United States District Court, N.D. Illinois, Eastern Division
MEMORANDUM OPINION AND ORDER
Sunil
R. Harjani, United States Magistrate Judge.
Plaintiff
Kenneth P.[1] seeks judicial review of the final
decision of the Commissioner of Social Security denying his
application for Disability Insurance Benefits and
Supplemental Security Income Benefits. Specifically, Kenneth
seeks an award of benefits, or in the alternative, a remand
to the Commissioner for further proceedings. The Commissioner
filed a motion for summary judgment, asking the Court to
affirm the ALJ's denial of benefits. For the reasons set
forth below, the ALJ's decision is reversed and this case
is remanded for further proceedings consistent with this
Memorandum Opinion and Order.
I.
BACKGROUND
Before
filing for disability benefits in 2014, Kenneth worked as a
mailer and warehouse worker. (R. 302). In 2011, Kenneth was
diagnosed with Multiple Sclerosis (MS), after he began
experiencing problems with vision, speech, and balance.
Id. at 396, 418, 431. Following his diagnosis,
Kenneth began taking weekly injections of a medication called
Avonex but continued to report issues with balance and
vision; he additionally conveyed difficulties with memory,
concentration, mood, pain, and weight loss. Id. at
412, 431. At his hearing before the ALJ, Kenneth testified
that in 2013 he was fired from his most recent job because
his supervisor had to keep reminding him about simple tasks.
Id. at 48-49, 68-69. According to Kenneth, his
memory “wasn't working like it should.”
Id. at 69. After filing for disability benefits,
Kenneth was examined and evaluated by several medical
professionals.
Kenneth
filed applications for disability benefits and supplemental
security income benefits in April of 2014, alleging
disability beginning January 26, 2013. (R. 18). Kenneth's
claims were initially denied on September 2, 2014, and upon
reconsideration on May 22, 2015. Id. Upon
Kenneth's written request for a hearing, he appeared and
testified at a hearing held on February 1, 2017 before ALJ
James D. Wascher. Id. The ALJ also heard testimony
from vocational expert Linda Gels. Id. at 36.
On May
26, 2017, the ALJ issued a decision denying Kenneth's
applications for disability benefits and supplemental
security income benefits. (R. 29). The opinion followed the
required five-step evaluation process. 20 C.F.R. §
404.1520. At step one, the ALJ found that Kenneth had not
engaged in substantial gainful activity since January 26,
2013, the alleged onset date. Id. at 20. At step
two, the ALJ found that Kenneth had the severe impairments of
relapsing and remitting multiple sclerosis, degenerative disc
disease of cervical spine, and depressive disorder.
Id. At step three, the ALJ determined that Charles
did not have an impairment or combination of impairments that
met or medically equaled the severity of one of the listed
impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1 (20
C.F.R. §§ 404.1520(d), 404.1525, 404.1526,
416.920(d), 416.925, and 416.926). Id. at 21.
The ALJ
then concluded that Kenneth retained the residual functional
capacity (“RFC”) to perform sedentary work as
defined in 20 C.F.R. § 404.1567(a) and 416.967(a),
except that he:
can never climb ladders, ropes, or scaffolds, occasionally
climb ramps and stairs, occasionally stoop, kneel, crouch,
and crawl, frequently reach overhead bilaterally, can have
only occasional exposure to extreme cold and extreme heat,
must avoid all hazards such as machinery with moving
mechanical parts and unprotected heights, only occasional
bilateral wrist flexion and extension, and is able to perform
simple tasks with no interaction with the public.
(R. 22). Based on this RFC, the ALJ determined at step four
that Kenneth could not perform his past relevant work as a
warehouse worker and machine feeder. Id. at 27. At
step five, the ALJ found that there were jobs that exist in
significant numbers in the national economy that Kenneth
could perform. Id. at 28-29. Specifically, the ALJ
found Kenneth could work as a document repairer, table
worker, and touch up screener. Id. at 28. Because of
this determination, the ALJ found that Kenneth was not
disabled. Id. at 28-29. The Appeals Council denied
Kenneth's request for review on April 11, 2018, leaving
the ALJ's decision as the final decision of the
Commissioner. Id. at 1; McHenry v.
Berryhill, 911 F.3d 866, 871 (7th Cir. 2018).
II.
DISCUSSION
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). To determine whether a claimant is disabled,
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 listings 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)(4); 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)(4). “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. Steele v.
Barnhart, 290 F.3d 936, 940 (7th Cir. 2002). Substantial
evidence is “such relevant evidence as a reasonable
mind might accept as adequate to support a conclusion.”
Richardson v. Perales, 402 U.S. 389, 401 (1971).
“Although this standard is generous, it is not entirely
uncritical.” Steele, 290 F.3d at 940. Where
the Commissioner's decision “lacks evidentiary
support or is so poorly articulated as to prevent meaningful
review, the case must be remanded.” Id.
The ALJ
found Kenneth not disabled at step five of the sequential
analysis because he retains the RFC to perform other work
that exists in significant numbers in the national economy.
Kenneth asserts that the ALJ committed several reversible
errors. First, Kenneth argues that the ALJ erred in failing
to assess his subjective allegations according to SSR 16-3p.
Second, Kenneth argues that the ALJ erred in failing to
afford great weight to the opinion of Kenneth's treating
neurologist, Dr. Afif Hentati. Third, Kenneth asserts that
the ALJ's RFC assessment and hypothetical questions to
the vocational expert did not reflect Kenneth's
difficulty with concentration, persistence, or pace.
The
Court finds that the ALJ erred in the discounting of Dr.
Hentati's opinion. The Court also finds that the
ALJ's RFC assessment and the relied-upon hypothetical
question did not adequately encompass Kenneth's issues
with concentration, persistence, or pace.[2] Accordingly, for
the reasons discussed below, the ALJ's decision must be
reversed.
A.
Treating Physician Dr. Hentati
Kenneth
argues that the ALJ erred when he afforded only “some
weight” to Kenneth's treating neurologist, Dr.
Hentati. Kenneth further asserts that the reasons the ALJ
provided for discounting Dr. Hentati's opinion were
“based on legal or factual errors.” (Doc. 18 at
9). The Commissioner responds that the ALJ reasonably adopted
the majority of Dr. Hentati's opinion, while discounting
“those portions of the opinion that were unsupported by
evidence.” (Doc. 29 at 1).
The
opinion of a treating source is entitled to controlling
weight if the opinion “is well-supported by medically
acceptable clinical and laboratory diagnostic techniques and
is not inconsistent with the other substantial evidence in
[the] record.” 20 C.F.R. § 404.1527(c)(2);
Kaminski v. Berryhill, 894 F.3d 870, 874, 874 n.1
(7th Cir. 2018) (for claims filed before March 27, 2017, an
ALJ “should give controlling weight to the treating
physician's opinion as long as it is supported by medical
findings and consistent with substantial evidence in the
record.”). An ALJ must “offer good reasons for
discounting a treating physician's opinion.”
Campbell v. Astrue, 627 F.3d 299, 306 (7th Cir.
2010) (citations omitted); see also Walker v.
Berryhill, 900 F.3d 479, 485 (7th Cir. 2018). Those
reasons must be “supported by substantial evidence in
the record; a contradictory opinion of a non-examining
physician does not, by itself, suffice.” Gudgel v.
Barnhart, 345 F.3d 467, 470 (7th Cir. 2003). "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).
In Dr.
Hentati's medical source statement, he drew opinions
about Kenneth's physical and mental limitations. With
respect to Kenneth's physical limitations, Dr. Hentati
concluded that Kenneth would be "unable to perform jobs
...