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Channing S. Vanwinkle v. Michael Astrue

January 9, 2013


The opinion of the court was delivered by: Joe Billy McDADE United States Senior District Judge


Thursday, 10 January, 2013 01:10:53 PM Clerk, U.S. District Court, ILCD


This matter is before the Court on Plaintiff's Motion for Summary Judgment and Defendant's Motion for Summary Affirmance, both addressing this Court's review of Defendant's final decision denying Social Security benefits to Plaintiff. (Docs. 17 & 21). For the reasons stated below, Plaintiff's Motion for Summary Judgment is denied and Defendant's Motion for Summary Affirmance is granted.


To be entitled to disability benefits under the Social Security Act, a claimant must prove that he is unable to "engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment." 42 U.S.C. § 423(d)(1)(A). To determine if the claimant is unable to engage in any substantial gainful activity, the Commissioner of Social Security engages in a factual determination. See McNeil v. Califano, 614 F.2d 142, 143 (7th Cir. 1980). That factual determination is made by using a five-step sequential analysis. 20 C.F.R. §§ 404.1520, 416.920; see also Maggard v. Apfel, 167 F.3d 376, 378 (7th Cir. 1999).

In the first step, a threshold determination is made to decide whether the claimant is presently involved in a substantially gainful activity. 20 C.F.R. §§ 404.1520(a)(i), 416.920(a)(i). If the claimant is not under such employment, the Commissioner of Social Security proceeds to the next step. At the second step, the Commissioner evaluates the severity and duration of the impairment. 20 C.F.R. §§ 404.1520(a)(iii), 416.920(a)(iii). If the claimant has an impairment that significantly limits his physical or mental ability to do basic work activities, the Commissioner will proceed to the next step. At the third step, the Commissioner compares the claimant's impairments to a list of impairments considered severe enough to preclude any gainful work; and, if the elements of one of the Listings are met or equaled, he declares the claimant eligible for benefits. 20 C.F.R. §§ 404.1520(a)(iv), 416.920(a)(iv); 20 C.F.R. Part 404, Subpart P, Appendix 1.

If the claimant does not qualify under one of the listed impairments, the Commissioner proceeds to the fourth and fifth steps. At the fourth step, the claimant's residual functional capacity ("RFC") is evaluated to determine whether the claimant can pursue his past work. 20 C.F.R. §§ 404.1520(a)(iv), 416.920(a)(iv). If he cannot, then, at step five, the Commissioner evaluates the claimant's ability to perform other work available in the economy. 20 C.F.R. §§ 404.1520(a)(v), 416.920(a)(v). If the claimant is disabled, but there is evidence of drug or alcohol abuse, the Commissioner must consider whether the claimant would still be considered disabled if he stopped using drugs and/or alcohol; if not, he cannot receive benefits. 42 U.S.C. § 423(d)(2)(C); 20 C.F.R. § 404.1535.

The claimant has the burden to prove disability through step four of the analysis, i.e., he must demonstrate an impairment that is of sufficient severity to preclude his from pursuing his past work. McNeil, 614 F.2d at 145. However, once the claimant shows an inability to perform his past work, the burden shifts to the Commissioner, at step five, to show the claimant is able to engage in some other type of substantial gainful employment. Id.

Once a case reaches a federal district court, the court's review is governed by 42 U.S.C. § 405(g), which provides, in relevant part, "The findings of the Commissioner of Social Security as to any fact, if supported by substantial evidence, shall be conclusive." Substantial evidence is "such evidence as a reasonable mind might accept as adequate to support a conclusion." Maggard, 167 F.3d at 379 (quoting Richardson v. Perales, 402 U.S. 389, 401 (1971)). In a substantial evidence determination, the Court will review the entire administrative record, but it will "not reweigh the evidence, resolve conflicts, decide questions of credibility, or substitute [its] own judgment for that of the Commissioner." Clifford v. Apfel, 227 F.3d 863, 869 (7th Cir. 2000). The Court must ensure that the administrative law judge ("ALJ") "build[s] an accurate and logical bridge from the evidence to his conclusion," even though he need not have addressed every piece of evidence. Id. at 872.


I. Procedural History

Plaintiff filed an application for disability benefits on March 6, 2009. (Tr. 125, 147).*fn1 His claim was denied initially and upon reconsideration. (Tr. 70-79). Plaintiff requested a hearing, which was held on August 25, 2010. (Tr. 11-41, 80-81). Following the ALJ's December 16, 2010 decision denying benefits, Plaintiff filed a request for review by the Appeals Counsel, which was denied on September 29, 2011. (Tr. 65-68, 123). Plaintiff then filed the instant action on November 7, 2011 pursuant to 42 U.S.C. § 405(g). (Doc. 1).

II. Relevant Medical History*fn2

On November 11, 2008, Plaintiff was admitted to the hospital following an overdose of medication with alcohol; his mother reported that he had been depressed lately. (Tr. 219). He reported to a nurse that he had recently broken up with his girlfriend, and had lost his job. (Doc. 352). While in the hospital, Plaintiff stayed in his room, refusing to attend group therapy or to socialize with other patients. (Tr. 352). A provider believed that he would benefit from inpatient care, as well as a referral to a community support program. (Tr. 416). On November 12, 2008, Plaintiff was still somewhat of a threat to himself; acknowledged the need to recover, but was not ready to engage in a discussion about the necessary actions; was unable to understand his disease and its management; and was inconsistent with taking his medications. (Tr. 360-61).

Upon his November 14, 2008 discharge, Plaintiff reported that he would live with his brother, and that he would seek counseling through his church. (Tr. 420). Dr. Eric Ritterhoff, who had been treating Plaintiff during his stay, noted in his discharge summary that, during his admission, Plaintiff had not shown "ongoing depression, sadness, hopelessness," and that he had denied being suicidal. (Tr. 321). Plaintiff had been advised that he needed to remain in the hospital longer in order to get the full effect of his medication, but he was discharged against medical advice. (Tr. 321). Plaintiff initially complained of upset stomach caused by his medication, but Dr. Ritterhoff had prescribed a medication to alleviate that problem. (Tr. 321). As to his work abilities, Dr. Ritterhoff noted that Plaintiff "talked in a categorical fashion with no insight as to not being able to work," and that Plaintiff had reported some problems with concentration and nervousness. (Tr. 321-22). Dr. Ritterhoff questioned Plaintiff's prognosis, as it was uncertain whether he would follow through with treatment. (Tr. 322).

Plaintiff participated in formulating an Individual Treatment Plan on November 21, 2008. (Tr. 442-43). He stated that he would "continue to maintain [his] mental health by taking [his] medication;" the clinician noted that he was capable of self-medication. (Tr. 442-43).

Dr. Ritterhoff saw Plaintiff on December 5, 2008. Dr. Ritterhoff reported that Plaintiff was dwelling on his negative feelings over having lost his girlfriend, apartment, and job, but was exploring getting a different doctor in order to avoid the topic of having to work on his behavior rather than merely getting new medications, especially an antidepressant. (Tr. 495). Dr. Ritterhoff explained that Plaintiff was not having "biologic depression," but was merely experiencing natural negative feelings, and so questioned the need for an antidepressant medication. (Tr. 495).

At Plaintiff's December 19, 2008 visit with Dr. Ritterhoff, the doctor noted that Plaintiff was beginning community support program services. (Tr. 494). Dr. Ritterhoff found no evidence of depression, sadness, or hopelessness, but Plaintiff showed "low productivity" and reported that he could not "make himself do anything." (Tr. 494). In order to show that he could control himself, Dr. Ritterhoff advised Plaintiff to begin a behavioral program of activity, beginning with walking every day for an hour, followed by beginning to attempt some sort of work. (Tr. 494).

Plaintiff reported having a problem with concentration in January 2009, but rejected Dr. Ritterhoff's offer of treatment for that issue; he had not begun the behavioral program suggested at the previous visit. (Tr. 493). In February 2009, Plaintiff refused Dr. Ritterhoff's suggestion of going to a day hospital for additional treatment, though Dr. Ritterhoff "explicitly advised" him that he needed "more intensive therapy." (Tr. 491). In apparent response to Plaintiff's statements, Dr. Ritterhoff told him that the medical staff was not concerned about his Social Security status, as his problems will persist even if he gets Social Security; Dr. Ritterhoff noted that ...

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