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Tasha C. v. Saul

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

December 17, 2019

TASHA C., Plaintiff,
ANDREW M. SAUL, Acting Commissioner of Social Security, Defendant.



         Plaintiff Tasha C.[1] seeks judicial review of the final decision of the Commissioner of Social Security denying her application for Disability Insurance Benefits. Tasha asks the Court to reverse and remand the ALJ's decision, and the Commissioner moves for its affirmance. 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

         Tasha suffered a workplace injury in March 2009, which led to Tasha undergoing rotator cuff surgery in October 2009 and anterior spinal discectomy and fusion surgery in May 2011. (R. 367-70, 419, 732). In July 2012, Tasha left her job as a machine and line operator due to worsening back pain. Id. at 44-46. Near the time of her exit, she presented to pain specialist, Dr. Jalaja Piska, with intense low back pain, numbness, tingling and weakness. Id. at 398. Tasha further reported difficulties with sleeping, walking, standing, and getting up from a sitting position. Id. Additionally, Tasha informed Dr. Piska that it was difficult for Tasha to stand, walk, or sit for long periods of time. Id.

         Tasha's subsequent medical record is immense and details Tasha undergoing surgery, physical therapy, and more in response to a wide array of ailments. For instance, the treatment records describe Tasha's February 2013 left knee surgery after a meniscus tear, (R. 968, 971), as well as several emergency room visits for knee, neck, shoulder, and back pain in 2013. See, e.g., Id. at 1073, 1094, 1184, and 1210. According to her treatment records, Tasha underwent a series of left knee injections in June 2014, id. at 977, had corrective surgery on her right shoulder in July 2015, id. at 1392-1393, and received epidural steroid injections for cervical radiculopathy in February 2017. Id. at 1548. Tasha participated in physical therapy for her left knee and right shoulder in the fall of 2015, id. at 1655, for cervical spine and shoulder pain over the span of several months in 2016, and for cervical spine pain in early 2017. Id. at 1799, 1874, 1890, 1894.

         The record is varied on the success of these treatments. As an example, Tasha was discharged from physical therapy in November 2016 with Physical Therapist Wendy Jorjorian stating that Tasha had a full range of motion in her neck and shoulders, and that her pain and radicular symptoms had been abolished. (R. 1890). Yet only a few months later, Tasha began physical therapy again for cervical spine pain, reporting that she was experiencing anywhere from 3/10 to 10/10 pain and numbness in her right hand. Id. at 1894, 1907. Following that report, Tasha received epidural steroid injections for cervical radiculopathy. Id. at 1548.

         In the midst of these medical treatments, Tasha attempted to work. At her hearing before the ALJ, Tasha testified that she started numerous jobs that lasted only a couple of days to a couple of weeks, due to her injuries. According to Tasha, her job as an assembly line packer in 2015 ended after a couple of days because she could not remain standing. (R. 44). Tasha testified that in 2016 she started two machine operating jobs that ended prematurely due to the pain she was experiencing in her legs and because of her knee injuries. Id. at 42-43. In December 2016, Tasha obtained a temporary assignment stocking shelves for a department store, which lasted approximately ten days. Id. at 39-41.

         Tasha filed applications for disability benefits in September 2014, alleging disability beginning July 10, 2012. (R. 233). Tasha's claim was initially denied on December 15, 2014, and upon reconsideration on April 8, 2015. Id. at 116-19, 121-25. Upon Tasha's written request for a hearing, she appeared before ALJ Diane S. Davis on two occasions. At the first hearing, on September 21, 2016, the ALJ continued the hearing because Tasha was waiting on medical records from the 2015 to 2016 time period. Id. at 80-83. Dr. Ashok G. Jilhewar, who appeared as a medical expert, testified that he could not state his opinion without reviewing the missing records. Id. at 82-83. At the second hearing, on February 17, 2017, the ALJ heard testimony from Tasha and the vocational expert, Robert Burkins. Id. at 33. However, no medical expert appeared or presented testimony at the second hearing.

         On June 28, 2017, the ALJ issued a decision denying Tasha's application for disability benefits. (R. 23). The opinion followed the required five-step evaluation process. 20 C.F.R. § 404.1520. At step one, the ALJ found that Tasha had not engaged in substantial gainful activity since July 10, 2012, the alleged onset date. (R. 16). At step two, the ALJ found that Tasha had the severe impairments of status-post lumbar fusion, right shoulder arthropathy, with two repairs to rotator cuff, and degenerative joint disease of the left knee, status-post left knee medial meniscus repair. Id. at 17. At step three, the ALJ determined that Tasha 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, and 404.1526). Id. at 17-18.

         The ALJ then concluded that Tasha retained the residual functional capacity (“RFC”) to perform light work as defined in 20 C.F.R. § 404.1567(b), except that she:

can lift and/or carry twenty pounds occasionally, and ten pounds frequently. She can stand and/or walk for four hours total in an eight-hour workday with normal breaks and sit for about six hours in an eight-hour workday with normal breaks. She can occasionally stoop, kneel, crouch, crawl, and climb. She can frequently reach in all directions with the right, dominant upper extremity.

         (R. 18). Based on this RFC, the ALJ determined at step four that Tasha could not perform her past relevant work as a machine feeder. Id. at 21-22. At step five, the ALJ found that there were jobs that exist in significant numbers in the national economy that Tasha could perform. Id. at 22-23. Specifically, the ALJ found Tasha could work as an injection mold machine tender or sorter. Id. at 22. Because of this determination, the ALJ found that Tasha was not disabled. Id. at 23. The Appeals Council denied Tasha's request for review on May 4, 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).


         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 her former occupation; and (5) whether the claimant is unable to perform any other available work in light of her 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 Tasha not disabled at step five of the sequential analysis because she retains the RFC to perform other work that exists in significant numbers in the national economy. Tasha argues that the ALJ committed several reversible errors. First, Tasha asserts that the ALJ relied upon improper inferences and engaged in cherry picking to reject her symptom allegations. Doc. [13] at 7-11. Second, Tasha states that the ALJ improperly weighed the medical opinions. Id. at 11-12. Third, Tasha contends that the ALJ tailored the RFC assessment to “eke out a finding” that Tasha is not disabled. Id. at 12-13. Finally, Tasha argues that the ALJ erroneously accepted the vocational expert's testimony regarding available jobs that Tasha would be able to perform. Id. at 13-14.

         The Court finds that the ALJ failed to properly weigh the medical opinions in this case, mischaracterized the record, and failed to properly develop the medical evidence. These errors, in combination, are not harmless. Accordingly, for the reasons discussed below, the ALJ's decision must be reversed.[2]

         A. Weighing of Medical Opinions

         Tasha argues that the ALJ “virtually ignored” the regulatory factors in weighing the medical opinions of treating and non-treating physicians. Doc. [13] at 11. According to Tasha, the ALJ “simply assigned little or no weight to each professional's opinion, without any discussion of the regulatory factors, and seemingly without regard to what the opinion was.” Id.

         1. Applicable Law

         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) (internal quotation marks and 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, ...

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