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Goffron v. Berryhill

United States District Court, N.D. Illinois, Eastern Division

May 24, 2018

DONNA M. GOFFRON, Plaintiff,
NANCY A. BERRYHILL, Deputy Commissioner for Operations, performing the duties and functions not reserved to the Commissioner of Social Security, Defendant.


          M. David Weisman United States Magistrate Judge

         Plaintiff Donna M. Goffron appeals the Commissioner's decision denying Plaintiff's claims for Disability Insurance benefits and Supplemental Security Income benefits under §§ 216(i), 223, 1611, and 1614 of the Social Security Act (“SSA”). For the reasons set forth below, the Court reverses the Commissioner's decision.


         This is the second time the denial of Plaintiff's disability benefits has been litigated in court. Plaintiff applied for benefits on February 17, 2010, alleging a disability onset of October 30, 2009 due to seizures, bipolar disorder, and depression. (R. 340-50; 469.) The Administrative Law Judge (“ALJ”) issued a partially favorable decision finding that Plaintiff was not disabled prior to January 1, 2013, but became disabled on that date and has continued to be disabled. (R. 1113-1130.) Plaintiff requested judicial review of the ALJ's decision (R. 1146- 49) and the matter was eventually remanded on February 1, 2016. (R. 1154-65.) On December 29, 2016, the ALJ again issued a partially favorable decision, finding that Plaintiff became disabled on January 1, 2013 and has continued to be disabled. (R. 1040-1070.) 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).


         The 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)). While generous, this standard “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).

         Under 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 Commissioner 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 she 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 Commissioner 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).

         At step one, the ALJ found that Plaintiff has not engaged in substantial gainful activity since November 4, 2009. (R. 1048.) At step two, the ALJ found that beginning or after November 4, 2009, Plaintiff had the following severe impairments: “seizure disorder controlled with medication, bipolar disorder, degenerative brain disorder with cerebral atrophy, tremors, syncopal episodes and memory loss, and history of substance abuse in full sustained remission.” (R. 1048.) At step three, the ALJ found that prior to January 1, 2013, Plaintiff “did not have an impairment or combination of impairments that meets or medically equals the severity of one of the listed impairments . . . .” (R. 1049.) This finding led the ALJ to conclude at step four that although Plaintiff could not perform any past relevant work prior to January 1, 2013, Plaintiff had the residual functional capacity “to perform a full range of work at all exertional levels” with certain exceptions. (R. 1055.) At step five, the ALJ determined that jobs existed in significant numbers in the national economy that Plaintiff could have performed, and thus she was not disabled prior to January 1, 2013. (R. 1067.)

         Evaluation of Opinion Evidence

         Plaintiff contends that the ALJ erroneously weighed the opinion evidence of non-examining physicians. The regulations state that “because nonexamining sources have no examining or treating relationship with [the claimant], the weight [given] their opinions will depend on the degree to which they provide supporting explanations for their opinions.” 20 C.F.R. §§ 404.1527(c)(3). Generally, “the more consistent a medical opinion is with the record as a whole, the more weight we will give to that medical opinion.” 20 C.F.R. §§ 404.1527(c)(4).

         Dr. Freeman

         Although Dr. Freeman's testimony is consistent with Dr. Shapiro's testimony (discussed further below), the ALJ “did not give Dr. Freeman's opinion great weight, ” finding his opinion “speculative” and “not supported by the objective medical evidence.” (R. 1063.) To the contrary, Dr. Freeman's opinion relied heavily on diagnostic testing, a fact that the ALJ himself acknowledged by stating that “Dr. Freeman supported his position by noting a CT scan that showed extensive cerebral atrophy.” (R. 1062.) While arguing that the objective medical evidence did not support Dr. Freeman's conclusion, the ALJ also simultaneously (and confusingly) contends that Dr. Freeman discounted the opinions of Plaintiff's treating physicians and placed too much weight on diagnostic testing - which constitutes quintessential objective medical evidence. (R. 1063.) Dr. Freeman stated that a number of Plaintiff's diagnoses were “confirmed medically to a high level of certainty” based on imaging and laboratory data. (R. 1032.) The regulations provide that “[t]he more a medical source presents relevant evidence to support a medical opinion, particularly medical signs and laboratory findings, the more weight [an ALJ should] give that medical opinion.” C.F.R. § 404.1527(c)(3). Accordingly, Dr. Freeman's reliance on laboratory findings should lend his opinion more, not less, weight. Moreover, one of the psychological consultative examinations that Dr. Freeman allegedly did not account for resulted in the following notes: Plaintiff's “appearance and hygiene were quite good, that her hair was neatly brushed, her clothing clean and her nails well-kept and polished.” (R. 1063.) Yet, a bipolar individual may be both well-groomed and disabled; physical appearance does not necessarily confirm a person's mental condition.

         The ALJ also mischaracterizes Dr. Freeman's opinion in finding that he “discount[ed] the reliability of clinical examination findings by Claimant's treating physicians.” (R. 1063.) In his opinion, Dr. Freeman merely noted that the diagnostic reliability of imaging/laboratory data is “extremely high, ” while that of clinical exam findings is “quite low.” (R. 1032.) He goes on to state that “independent of any clinical history or examination findings, ” the diagnoses were confirmed to a high level of certainty. (R. 1032.) The Court does not construe Dr. Freeman's use of the word “independent” as a signal that he “disregard[ed]” the clinical history, as the Commissioner argues; instead, he was stating that the diagnoses confirmed through imaging were reliable enough to stand on their own. (Dkt. 28 at p. 4.)

         The ALJ's challenge of Dr. Freeman's opinion based on its apparent failure to address inconsistencies and evidence of improvement, including reports of Plaintiff's stability, also lacks merit. (R. 1065.) As an initial matter, evidence suggesting that Plaintiff was “stable” prior to January 2013 does not confirm Plaintiff's actual health at the time. Courts have repeatedly held that “a person can have a condition that is ...

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