United States District Court, N.D. Illinois, Eastern Division
FINNEGAN, UNITED STATES MAGISTRATE JUDGE
Douglas M. seeks to overturn the final decision of the
Commissioner of Social Security (“Commissioner”)
denying his applications for Disability Insurance Benefits
(“DIB”) and Supplemental Security Income
(“SSI”) under Titles II and XVI, respectively, of
the Social Security Act (“SSA”). (Doc. 1). The
parties consented to the jurisdiction of the United States
Magistrate Judge pursuant to 28 U.S.C. § 636(c), and the
case was reassigned to this Court. (Docs. 7, 8). The parties
filed cross-motions for summary judgment. (Docs. 11, 19).
After careful review of the record and the parties'
respective arguments, the Court concludes that the case must
be remanded for further proceedings as outlined below. The
Court therefore denies the Commissioner's motion and
grants Plaintiff's request for remand.
applied for DIB and SSI on January 23, 2015, alleging
disability since January 1, 2012 due to chronic obstructive
pulmonary disease (“COPD”) and bipolar disorder.
(R. 15, 64, 82, 102-103, 118-119, 207, 214,
239). Born in May 1966, Plaintiff was 45 years
old at the time of the alleged onset date (R. 31, 235), which
is defined as a younger individual. 20 C.F.R. §
404.1563(c). His date last insured was September 30, 2012.
(R. 17, 235).
Social Security Administration denied Plaintiff's
applications initially on August 19, 2015, and on
reconsideration on December 22, 2015. (R. 100-01, 129-30,
149-51, 153-55). Plaintiff then requested a hearing, which
was held before Administrative Law Judge (“ALJ”)
Carla Suffi on May 24, 2017, where Plaintiff was represented
by counsel. (R. 38-63, 157-58). Both Plaintiff and Vocational
Expert (“VE”) Grace Gianforte testified at the
hearing. (R. 15, 38-63).
denied Plaintiff's claims in a decision dated September
12, 2017. (R. 12-37). The ALJ found that Plaintiff's
obesity, asthma and COPD, bipolar disorder, antisocial
personality disorder, and history of substance abuse are
severe impairments, but they do not meet or equal any of the
listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix
1. (R. 17-22). The ALJ concluded that Plaintiff was not
disabled from his January 1, 2012 alleged onset date through
the date of the decision because he retained the residual
functional capacity (“RFC”) to perform medium
work with physical limitations not at issue here and mental
restrictions, as described to the VE, and is capable of
performing past relevant work and other jobs that exist in
significant numbers in the national economy. (R. 15-16, 22,
Appeals Council denied Plaintiff's request for review on
April 11, 2018 (R. 1-6), rendering the ALJ's September
2017 decision the final decision of the Commissioner
reviewable by this Court. Shauger v. Astrue, 675
F.3d 690, 695 (7th Cir. 2012). Plaintiff commenced this
action on May 31, 2018 and now seeks reversal or remand,
arguing that the ALJ: (1) improperly weighed the medical
opinions; (2) omitted mental limitations from the
hypothetical posed to the VE; (3) failed to consider the
medical evidence; and (4) erroneously evaluated his
subjective allegations of mental impairment. As explained
below, the Court concludes that this case must be remanded
because the ALJ relied on opinion evidence that does not
support the RFC and failed to account for all of
Plaintiff's limitations in the RFC and corresponding
hypothetical to the VE.
Work and Medical History
has a general equivalency diploma. (R. 42, 240). He worked
from 2002 to 2005 or 2006 as a homemaker and from 2008 to
2009 as a laborer. (R. 44-45, 240). He stopped working in
2009 for reasons unrelated to his impairments and has not
worked at all since 2012. (R. 17, 22, 44, 239). Plaintiff was
in the custody of the Illinois Department of Corrections
(“IDOC”) from October 2012 to January 2015.
(See R. 460, 517). Plaintiff alleges disability
beginning January 1, 2012, and his date last insured for
purposes of DIB was September 30, 2012. (R. 15, 17, 64, 82,
102-103, 118-119, 207, 214, 235, 239). The bulk of
Plaintiff's treatment records are from the period of his
incarceration from October 2012 to January 2015; the record
does not include treatment records before this period and
includes only very limited records after his release.
incarcerated, in October 2012, a psychiatrist diagnosed
Plaintiff with bipolar disorder, assigned a Global Assessment
of Functioning (“GAF”) score of 50, and
prescribed observation and medications. (R.
459). Several days later, a psychologist
performed an intake evaluation of Plaintiff, noted variable
affect but otherwise normal findings, referred Plaintiff for
continued mental health services, and concluded that he
“seems okay for a general population
institution.” (R. 460). In December 2012, another
psychologist performed a mental health screening, assigned a
GAF score of 70, and referred Plaintiff to a psychiatrist for
“routine” services. (R. 461-63).
2013, Plaintiff attended group and individual therapy
sessions in prison and displayed “appropriate”
mental status in terms of appearance, behavior, mood, affect,
concentration, memory, speech, and thoughts. (R. 464, 466,
469-70, 589-90). In February 2013, a doctor assigned a GAF
score of 50 and restarted medication, which Plaintiff was
willing to take once he understood it was for bipolar
disorder and could help him sleep. (R. 587). In November
2013, a psychiatrist noted appropriate mental status
findings, but found that Plaintiff was not cooperative, not
coherent, did not make appropriate eye contact, and had poor
insight, judgment, and impulse control. (R. 468). In December
2013, a psychiatrist assigned a GAF score of 60-65. (R.
2014, Plaintiff continued to attend group and individual
therapy sessions in prison and displayed appropriate mental
status throughout the year. (R. 471, 475-76, 495, 498-501,
505-10, 514-16). In March 2014, a psychotherapist noted
agitated mood and irritable affect but otherwise appropriate
mental status findings. (R. 474). In May 2014, a psychologist
observed that Plaintiff was posturing aggressively,
guarded/suspicious, and irritable, but noted otherwise normal
findings. (R. 479-80, 490). Beginning in June 2014,
Plaintiff's treatment plan included a GAF score of 68;
and, for the rest of the year, Plaintiff reported no mental
health issues. (R. 498-99, 501-08, 511-15). In April, May,
and July of 2014, a psychiatrist assigned GAF scores of 60-65
and, in November, a GAF score of 65-70; the psychiatrist
consistently noted no current medications. (R. 475, 495-97,
500, 509). In January 2015, Plaintiff displayed appropriate
mental status, and he reported no mental health issues. (R.
517). Shortly thereafter, he was released from prison.
his release, Plaintiff applied for DIB and SSI (on January
23, 2015) and also sought services from the Human Resources
Development Institute (“HRDI”). In February 2015,
a mental health professional assessed Plaintiff, noting
apparent moderate impairment of functioning based on his
social isolation, finding his prognosis to be fair, and
describing a favorable prognosis of a decrease in symptoms
through medication and therapy. (R. 547-48, 555, 579-81). A
complete psychiatric evaluation was scheduled for later that
month (R. 555-56, 579), but the record does not include
documentation of that appointment.
April 2015, a case manager completed a Level of Care
Utilization System (“LOCUS”) assessment to make
treatment recommendations, assigning Plaintiff a total score
of 19 and requesting Level III Community Support Team
services. (R. 548, 553-54, 574-81). The LOCUS assessment does
not include accompanying findings of specific functional
limitations. (R. 574-77). HRDI records also reflect diagnoses
of bipolar and antisocial personality disorders and a GAF
score of 51, but do not indicate when and by whom those
assessments were made or include accompanying findings. (R.
548, 574). The HRDI case manager called Plaintiff twice in
May 2015 for routine wellness checks; he reportedly had
attended only one group therapy session because he was
helping care for his ailing mother (R. 551-52), however, the
record does not include documentation of that visit. There
are no other treatment notes from HRDI (or any other provider
for that matter) after May 2015 through the hearing before
the ALJ in May 2017.
20, 2015, consultative examining physician Ana Gil, M.D.
performed a psychiatric examination of Plaintiff. (R.
613-17). Dr. Gil observed that Plaintiff was well groomed,
had good hygiene, and wore clothes that were clean and
appropriate for the weather. (R. 613). He understood that the
purpose of the visit was to evaluate his claim for disability
benefits. (Id.). Plaintiff reported taking
medications, having mood swings, feeling irritable and angry,
having rapid speech and racing thoughts, experiencing periods
of depression, and having short-term memory impairment. (R.
613-14). His activities of daily living included performing
daily grooming and hygiene, making meals, taking public
transportation, attending weekly group therapy sessions,
paying bills, and keeping up with the news. (R.
found that Plaintiff was cooperative and polite, but he
related in a distant manner and displayed poor eye contact,
downcast gaze, moderate psychomotor agitation, extreme
restlessness, and poor attention span. (R. 613, 615-16). Dr.
Gil found that it was difficult to get Plaintiff to
concentrate and had to repeat questions and redirect him
throughout the examination. (Id.). Dr. Gil
determined that Plaintiff had a mildly anxious, sad,
irritable, and restricted affect and a moderately depressed
mood. (R. 615-16). Plaintiff had flight of ideas and
tangentiality, but Dr. Gil found no evidence of thought
process disorder. (R. 613, 615-16). Dr. Gil assessed
Plaintiff's speech as coherent, but pressured,
hyper-inclusive, loud, and at times irrelevant. (R. 613,
615). Dr. Gil diagnosed bipolar disorder, history of heroin
abuse, antisocial personality disorder, and conduct disorder.
(R. 616). Dr. Gil concluded that Plaintiff would not be able
by himself to handle any funds awarded. (R. 617).
July 20, 2015, consultative examining physician Rochelle
Hawkins, M.D. performed a physical examination of Plaintiff.
(R. 602-10). Plaintiff understood that the purpose of the
visit was to evaluate his claim for disability benefits. (R.
602). Dr. Hawkins noted that Plaintiff was independent with
activities of daily living. (R. 603). Dr. Hawkins found that
Plaintiff's speech was normal, he was alert and oriented,
his grooming and hygiene were good, his memory was fair, and
his judgment was intact. (R. 603, 605). Dr. Hawkins concluded
that Plaintiff would need assistance handling his funds. (R.
State Agency Reviewing Physician Opinions
initial review on August 5, 2015, state agency reviewing
physician David Biscardi, Ph.D. opined that Plaintiff
retained the capacity to understand, remember, carry out, and
sustain performance of one- to three-step tasks; complete a
normal workday; interact briefly/superficially with
coworkers/supervisors with no public contact; and adapt to
changes/stressors associated with simple routine competitive
work activities. (R. 79, 97). On reconsideration on December
11, 2015, state agency reviewing physician Kirk Boyenga,
Ph.D. rendered the same opinion. (R. 115).