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Hughes v. Berryhill

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

August 1, 2018

NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.



         Plaintiff Stephanie Hughes (“Hughes”) seeks judicial review of the final decision of the Commissioner of Social Security (“Commissioner”) denying her application for Disability Insurance Benefits (“DIB”) and Supplemental Security Income (“SSI”). Hughes asks the Court to reverse and remand the ALJ's decision, and the Commissioner seeks an order affirming the decision. For the reasons set forth below, the ALJ's decision is reversed and this case is remanded to the Social Security Administration for further proceedings consistent with this Opinion.

         I. BACKGROUND

         Hughes was born on July 4, 1964 and has a history of shortness of breath, leg and knee pain, and a heart attack in November 2013. Hughes alleges that she became totally disabled on August 1, 2012 due to coronary artery disease, hypertension, gastroesophageal reflux disease, and hyperlipidemia.[1] Hughes has a high school education and previously worked as a babysitter, bagger, cashier, and parent facilitator. Hughes' insured status for DIB purposes expired on September 30, 2014, which means Hughes had to show she was disabled on or before that date in order to be eligible for DIB. Shideler v. Astrue, 688 F.3d 308, 311 (7th Cir. 2012) (noting “the claimant must establish that he was disabled before the expiration of his insured status . . . to be eligible for disability insurance benefits.”).

         Under the standard five-step analysis used to evaluate disability, the ALJ found that Hughes had not engaged in substantial gainful activity since her alleged onset date of August 1, 2012 (step one) and her coronary artery disease, bilateral knee osteoarthritis, and restless legs syndrome (“RLS”) were severe impairments (step two). (R. 15). He determined that Hughes' hypertension, hyperlipidemia, and GERD were non-severe because they did not cause more than a minimal limitation in functioning. (R. 16). The ALJ found that that Hughes' coronary artery disease, bilateral knee osteoarthritis, and RLS did not qualify as a listed impairment (step three). (R. 20-21). The ALJ concluded that Hughes retained the residual functional capacity (“RFC”) to perform light work (i.e., “lifting no more than 20 pounds at a time with frequent lifting or carrying of objects weighing up to 10 pounds . . . [and] a good deal of walking or standing, or when it involves sitting most of the time with some pushing and pulling of arm or leg controls.”), see 20 C.F.R. § 404.1567(b); 416.967(b), except that she was limited to work requiring no climbing ladders, ropes, or scaffolds, kneeling, or crawling; occasional climbing of ramps and stairs, balancing, stooping, and crouching; no work in concentrated exposure to extreme cold or extreme heat; and no work around hazards such as unprotected heights and exposed moving mechanical parts. (R. 21).

         Given this RFC, the ALJ concluded that Hughes was able to perform her past relevant work as a child monitor as actually performed. (R. 23). As an alternate finding, at step five, the ALJ found that Hughes could perform other jobs that existed in significant numbers in the national economy, such as marker jobs, information clerk jobs, and ticket seller jobs. (R. 24). The Appeals Council denied Hughes' request for review on May 26, 2017. (R. 1-6). Hughes now seeks judicial review of the final administrative decision of the Commissioner, which is the ALJ's decision. O'Connor-Spinner v. Astrue, 627 F.3d 614, 618 (7th Cir. 2010).


         Under the Social Security Act, a person is disabled if he has an “inability to engage in any substantial gainful activity by reason of a 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 twelve months.” 42 U.S.C. § 423(d)(1)(a). In order to determine whether a claimant is disabled within the meaning of the Social Security Act, the ALJ conducts a five-step inquiry: (1) whether the claimant is currently unemployed; (2) whether the claimant has a severe impairment; (3) whether the claimant's impairment meets or equals any of the listing found in the regulations, see 20 C.F.R.' 404, Subpt. P, App. 1 (2004); (4) whether the claimant is unable to perform his former occupation; and (5) whether the claimant is unable to perform any other available work in light of his age, education, and work experience. 20 C.F.R.' 404.1520(a), 416.920(a) (2012); Clifford v. Apfel, 227 F.3d 863, 868 (7th Cir. 2000). These steps are to be performed sequentially. 20 C.F.R.' 404.1520(a) (2012). “An affirmative answer leads either to the next step, or, on Steps 3 and 5, to a finding that the claimant is disabled. A negative answer at any point, other than Step 3, ends the inquiry and leads to a determination that a claimant is not disabled.” Clifford, 227 F.3d at 868 (quoting Zalewski v. Heckler, 760 F.2d 160, 162 n.2 (7th Cir. 1985)).

         Judicial review of the ALJ's decision is limited to determining whether the ALJ's findings are supported by substantial evidence or based upon a legal error. Stevenson v. Chater, 105 F.3d 1151, 1153 (7th Cir. 1997). Substantial evidence is “such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” Ricardson v. Perales, 402 U.S. 389, 401 (1971). A reviewing court may not substitute its judgment for that of the Commissioner by reevaluating facts, reweighing evidence, resolving conflicts in evidence, or deciding questions of credibility. Estok v. Apfel, 152 F.3d 636, 638 (7th Cir. 1998). Finally, an ALJ's credibility determination should be upheld “unless it is patently wrong.” Schaaf v. Astrue, 602 F.3d 869, 875 (7th Cir. 2010).

         The ALJ denied Hughes' claim at step four and alternatively, at step five of the sequential evaluation process, finding that Hughes retains the residual functional capacity to perform her past relevant work as a child monitor as actually performed and a significant number of unskilled light jobs in the national economy. Hughes challenges the ALJ's decision on four grounds: (1) the ALJ erroneously failed to evaluate Hughes' obesity in combination with her other impairments; (2) the ALJ failed to adequately evaluate Hughes' bilateral osteoarthritis of the knees; (3) the ALJ failed to properly evaluate Hughes' RLS; and (4) substantial evidence does not support the ALJ's step-four decision that Hughes can perform her past relevant work as a child monitor as actually performed. The Court finds that the ALJ erred in determining Hughes' RFC by failing to evaluate Hughes' obesity and improperly evaluating her bilateral osteoarthritis of the knees and RLS. Because the ALJ will reevaluate Hughes' RFC on remand, the Court need not address whether the ALJ also erred at steps four and five as those determinations are dependent upon the flawed RFC assessment.

         A. The ALJ's Failure to Consider Hughes' Obesity

         Hughes contends that the ALJ failed to adequately evaluate her obesity including the aggravating impact that her obesity has on her bilateral knee osteoarthritis and RLS when formulating the RFC. Hughes suggests that her obesity aggravates the symptoms of her bilateral knee osteoarthritis and RLS and limits her ability to stand and/or walk. The Court agrees that the ALJ failed to specifically address Hughes' obesity and offered no analysis of the exacerbating effect of her obesity on her underlying conditions. The ALJ's failure to consider Hughes' obesity along with her other impairments was not harmless error.

         “According to SSR 02-1p, an ALJ should consider the effects of obesity together with the underlying impairments, even if the individual does not claim obesity as an impairment.” Prochaska v. Barnhart, 454 F.3d 731, 736 (7th Cir. 2006); see also Arnett v. Astrue, 676 F.3d 586, 593 (7th Cir. 2012) (stating “[a]n ALJ must factor in obesity when determining the aggregate impact of [a claimant's] impairments.”). That is so because “[t]he combined effects of obesity with other impairments can be greater than the effects of each of the impairments considered separately.” SSR 02-1p, 2002 WL 34686281, at *1 (Sept. 12, 2002).

         The record demonstrates that Hughes was obese during some of the applicable period. On March 3, 2014, Hughes' Body Mass. Index (BMI) was 30.81. (R. 448). A BMI of 30.0 or above is classified as obese. SSR 02-1p, 2002 WL 34686281, at *2 (Sept. 12, 2002). Hughes is 5'1” tall and her weight during the March 19, 2014 consultative examination with Dr. Velis was 165 pounds, meaning her BMI was 31.2.[2] (R. 19, 433). On November 16, 2015, Hughes had a BMI of 31.366. (R. 800). Her BMI increased to 32.783 on February 1, 2016. (R. 820). When Hughes saw Dr. Goldberg on May 10, 2016, her BMI was 33.444. (R. 842).

         Hughes argues that the ALJ failed to address how her obesity affected her knee pain and her ability to stand and/or walk six hours in an eight-hour workday. Hughes' argument has merit. “[U]nder S.S.R. 02-1p the ALJ must specifically address the effect of obesity on a claimant's limitations.” Villano v. Astrue, 556 F.3d 558, 562 (7th Cir. 2009). The ALJ barely acknowledged Hughes' weight in his decision. Apart from a reference to Hughes' testimony regarding her height and weight and one incorrect reference to Hughes being “overweight” with a BMI of 33.46, the ALJ did not discuss Hughes' weight. (R. 19, 22).[3] The ALJ did not mention the words “obese” or “obesity” in his decision. Accordingly, the ALJ erred by failing to specifically address the effect of Hughes' obesity when formulating the RFC. See Goins v. Colvin, 764 F.3d 677, 681 (7th Cir. 2014) (finding “[t]he [ALJ] gave meager attention to the plaintiff's obesity . . . . We keep telling . . . [ALJs] that they have to consider an applicant's medical problems in combination.”).

         The Commissioner does not dispute that Hughes was obese during the relevant time period and that the ALJ did not recognize that Hughes was obese. The Commissioner appears to suggest that the ALJ implicitly factored Hughes' obesity into the decision as part of the state agency physicians' opinions. (Doc. 19 at 2-3). In some cases, an ALJ's failure to explicitly discuss the impact of obesity may be harmless. “[T]his type of error may be harmless when the RFC is based on limitations identified by doctors who specifically noted obesity as a contributing factor to the exacerbation of other impairments.” Pepper v. Colvin, 712 F.3d 351, 364 (7th Cir. 2013); Skarbek v. Barnhart, 390 F.3d 500, 504 (7th Cir. 2004) (noting that “the ALJ adopted the limitations suggested by the specialists and reviewing ...

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