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Douglas M. v. Saul

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

November 19, 2019

DOUGLAS M., Plaintiff,
ANDREW M. SAUL, Commissioner of Social Security, Defendant.



         Plaintiff 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.


         I. Procedural History

         Plaintiff 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).[1] 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).

         The 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).

         The ALJ 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, 30-32, 60-61).[2]

         The 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.[3] 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.

         II. Work and Medical History

         Plaintiff 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.

         While 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).[4] 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).[5]

         Throughout 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).[6] 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. 470).[7]

         In 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.[8] (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.[9] (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. (Id.).

         Following 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.

         In 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).[10] 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.

         III. Consultative Examinations

         On July 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. 614-15).[11]

         Dr. Gil 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).

         Also on 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. 605).

         IV. State Agency Reviewing Physician Opinions

         On 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).[12]


         I. ...

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