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Delaina N. C. v. Commissioner of Social Security

United States District Court, S.D. Illinois

July 30, 2018

Delaina N. C.[1] Plaintiff,



         In accordance with 42 U.S.C. § 405(g), plaintiff Delaina N. C. (Plaintiff) seeks judicial review of the final agency decision denying her application for Disability Insurance Benefits (DIB) pursuant to 42 U.S.C. § 423.

         Procedural History

         Plaintiff applied for DIB on August 12, 2013, alleging a disability onset date of June 3, 2013. (Tr. 181-87). Her application was denied at the initial level and again upon reconsideration. (Tr. 75, 89). Plaintiff requested an evidentiary hearing, which Administrative Law Judge (ALJ) Kevin R. Martin conducted in May 2016. (Tr. 37-74). ALJ Martin reached an unfavorable decision on August 17, 2016. (Tr. 15-36). The Appeals Council denied Plaintiff's request for review, rendering the ALJ's decision the final agency decision. (Tr. 1-6). Plaintiff exhausted her administrative remedies and filed a timely Complaint with this Court. (Doc. 1).

         Issues Raised by Plaintiff

         Plaintiff argues the ALJ erred in assessing the medical opinions of record and her allegations of the severity of her symptoms. She also asserts the ALJ's residual functional capacity assessment was not supported by substantial evidence.

         Applicable Legal Standards

         To qualify for DIB, a claimant must be disabled, which means 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).

         A “physical or mental impairment” is an impairment resulting from anatomical, physiological, or psychological abnormalities which are demonstrable by medically acceptable clinical and laboratory diagnostic techniques. 42 U.S.C. § 423(d)(3). “Substantial gainful activity” is work activity that involves doing significant physical or mental activities, and that is done for pay or profit. 20 C.F.R. § 404.1572.

         Social Security regulations set forth a sequential five-step inquiry to determine whether a claimant is disabled. The Seventh Circuit Court of Appeals has explained this process as follows:

The first step considers whether the applicant is engaging in substantial gainful activity. The second step evaluates whether an alleged physical or mental impairment is severe, medically determinable, and meets a durational requirement. The third step compares the impairment to a list of impairments that are considered conclusively disabling. If the impairment meets or equals one of the listed impairments, then the applicant is considered disabled; if the impairment does not meet or equal a listed impairment, then the evaluation continues. The fourth step assesses an applicant's residual functional capacity (RFC) and ability to engage in past relevant work. If an applicant can engage in past relevant work, he is not disabled. The fifth step assesses the applicant's RFC, as well as his age, education, and work experience to determine whether the applicant can engage in other work. If the applicant can engage in other work, he is not disabled.

Weatherbee v. Astrue, 649 F.3d 565, 568-569 (7th Cir. 2011).

         Stated another way, it must be determined: (1) whether the claimant is presently unemployed; (2) whether the claimant has an impairment or combination of impairments that is serious; (3) whether the impairments meet or equal one of the listed impairments acknowledged to be conclusively disabling; (4) whether the claimant can perform past relevant work; and (5) whether the claimant is capable of performing any work within the economy, given his or her age, education and work experience. 20 C.F.R. § 404.1520; Simila v. Astrue, 573 F.3d 503, 512-513 (7th Cir. 2009); Schroeter v. Sullivan, 977 F.2d 391, 393 (7th Cir. 1992).

         If the answer at steps one and two is “yes, ” the claimant will automatically be found disabled if he or she suffers from a listed impairment, determined at step three. If the claimant does not have a listed impairment at step three, and cannot perform his or her past work (step four), the burden shifts to the Commissioner at step five to show that the claimant can perform some other job. Rhoderick v. Heckler, 737 F.2d 714, 715 (7th Cir. 1984). See also Zurawski v. Halter, 245 F.3d 881, 886 (7th Cir. 2001) (Under the five-step evaluation, an “affirmative answer leads either to the next step, or, on Steps 3 and 5, to a finding that the claimant is disabled. . . . If a claimant reaches step 5, the burden shifts to the ALJ to establish that the claimant is capable of performing work in the national economy.”).

         This Court reviews the Commissioner's decision to ensure that the decision is supported by substantial evidence and that no mistakes of law were made. It is important to recognize that the scope of review is limited. “The findings of the Commissioner of Social Security as to any fact, if supported by substantial evidence, shall be conclusive . . . .” 42 U.S.C. § 405(g). Thus, this Court must determine not whether plaintiff was, in fact, disabled at the relevant time, but whether the ALJ's findings were supported by substantial evidence and whether any errors of law were made. See Books v. Chater, 91 F.3d 972, 977-78 (7th Cir. 1996) (citing Diaz v. Chater, 55 F.3d 300, 306 (7th Cir. 1995)). This Court uses the Supreme Court's definition of substantial evidence, i.e., “such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” Richardson v. Perales, 402 U.S. 389, 401 (1971).

         In reviewing for “substantial evidence, ” the entire administrative record is taken into consideration, but this Court does not reweigh evidence, resolve conflicts, decide questions of credibility, or substitute its own judgment for that of the ALJ. Brewer v. Chater, 103 F.3d 1384, 1390 (7th Cir. 1997); Moore v. Colvin, 743 F.3d 1118, 1121 (7th Cir. 2014). However, while judicial review is deferential, it is not abject; this Court does not act as a rubber stamp for the Commissioner. See Parker v. Astrue, 597 F.3d 920, 921 (7th Cir. 2010), and cases cited therein.

         The ALJ's Decision

         The ALJ applied the five-step analytical framework set forth above. He determined Plaintiff met the insured status requirements through December 31, 2018 and had not engaged in substantial gainful activity since June 7, 2013. (Tr. 20). Plaintiff had severe impairments of degenerative disc disease status post surgeries, fibromyalgia, chronic pain syndrome, anxiety, and depression. (Tr. 21). She had the RFC to perform sedentary work with several additional limitations, which precluded her from performing any past relevant work. (Tr. 24, 29). However, there were other jobs in the national economy Plaintiff could perform, so she was not disabled. (Tr. 29-30).

         The Evidentiary Record

         The Court has reviewed and considered the entire evidentiary record in formulating this Memorandum and Order. The following summary of the record is directed to the points raised by Plaintiff.

         1. Agency Forms

         In her agency forms, Plaintiff alleged that spinal stenosis, degenerative disc disease, a lumbar fusion, failed back surgery syndrome, anxiety, depression, a leg length discrepancy, insomnia, GERD, and severe back pain limited her ability to work. (Tr. 202).

         Plaintiff completed a function report in March 2014 and stated she was unable to stand for more than 10 to 15 minutes at a time without severe pain in her back and right leg. She could not sit in a chair for more than 30 minutes without pain. Plaintiff could not bend, twist, stoop, squat, or kneel excessively. She could not lift more than 20 pounds. Plaintiff could walk for about 20 to 30 minutes and could sometimes tolerate walking for up to an hour. (Tr. 216, 221). On an average day, Plaintiff woke up, made her bed, let her dogs outside, sat on the couch and drank coffee, showered, and then sat in a chair to finish getting ready. Showering caused her pain. After getting ready, she drove herself to physical therapy for an hour. (Tr. 217). She sometimes ran errands after physical therapy if she was not in pain. She usually had to lie down for an hour to rest her back after getting home. After resting, Plaintiff emptied the dishwasher and picked up around the house. She helped fix supper and fed her dogs. (Tr. 223).

         Plaintiff was able to feed and water her dogs and let them outside. Her spouse shared these responsibilities with her. She could also prepare complete meals with several courses on a daily basis. She had to sit on a stool to do most of her cooking and her husband helped. Plaintiff did laundry, washed dishes, went grocery shopping, and dusted on a weekly basis. Plaintiff needed help with groceries and dusting on occasion. Sometimes, Plaintiff was in too much pain to fall asleep. She could not drive more than 30 miles due to pain. Plaintiff's hobbies included reading, crafting, traveling, and antiquing. She could “do all of them well.” However, she could not craft as much as she used to because she could not sit for long periods. Her ability to travel and antique was also limited because she could not ride in a car or walk for long periods. (Tr. 217-20).

         Plaintiff's husband, Daniel, completed a third party function report, which corroborated Plaintiff's alleged limitations. He also stated Plaintiff and he were no longer able to have date nights because of Plaintiff's pain. Overall, they spent less time as a family because of her conditions. (Tr. 230-37).

         Plaintiff completed an additional function report in May 2014. She stated she had to have a chair in her shower because she could not wash her hair or body, or shave without extreme pain. She also used a chair to cook, wash dishes, and get ready because she could not stand long enough to complete these activities without pain. Her husband helped her grocery shop because she could not carry or load bags. Her husband also drove her anywhere that was more than 10 minutes away. Plaintiff's daily chores were “very light duty with several breaks every 15-20 minutes” where she had to lay flat for 10-15 minutes at a time. (Tr. 253, 261).

         2. Medical Records

         Dr. Evan Belfer was Plaintiff's primary care physician from February 23, 2009 until March 30, 2016. The record reflects that Plaintiff saw Dr. Belfer on over 20 occasions from March 2012 to May 2016. Dr. Belfer's notes are handwritten and often illegible. However, it appears Plaintiff frequently complained of back and muscle pain, difficulty sleeping, and depression. Dr. Belfer assessed Plaintiff with lower back pain, insomnia, hypothyroidism, myalgia, and depression. He prescribed a variety of medications at different points, including Wellbutrin, Topiramate, Temazepam, Cyclobenzaprine, Ativan, Cymbalta, Depakote, and Flexeril. (Tr. 603-13, 931-34, 965-76).

         On February 15, 2013, Plaintiff began seeing Dr. Joel Ray, a neurosurgeon, for back and leg pain. At the initial consultation, she stated she was able to get into positions that offered almost complete relief, but those positions were not functional with bending her knees, bending her back to open up the spine, or lying down. As soon as she stood for any period, she had excruciating leg pain and increased back pain. Dr. Ray noted that Plaintiff continued to work and was “apparently tolerating that.” She tolerated her work environment but felt her life was very dysfunctional due to her pain. On physical examination, Plaintiff demonstrated leg and back pain while standing. A straight leg raise was positive on the right at about 30 degrees, with a mild increase in her right leg pain. Resistive motor testing was 5/5 and equal and there was some slight decrease to external rotation of the right foot and minimal decrease of the great toe. Her reflexes were � and equal bilaterally with a slightly increased ankle jerk on the right. Dr. Ray referred Plaintiff for electrical studies and a pain management consultation and scheduled MRIs and CAT scans. He also recommended an aquatics therapy program and told her to consider a dorsal column stimulator (DCS) and a right L5-S1 transforaminal lumbar interbody fusion (TLIF). (Tr. 759-62).

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