United States District Court, N.D. Illinois, Eastern Division
MEMORANDUM OPINION AND ORDER
GARY FEINERMAN, District Judge.
In March 2011, Melissa Stalmack filed a claim for disability insurance benefits ("DIB") and supplemental security income benefits ("SSI") with the Social Security Administration. Doc. 10-4 at 2-5. Because the disability standards for DIB and SSI are "materially the same, " Donahue v. Barnhart, 279 F.3d 441, 443 (7th Cir. 2002), and because the parties do not suggest otherwise, the court will ignore the distinction for purposes of this opinion. The Commissioner denied the claim, and then denied Stalmack's request for reconsideration. Doc. 10-5 at 2-6, 8-15. Stalmack sought and received a hearing before an administrative law judge ("ALJ") pursuant to 20 C.F.R. § 404.914. Doc. 10-3 at 65-101. The ALJ denied the claim, id. at 10-24, and the Social Security Appeals Council denied Stalmack's request for review of the ALJ's decision, id. at 2-4, making the ALJ's decision the final decision of the Commissioner. See Scrogham v. Colvin, 765 F.3d 685, 695 (7th Cir. 2014). Stalmack has timely sought judicial review pursuant to 42 U.S.C. § 405(g). Doc. 1. For the following reasons, Stalmack's motion to reverse or remand (Doc. 14) is granted, the Commissioner's summary judgment motion (Doc. 21) is denied, and the case is remanded to the Commissioner for further proceedings consistent with this opinion.
Stalmack has a lengthy medical history, discussed at length in her brief. Doc. 14 at 8-17. For concision, the court will not reiterate that history here, except insofar as it is relevant to the principal issue raised in this appeal: whether the ALJ erred in concluding that Stalmack had a greater residual functional capacity than her primary care physician and her insurance company's independent medical expert had opined. All facts are taken from the administrative record.
A. Factual Background
Stalmack is 35 years old and previously worked for an auto parts manufacturer as a customer service and delivery representative. Doc. 10-7 at 34. She claims to have become disabled on November 1, 2010, due to a combination of scleroderma, hypothyroid, anemia, migraines, asthma, and hypertension. Doc. 10-5 at 11. She has not returned to work since that time, and currently receives $949 per month in long-term disability insurance. Doc. 10-3 at 74-75.
Stalmack's primary care physician is Dr. David Levy. In February 2011, Dr. Levy filled out an "Interactive Process Questionnaire" evaluating Stalmack's ability to perform the responsibilities of her customer service job. Doc. 10-8 at 118-121. Dr. Levy stated that scleroderma and abdominal pain prevented Stalmack from performing her job functions because she "cannot stand at this point for any prolonged activity period" and because there were no reasonable accommodations for her "chronic pain." Id. at 119. In April 2011, Dr. Levy filled out another form, titled "Medical Evaluation-Physician's Report." Doc. 10-8 at 102-05. There, Dr. Levy stated that Stalmack suffered from scleroderma, a pulmonary embolism, and endometriosis. Id. at 102. He rated her as having "more than 50% reduced capacity" during an eight-hour workday in the following categories: bending, climbing, travel (public conveyance), and performing activities of daily living. Id. at 105. He rated her at "20 to 50% reduced capacity" in standing, turning, pushing, pulling, and fine and gross manipulation. Ibid. Finally, he stated that Stalmack could lift no more than 10 pounds at a time during the workday. Ibid. Also in April 2011, Dr. Levy completed a Statement of Continued Disability for Stalmack's insurer, id. at 110-11, but the copy in the record is largely illegible.
In October 2012, Dr. Levy submitted a "Physical Capacities Evaluation" indicating that Stalmack could not adequately use either hand for grasping, pushing and pulling, fine manipulation, or repetitive motion tasks such as writing, typing, and assembly. Doc. 10-14 at 19-22. He also indicated that Stalmack could lift or carry no more than five pounds, and only on an "occasional" basis (that is, up to one-third of the day). Id. at 20. Dr. Levy opined that Stalmack suffered from disabling fatigue and pain that prevented her from working full time, even in a sedentary position. Id. at 20-21. Finally, Dr. Levy stated that Stalmack's pain constituted a "significant handicap with sustained attention... [that] would eliminate skilled work tasks." Id. at 22.
Several other doctors evaluated Stalmack in 2012; three in particular are worth mentioning, because the ALJ relied on their impressions in discounting Dr. Levy's October 2012 opinion. The first is Dr. Troy Buck, who saw Stalmack at the Loyola Pain Medicine Clinic in January 2012. Doc. 10-10 at 99-102. Stalmack told Dr. Buck that her pain had gotten worse, rating its intensity as 7/10, and reported new pain and numbness from her neck to her fingers. Id. at 99. The second is Dr. Rochella Ostrowksi, a rheumatologist who saw Stalmack in April and May 2012 for localized scleroderma. Doc. 10-11 at 48-52. In April, Dr. Ostrowski noted a lesion in Stalmack's right chest wall, and wrote that Stalmack had "widespread pain, but overall improved on current pain regimen." Id. at 49-50. When Stalmack returned the following month, Dr. Ostrowski noted that the lesion had "improved significantly, " and that although she "[s]till has fibromyalgia pain, " it appeared "somewhat improved with current regiment; occasionally has sharp pain going into all extremities. No associated numbness/tingling." Id. at 48. The third is Dr. Rosenbaum, a gastroenterologist whose first name is not in the record. Dr. Rosenbaum saw Stalmack in August 2012, Doc. 10-11 at 46-47, but, as stated by the ALJ, "did not give a diagnosis or report clinical signs." Doc. 10-3 at 21.
In December 2012, Dr. Anand Lal reviewed Stalmack's medical charts and conducted a physical examination on behalf of Hartford Life Insurance, Stalmack's insurer. Doc. 10-14 at 24-30. Dr. Lal opined that Stalmack could stand for 1.5 hours a day, 15-20 minutes at a time, that she could sit three hours a day with some stretching, and that she could lift about 12 pounds of weight occasionally. Id. at 29. He estimated that Stalmack was reasonably capable of working "4.5 hours a day... and 22.5 hours/week on a good day." Id. at 30. But "[o]n a bad day, " Dr. Lal wrote, Stalmack "may not be able to do any [work] at all." Ibid.
Stalmack was also evaluated by three different state agency medical consultants during the course of her application: Dr. Manesh Shah, Dr. Richard Smith, and Dr. Charles Kennedy. Dr. Shah performed a consultative examination for the Bureau of Disability Determination Services in July 2011. Doc. 10-9 at 53-57. He indicated that Stalmack's "[f]inger grasp and hand grip [were] unimpaired bilaterally" and that her "[f]ine and gross manipulations were intact." Id. at 56. Dr. Shah observed mild pain and stiffness in Stalmack's right shoulder and tingling and numbness in her fingers, but stated that "the physical exam is fairly unremarkable"; he also stated that Stalmack's asthma, blood pressure, and migraines were all "ok" or under "fair" or "good control." Id. at 57.
One month later, Dr. Smith assessed Stalmack. Id. at 58-65. Dr. Smith indicated that Stalmack could occasionally lift 20 pounds and could frequently lift 10 pounds, and found that she could stand or walk for six hours a day. Id. at 59. Dr. Smith found no limitations in handling, fingering, or feeling, with only occasional reaching overhead. Id. at 61. Additionally, he stated that Stalmack's grip was "normal" and that her alleged impairments "could reasonably be expected to produce the alleged symptoms, but their intensity and the effect on functioning are not consistent with the total file of evidence." Id. at 65.
In March 2012, Dr. Kenney assessed Stalmack. Doc. 10-10 at 68-75. He opined that Stalmack could lift up to 20 pounds occasionally and 10 pounds frequently during the workday and that she could stand or walk with normal breaks for at least two hours. Id. at 69. He also opined that Stalmack had no limitations in reaching, handling, or fingering, ...