United States District Court, N.D. Illinois, Eastern Division
MEMORANDUM OPINION AND ORDER
David Weisman United States Magistrate Judge.
Lynn Hane brings this action pursuant to 42 U.S.C. §
405(g) for judicial review of the Social Security
Administration's (“SSA's”) decision
denying her application for benefits. For the reasons set
forth below, the Court reverses the SSA's decision.
filed an application for benefits on July 26, 2013, alleging
a disability onset date of January 1, 2005. (R. 68-70.) Her
application was denied initially on December 6, 2013, and
again on reconsideration on August 13, 2014. (R. 68, 81.)
Plaintiff requested a hearing before an Administrative Law
Judge (“ALJ”), which was held on July 19, 2016.
(R. 34-59.) On October 18, 2016, the ALJ issued a decision
denying plaintiff's application. (R. 20-28.) The Appeals
Council denied review (R. 1-3), leaving the ALJ's
decision as the final decision of the Commissioner. See
Villano v. Astrue, 556 F.3d 558, 561-62 (7th Cir. 2009).
Court reviews the ALJ's decision deferentially, affirming
if it is supported by “substantial evidence in the
record, ” i.e., “‘such relevant
evidence as a reasonable mind might accept as adequate to
support a conclusion.'” White v. Sullivan,
965 F.2d 133, 136 (7th Cir. 1992) (quoting Richardson v.
Perales, 402 U.S. 389, 401 (1971)). “Although this
standard is generous, it is not entirely uncritical, ”
and the case must be remanded if the “decision lacks
evidentiary support.” Steele v. Barnhart, 290
F.3d 936, 940 (7th Cir. 2002).
the Social Security Act, 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). The regulations prescribe a five-part
sequential test for determining whether a claimant is
disabled. See 20 C.F.R. § 404.1520. Under the
regulations, the SSA must consider: (1) whether the claimant
has performed any substantial gainful activity during the
period for which she claims disability; (2) if not, whether
the claimant has a severe impairment or combination of
impairments; (3) if so, whether the claimant's impairment
meets or equals any listed impairment; (4) if not, whether
the claimant retains the residual functional capacity
(“RFC”) to perform her past relevant work; and
(5) if not, whether he is unable to perform any other work
existing in significant numbers in the national economy.
Id.; Zurawski v. Halter, 245 F.3d 881, 885
(7th Cir. 2001). The claimant bears the burden of proof at
steps one through four, and if that burden is met, the burden
shifts at step five to the SSA to provide evidence that the
claimant is capable of performing work existing in
significant numbers in the national economy. See 20
C.F.R. § 404.1560(c)(2).
one, the ALJ found that plaintiff had not engaged in
substantial gainful activity since the alleged onset date.
(R. 22.) At step two, the ALJ found that plaintiff has the
severe impairments of “autoimmune disorder; scoliosis;
obesity; history of cataract surgery; macular edema; and
hyperlipidemia.” (Id.) At step three, the ALJ
found that plaintiff does not have an impairment or
combination of impairments that meets or medically equals the
severity of a listed impairment. (R. 23.) At step four, the
ALJ found that plaintiff has the RFC to perform her past
relevant work as a hairstylist, and thus is not disabled. (R.
concluded that plaintiff can perform medium work without any
overhead reaching or fingering restrictions (R. 24, 26), a
conclusion plaintiff says is contrary to her testimony and
the record as a whole. Plaintiff testified that she has
“trouble reaching up” on her right side and, on
bad days, has difficulty using her right hand, which prevents
her from cooking, cleaning, and doing other household chores.
(R. 41-49.) As the ALJ pointed out, the medical evidence is
at odds with plaintiff's testimony. The clinical notes of
plaintiff's treating physician, Dr. Munn, which he cited
when asked to opine on the limitations caused by
plaintiff's condition (R. 434-36), show that
plaintiff's symptoms are controlled with medication.
(See, e.g., R. 360 (7/17/12 medical record noting
that plaintiff “is doing well on Enbrel and Plaquenil
in terms of joint pain and swelling without current
symptoms”); R. 364 (1/17/12 medical record stating that
plaintiff “is doing well on Enbrel and Plaquenil in
terms of joint pain and swelling with rare episodes
now”); R. 367, 3728/18/11 & 2/17/11 medical records
noting that plaintiff “improved on Enbrel and
[P]laquenil, ” and was “doing well without active
joint complaints”); R. 376 (8/12/10 medical record
stating that plaintiff “improved on Enbrel and
[P]laquenil, ” is “not having any joint pain or
swelling currently, ” and has “no limitations
physically right now due to the arthritis”); R. 379,
381 (2/11/10 & 8/31/09 medical records stating same).)
Similarly, two different consultative examiners found that
plaintiff had normal fine dexterity movements and 5/5 grip
strength in her hands, “no restriction of range of
motion, ” and “no limitation of any joint.”
(R. 344, 404.) In short, the ALJ's conclusion that
plaintiff had the physical RFC to perform medium work is
supported by substantial evidence.
also argues that the ALJ erred in rejecting the opinion of
plaintiff's treating physician, Dr. Munn. The ALJ was
required to give the treating physician's opinion
controlling weight if “it [was] well-supported by
medically acceptable clinical and laboratory diagnostic
techniques and . . . not inconsistent with the other
substantial evidence in [the] record.” 20 C.F.R. §
404.1527(c)(2); Scott v. Astrue, 647 F.3d 734,
739 (7th Cir. 2011). The ALJ must give good reasons for the
weight that it assigns a treating physician's opinion.
Roddy v. Astrue, 705 F.3d 631, 636 (7th Cir. 2013).
“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.”
Moss v. Astrue, 555 F.3d 556, 561 (7th Cir. 2009);
see 20 C.F.R. § 404.1527(c).
Munn opined that plaintiff had a “history of persistent
joint pain, swelling and tenderness involving multiple major
joints” and had “signs of joint inflammation . .
. on current physical examination despite prescribed therapy
for at least 3 months, ” which “resulted in
significant restriction of function of the affected
joints.” (R. 436.) The ALJ gave “[n]o
weight” to Dr. Munn's opinion because it
“does not set forth functional limitations, ”
some of his treatment records state that plaintiff “had
no limitations due to arthritis, ” and “there is
no indication that Dr. Dunn [sic] is familiar with the
Agency's rules and regulations for determining
disability.” (R. 27.)
the vague and conclusory nature of Dr. Munn's opinion,
the ALJ's failure to assess it in accordance with the
regulatory factors was harmless error. Though Dr. Munn said
plaintiff's joint function was significantly restricted,
he did not indicate what joints were affected or what
specific limitations the restriction caused. When he was
asked to identify the specific limitations, Dr. Munn simply
referred to his clinical notes (R. 434-36), which as
discussed above, state that plaintiff's symptoms are
controlled by medication and/or that her arthritis does not
cause any physical limitations. In other words, Dr.
Munn's “opinion” is vague, contradicted by
his own treatment notes, and sheds no light on
plaintiff's ability to engage in work activities. Because
assessing this opinion in accordance with the regulatory
factors would not have made it more substantial or relevant,
the ALJ's failure to do so is not a basis for remand.
fares better with her last argument, that the ALJ's RFC
“completely ignore[s] any limitations arising out of
Plaintiff's depression.” (Pl.'s Mem. Supp. Mot.
Summ. J., ECF 9 at 9.) With respect to this issue, the ALJ
The record contains notation of depression. However, there is
no evidence of symptoms or abnormal mental status tests
showing that the claimant has a mental disorder as described
in the 12.00 series of listings, including 12.04 for
affective disorders. In addition, there is no evidence of any
episodes of decompensation or any limitations in activities
of daily living, social functioning, and with regard to
concentration, persistence or pace. There is no evidence of
mental health treatment. Furthermore, the evidence does not
show that a mental disorder caused, or could be expected to