropes, or scaffolds. The claimant can
occasionally balance, stoop, kneel, crouch, and crawl. The claimant must
avoid concentrated exposure to wetness and is to avoid the operation of
heavy machinery and unprotected heights, and is not to work in the sun.

5.

The claimant is unable to perform any past relevant work.

6.

The claimant was 32 years old, which is defined as a younger individual age
18-44, 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 determination of disability
because using the Medical-Vocational Rules as a framework supports a
finding that the claimant is “not disabled” whether or not the claimant 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 since October 9, 2012, the date
the application was filed.

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.

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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 of 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.
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.”

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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 Plaintiff’s RFC and in determining that her

mental impairments are not severe. The Commissioner argues that the ALJ’s decision is supported
by substantial evidence.
Plaintiff has been diagnosed with anxiety, depression, and PTSD. Plaintiff’s treating
psychologist and social worker completed a questionnaire addressing Plaintiff’s work-related
limitations caused by her psychiatric symptoms. In this case, the ALJ stated that she gave
“significant weight” to the opinions of Plaintiff’s social worker and treating psychiatrist, but did not
give weight to the portions of the opinions that specifically dealt with Plaintiff’s ability to work, and

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concluded that Plaintiff’s mental disorders did not rise to the level of severe impairment.
“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. §
404.1527(d)(2)); 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 SSR 96–5p,
1996 WL 374183, at *5 (July 2, 1996)) (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.”).
Because the ALJ failed to give controlling weight to Plaintiff’s treating providers, she was
required to analyze the following factors to describe what weight to give their opinions: 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 Punzio, 630 F.3d at 710 (“[W]henever
an ALJ does reject a treating source’s opinion, a sound explanation must be given for that
decision.”).
In this case, the primary evidence the ALJ refers to in her decision to discount the treating

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sources’ opinions is that of Plaintiff’s daily activities. However, the fact that Plaintiff lives with
other people who also have significant health needs and that she has the ability to be “cooperative
and friendly” in short medical appointments do not obviously counter the treating sources’ notations
that Plaintiff has difficulties with maintaining attendance and performing activities on a schedule.
See Bjornson v. Astrue, 671 F.3d 640, 647 (7th Cir. 2012) (“The critical differences between
activities of daily living and activities in a full-time job are that a person has more flexibility in
scheduling the former than the latter, can get help from other persons . . . and is not held to a
minimum standard of performance, as []he would be by an employer. The failure to recognize these
differences is a recurrent, and deplorable, feature of opinions by administrative law judges in social
security disability cases.”); see also Punzio, 630 F.3d at 712 (explaining that a plaintiff’s ability to
complete activities of daily living does not mean that she can manage the requirements of the
workplace).
The ALJ’s decision to specifically discount only the portions of the provider statements that
address Plaintiff’s ability to work, and to use her limited daily activities as the primary reason to do
so, raises concerns about whether the ALJ properly weighed the evidence in the record. The
Seventh Circuit Court of Appeals has warned ALJs against cherry-picking evidence. “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, 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)

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(“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.”).
Not only did the ALJ discount the treating sources’ opinions without adequate explanation,
but she also failed to explain how she incorporated Plaintiff’s mental limitations into the RFC. 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). “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 S.S.R. 96-8p; Golembiewski v. Barnhart, 322 F.3d 912, 917 (7th Cir.
2003);
The ALJ concluded that Plaintiff was mildly limited in concentration, persistence, and pace,
but did not explain how she incorporated that limitation into the RFC. See Jelinek v. Astrue, 662
F.3d 805, 813-14 (7th Cir. 2011) (concluding that limitations to sedentary and light unskilled work
did not “address[] the impact of the mental limitations . . . which . . . limited [the plaintiff]’s ability
to maintain regular work attendance, to carry out instructions, and to deal with the stresses of fulltime employment”); Stewart v. Astrue, 561 F.3d 679, 684-85 (7th Cir. 2009) (rejecting the
contention “that the ALJ accounted for [the plaintiff]’s limitations of concentration, persistence, and
pace by restricting the inquiry to simple, routine tasks that do not require constant interactions with

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coworkers or the general public”); Underwood v. Colvin, No. 2:11-CV-354-JD-PRC, 2013 WL
2420874, at *2 (N.D. Ind. May 30, 2013) (“While it is true that the ALJ need not specifically include
limitations on concentration, persistence and pace in the RFC finding, . . . the requirement that the
ALJ ‘consider’ such limitations has certainly been interpreted to mean that a real ‘evaluation’ of the
effect of those limitations on the claimant’s ability to work must take place.”).
Indeed, the ALJ did not explain how she incorporated any limitations stemming from
Plaintiff’s mental disorders into the RFC. “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 v. Astrue, 630 F.3d 693, 698 (7th Cir. 2011) (“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, 322 F.3d at 918)). Similarly, as Plaintiff
argues, the ALJ also failed to address how she incorporated Plaintiff’s migraine headaches into the
RFC or explain how they, in combination with her other impairments, affect Plaintiff’s ability to
work. Also concerning is the ALJ’s explanation that she did not include Plaintiff’s use of calf braces
and a cane in the RFC because they were not prescribed for her. See Parker v. Astrue, 597 F.3d 920,
922 (7th Cir. 2010) (“Absurdly, the administrative law judge thought it suspicious that the plaintiff
uses a cane, when no physician had prescribed a cane. A cane does not require a prescription.”).
The regulations specifically remind ALJs to take into account that, for example, “[a]n individual

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may have structured his or her activities to minimize symptoms to a tolerable level by avoiding
physical activities . . . that aggravate his or her symptoms.” SSR 16-3p, 2016 WL 1119029, at *9
(Mar. 16, 2016) superseding SSR 96-7p, 1996 WL 374186, at *8 (Jul. 2, 1996) (“The individual’s
daily activities may be structured so as to minimize symptoms to a tolerable level or eliminate them
entirely, avoiding physical or mental stressors that would exacerbate the symptoms.”).
Although medical evidence “may be discounted if it is internally inconsistent or inconsistent
with other evidence,” Knight v. Chater, 55 F.3d 309, 314 (7th Cir. 1995) (citing 20 C.F.R. §
404.1527(c)) (other citations omitted), the ALJ “must provide a ‘logical bridge’ between the
evidence and his conclusions,” O’Connor-Spinner, 627 F.3d at 618. The ALJ failed to build that
logical bridge in this case. The Court is unable to follow the reasoning behind giving “significant
weight” to all but the parts of the treating sources’ opinions that address Plaintiff’s ability to work,
without pointing to contrary medical evidence in the record. Nor is it apparent how, or whether,
Plaintiff’s mental limitations, including her limitations in concentration, persistence, and pace, were
incorporated into the RFC, either alone or in combination with her other impairments. On remand,
the ALJ is instructed to fully review all of the medical and mental health evidence in the record and
to obtain updated 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)). She is directed to follow the applicable regulations in determining what limitations
Plaintiff experiences, and to fully explain how each of the limitations, alone and in combination, are
incorporated into the RFC, including Plaintiff’s mental impairments, her migraines, and her use of
supportive devices.

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IV.

Conclusion

For the foregoing reasons, the Court hereby GRANTS the relief requested in Plaintiff’s Brief
in Support of Reversing the Decision of the Commissioner of Social Security [DE 16] and
REMANDS this matter for further proceedings consistent with this opinion.
SO ORDERED this 28th day of September, 2017.
s/ John E. Martin
MAGISTRATE JUDGE JOHN E. MARTIN
UNITED STATES DISTRICT COURT
cc:

All counsel of record

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