ADAMS v. COLVIN
ORDER on Judicial Review. The Commissioner's decision is REVERSED and this case is REMANDED for further proceedings consistent with this Entry. (S.O.). Signed by Judge William T. Lawrence on 1/20/2017.(MAC)
UNITED STATES DISTRICT COURT
SOUTHERN DISTRICT OF INDIANA
JOHN P. ADAMS,
CAROLYN W. COLVIN, Acting
Commissioner of the Social Security
) Cause No. 1:15-cv-2078-WTL-DKL
ENTRY ON JUDICIAL REVIEW
Plaintiff John P. Adams requests judicial review of the final decision of Defendant
Carolyn W. Colvin, Acting Commissioner of the Social Security Administration
(“Commissioner”), denying Adams’s application for Disability Insurance Benefits (“DIB”) and
Supplemental Security Insurance Benefits (“SSI”) under Titles II and XVI of the Social Security
Act (“the Act”). The Court, having reviewed the record and the briefs of the parties, now rules
Adams filed for DIB and SSI on August 31, 2012, alleging he became disabled on
February 13, 2012, due to coronary artery disease, syncope, degenerative disc disease, and other
disabilities. Adams’s application was denied initially on January 9, 2013, and again upon
reconsideration. Following the denial upon reconsideration, Adams requested and received a
hearing in front of an Administrative Law Judge (“ALJ”). That hearing, during which Adams
was represented by counsel, was held on October 16, 2014, before ALJ Belinda J. Brown. The
ALJ issued her decision on October 31, 2014, denying Adams’s claim. Adams requested review
by the Appeals Council, and the Appeals Council denied the request for review. Adams then
filed this timely appeal.
Disability is defined as “the 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 12 months.” 42 U.S.C. § 423(d)(1)(A). In order to be found disabled, a claimant must
demonstrate that his physical or mental limitations prevent him from doing not only his previous
work, but any other kind of gainful employment which exists in the national economy,
considering his age, education, and work experience. 42 U.S.C. § 423(d)(2)(A).
In determining whether a claimant is disabled, the Commissioner employs a five-step
sequential analysis. At step one, if the claimant is engaged in substantial gainful activity, he is
not disabled, despite his medical condition and other factors. 20 C.F.R. § 416.920(a)(4)(i).1 At
step two, if the claimant does not have a “severe” impairment (i.e., one that significantly limits
his ability to perform basic work activities), he is not disabled. 20 C.F.R. § 416.920(a)(4)(ii). At
step three, the Commissioner determines whether the claimant’s impairment or combination of
impairments meets or medically equals any impairment that appears in the Listing of
Impairments, 20 C.F.R. pt. 404, subpt. P, App. 1, and whether the impairment meets the twelvemonth duration requirement; if so, the claimant is deemed disabled, 20 C.F.R. §
416.920(a)(4)(iii). At step four, if the claimant is able to perform his past relevant work, he is
The Code of Federal Regulations contains separate sections relating to DIB and SSI
that are identical in all respects relevant to this case. For the sake of simplicity, this Entry
contains citations to SSI sections only, with the exception of DIB section cites where they
provide information beyond that found in the SSI sections.
not disabled. 20 C.F.R. § 416.920(a)(4)(iv). At step five, if the claimant can perform any other
work in the national economy, he is not disabled. 20 C.F.R. § 416.920(a)(4)(v).
In reviewing the ALJ’s decision, the ALJ’s findings of fact are conclusive and must be
upheld by this court “so long as substantial evidence supports them and no error of law
occurred.” Dixon v. Massanari, 270 F.3d 1171, 1176 (7th Cir. 2001). “Substantial evidence
means such relevant evidence as a reasonable mind might accept as adequate to support a
conclusion,” id., and this Court may not reweigh the evidence or substitute its judgment for that
of the ALJ, Overman v. Astrue, 546 F.3d 456, 462 (7th Cir. 2008) (citation omitted). The ALJ is
required to articulate only a minimal, but legitimate, justification for her acceptance or rejection
of specific evidence of disability. Scheck v. Barnhart, 357 F.3d 697, 700 (7th Cir. 2004). In
order to be affirmed, the ALJ must articulate her analysis of the evidence in her decision; while
she “is not required to address every piece of evidence or testimony,” she must “provide some
glimpse into her reasoning . . . [and] build an accurate and logical bridge from the evidence to
her conclusion.” Dixon, 270 F.3d at 1176 (citations omitted).
ALJ BROWN’S DECISION
ALJ Brown determined at step one that Adams had not engaged in substantial gainful
activity since February 13, 2012, the alleged onset date. Record at 17. At steps two and three,
the ALJ concluded that Adams had the severe impairments of coronary artery disease, syncope,
and degenerative disc disease, as well as several non-severe impairments, including diabetes with
neuropathy and gastroparesis; symptoms of fecal incontinence, nausea, and vomiting; adjustment
disorder, and chronic brain syndrome. R. at 17-19. At step four, the ALJ determined that Adams
had the following residual functional capacity (“RFC”):
[T]he claimant has the [RFC] to perform sedentary work . . . except he can never
balance, kneel, crouch, crawl, or climb ladders, ropes, or scaffolds; occasionally
climb ramps or stairs; never work at unprotected heights or around dangerous
moving machinery; never operate a motor vehicle; and have occasional exposure
R. at 21. The ALJ also determined that Adams was able to perform past relevant work as an
underwriter, as the position is found in the national economy, and district manager, as he had
performed the job and as it is found in the national economy. R. at 26. Accordingly, the ALJ
concluded that Adams was not disabled as defined by the Act.
EVIDENCE OF RECORD
The ALJ’s decision in combination with Adams’s brief (Dkt. No. 12) aptly sets forth the
medical evidence of record, which need not be recited here. Specific facts are introduced in the
discussion section below where relevant.
In his brief in support of his Complaint, Adams argues that the ALJ (1) erroneously
concluded at step two that Adams’s gastroparesis with accompanying fecal incontinence was not
a severe impairment; (2) failed to consider the combined effects of Adams’s severe and nonsevere impairments; (3) erroneously gave little weight to Adams’s treating physician’s August
2011 opinion and no weight to his subsequent opinions; and (4) erred in her credibility
determination by failing to consider Adams’s long work history and his effort to continue
working while in pain and undergoing surgeries and treatments.
Step Two and RFC
Adams argues that the ALJ erred in finding that his gastroparesis with fecal incontinence
was not a severe impairment and that this finding is not supported by substantial evidence. In
her decision, the ALJ noted that Adams made frequent trips to the restroom, wore protective
undergarments, and complained of diarrhea, nausea, and vomiting. R. at 18. She also
acknowledged that the medical records show that Adams “takes a number of medications for
diarrhea, vomiting, and nausea.” Id. She further acknowledged that a treating gastroenterologist
diagnosed Adams with mild gastritis. Id. She remarked, however, that “extensive workup of
[Adams]’s gastrointestinal tract and colon has been within normal range” and that “all workup
has been benign and unsupportive of serious findings.” Id. As a result, she concluded that
Adams’s gastroparesis was non-severe. Id.
“The Step 2 determination is ‘a de minimis screening for groundless claims’ intended to
exclude slight abnormalities that only minimally impact a claimant’s basic activities,”
O’Connor-Spinner v. Colvin, 832 F.3d 690, 697 (7th Cir. 2016) (quoting Thomas v. Colvin, 826
F.3d 953, 960 (7th Cir. 2016)); see also Meuser v. Colvin, 838 F.3d 905, 910 (7th Cir. 2016).
The Seventh Circuit has categorized errors in determining an impairment’s severity as harmless
as long as the ALJ otherwise finds one severe impairment, continues through the steps in the
evaluation process, and “consider[s] all of [the claimant]’s severe and non-severe impairments,
the objective medical evidence, [the claimant’s] symptoms, and [his] credibility when
determining [his] RFC immediately after step 3.” Curvin v. Colvin, 778 F.3d 645, 649 (7th Cir.
2015); see also Arnett v. Astrue, 676 F.3d 586, 591 (7th Cir. 2012) (“Deciding whether
impairments are severe at Step 2 is a threshold issue only; an ALJ must continue on to the
remaining steps of the evaluation process as long as there exists even one severe impairment.
Here the ALJ categorized two impairments as severe, and so any error of omission [at Step 2
regarding the severity of other impairments] was harmless.”) (emphasis in original) (citations
The Court need not determine whether the ALJ erred in finding Adams’s gastroparesis
with fecal incontinence non-severe. Here, the ALJ concluded that Adams had three severe
impairments - coronary artery disease, syncope, and degenerative disc disease. At that point, the
ALJ crossed step two’s threshold and continued the evaluation process. If the ALJ erred in
determining that Adams’s gastroparesis with fecal incontinence was not severe, such error will
be deemed harmless if the ALJ considered it, along with all of Adams’s other severe and nonsevere impairments, in making an RFC determination.
Although the ALJ states that she “considered all symptoms and the extent to which these
symptoms can reasonably be accepted as consistent with the objective medical evidence and
other evidence,” the ALJ’s RFC discussion fails to mention any of Adams’s non-severe physical
impairments, including diabetes, gastroparesis and symptoms of fecal incontinence, nausea, and
vomiting. “[A]n ALJ is required to consider the aggregate effects of a claimant’s impairments,
including impairments that, in isolation, are not severe.” Getch v. Astrue, 539 F.3d 473, 483 (7th
Cir. 2008) (citing 20 C.F.R. § 404.1523); see also Golembiewski v. Barnhart, 322 F.3d 912, 918
(7th Cir. 2003) (“the ALJ needed to consider the aggregate effect of this entire constellation of
ailments-including those impairments that in isolation are not severe”) (emphasis in original).
Because that did not happen in this case, the ALJ must, on remand, consider the combined
effects of all of Adams’s impairments, both severe and non-severe, in determining his RFC.
Adams also argues that the ALJ failed to give proper weight to the opinion of his treating
physician, Dr. Bret House. The ALJ afforded Dr. House’s early opinions regarding Adams’s
inability to work “little weight” because his opinion “was out of proportion to his clinical notes
and the other objective findings at the time of his statements.” R. at 25. The ALJ then gave “no
weight” to Dr. House’s later opinions “because they are conclusory and strikingly inconsistent
with his treatment notes, the claimant’s reported activities of daily living, and the lack of
treatment advised by treating specialists.” Id.
The Seventh Circuit describes what is commonly referred to as “the treating physician
rule” as follows:
A treating physician’s opinion is entitled to controlling weight if it is supported by
medical findings and consistent with substantial evidence in the record. If this
opinion is well supported and there is no contradictory evidence, there is no basis
on which the administrative judge, who is not a physician, could refuse to accept it.
But once well-supported contradicting evidence is introduced, the treating
physician’s evidence is no longer entitled to controlling weight and becomes just
one more piece of evidence for the ALJ to consider.
Bates v. Colvin, 736 F.3d 1093, 1099-100 (7th Cir. 2013) (internal quotation marks and citations
omitted). “‘If an ALJ does not give a treating physician’s opinion controlling weight, the
regulations require the ALJ to consider the length, nature, and extent of the treatment
relationship, frequency of examination, the physician’s specialty, the types of tests performed,
and the consistency and supportability of the physician’s opinion.’” Scott v. Astrue, 647 F.3d
734, 740 (7th Cir. 2011) (quoting Moss v. Astrue, 555 F.3d 556, 561 (7th Cir. 2009) (citing 20
C.F.R. § 404.1527(d)(2))); see also Yurt v. Colvin, 758 F.3d 850, 860 (7th Cir. 2014) (“the ALJ
should explicitly consider the details of the treatment relationship and provide reasons for the
weight given to their opinions”). “If the ALJ discounts the physician’s opinion after considering
these [§ 404.1527(c)] factors, we must allow that decision to stand so long as the ALJ ‘minimally
articulate[d]’ [her] reasons--a very deferential standard that we have, in fact, deemed ‘lax.’”
Elder v. Astrue, 529 F.3d 408, 415 (7th Cir. 2008) (emphasis added) (quoting Berger v. Astrue,
516 F.3d 539, 545 (7th Cir. 2008)).
Adams argues that the ALJ should have afforded special deference, i.e., controlling
weight, to Dr. House’s opinions because he is his treating physician. Adams also argues that the
ALJ erred by not considering the “checklist factors” found in 20 C.F.R. § 404.1527(c) when she
determined that she would not give controlling weight to Dr. House’s opinions.
The ALJ does not clearly articulate which of Dr. House’s opinions she affords little or no
weight.2 She also does not explicitly examine the factors outlined in 20 C.F.R. § 404.1527(c).
Accordingly, the ALJ erred in giving little or no weight to Dr. House’s opinions. This is not to
say that Dr. House’s opinions should receive controlling weight. Rather, on remand, the ALJ
should explicitly examine the factors in 20 C.F.R. § 404.1527(c), clearly express which of Dr.
House’s opinions she believes should receive less than controlling weight, and minimally
articulate reasons to support her ultimate conclusion.
Adams also asserts that the ALJ erred in her credibility determination. On remand, the
ALJ should evaluate all of Adams’s symptoms in accordance with the requirements in Social
Security Ruling 16-3p.
For the reasons set forth above, the Commissioner’s decision is REVERSED and this
case is REMANDED for further proceedings consistent with this Entry.
SO ORDERED: 1/20/17
Hon. William T. Lawrence, Judge
United States District Court
Southern District of Indiana
Copies to all counsel of record via electronic communication
Context tells the Court that one of the opinions to which the ALJ affords no weight is
the “Physical Residual Functional Capacity Assessment” Dr. House completed on August 6,
2014. See Dkt. No. 8-4 at 75-82.
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