Roberts v. Saul
| Decision Date | 18 March 2020 |
| Docket Number | Case No. 3:19-CV-086 JD |
| Parties | LISA A. ROBERTS Plaintiff, v. ANDREW M. SAUL, Commissioner of Social Security, Defendant. |
| Court | U.S. District Court — Northern District of Indiana |
Lisa Roberts applied for social security disability insurance benefits, alleging that she has been unable to work since October 11, 2012. The ALJ found that she has several severe impairments including degenerative disc disease of the lumbar spine with osteoarthritis, arthritis in her right shoulder with a rotator cuff tear, fibromyalgia, anxiety, and depression. The ALJ determined that Ms. Roberts was capable of light work with some additional limitations. Based on the Vocational Expert's testimony, the ALJ found that Ms. Roberts was unable to perform any past relevant work but could find other jobs in the economy including work as a school bus monitor, counter clerk, and investigator dealer accounts. (R. 95). Ms. Roberts argues that, in formulating her residual functional capacity, the ALJ improperly evaluated her treating physician's opinion and erred in weighing her subjective symptoms. The Court agrees that the ALJ improperly evaluated Ms. Roberts' treating physician's opinion and, therefore, remand is required.
Prior to the onset of her disability, Ms. Roberts worked at a manufacturing plant for ten years before it closed and then worked as a crane operator and shipping/receiving manager from 2008 to 2012. (R. 922). In 2012, Ms. Roberts was diagnosed with bulging discs in her back and began to see a pain management specialist for those problems. (R. 495, 515). She continued to experience persistent and chronic back pain for several years. (R. 495, 497, 480). In 2015, she also started to experience shoulder and hip pain. (R. 480, 526). For several years, Ms. Roberts completed physical therapy including aquatic therapy, which provided her with some pain relief. (R. 473, 479, 481, 526, 769, 896). In June of 2015, Ms. Roberts' medical records show that she began experiencing pain throughout her whole body, which was aggravated by any movement. (R. 476). She indicated to her treating physician, Dr. G. Larsen Kneller, that all movements were painful and that she was experiencing tenderness in all of her joints. Id. She also told her pain specialist, Dr. Kazi, that physical activity, exertion, weightlifting, and laying down all caused her pain. (R. 526). Dr. Kazi asked her to continue her physical therapy and prescribed her Lyrica to help manage the pain. (R. 528).
In December of 2015, Dr. Kneller referred Ms. Roberts to Dr. Domingo, a rheumatologist, for the pain she was experiencing all over her body. (R. 542). In her notes, Dr. Domingo stated that Ms. Roberts described the pain as severe and worsening, that Ms. Roberts experienced increased pain after cleaning houses (her work activity at the time), and that her symptoms were relieved by warm soaks and water therapy. Id. At this appointment, Dr. Domingo found Ms. Roberts to have multiple tender points (18/18), diagnosed her with fibromyalgia, and started her on Cymbalta. (R. 545). At the end of her medical note, Dr. Domingo indicated that Ms. Roberts would have to return to her primary care physician for treatment as she would not be able to follow Ms. Roberts' care on a regular basis. Id. At her two-month check-up following this diagnosis, Ms. Roberts indicated that she was still experiencingwidespread pain that was triggered by repetitive activity and that she had stopped taking Cymbalta because it caused her to suffer from headaches. (R. 551).
Ms. Roberts' problems with her back and fibromyalgia continued through 2016 and 2017. In May of 2016, in an appointment with Dr. Kneller, Ms. Roberts reported experiencing an ongoing pattern of pain throughout her body that was persistent, severe, and worsening. (R. 769). In the fall of 2016, she was directed by Dr. Kazi to complete two treatments of physical therapy per week for a month to help manage her pain. (R. 652). In the spring of 2017, she continued to be treated for chronic low back and bilateral hip pain, which was noted to be constant but controlled with her pain medication. (R. 738). She continued to attend physical therapy appointments in 2017 since she was still experiencing generalized pain with all active movements. (R. 840). In June of 2017, Ms. Roberts reported to Dr. Kneller that in the previous two months she experienced acute fatigue and Dr. Kneller noted that the likely cause of "most if not all of her complaints" was fibromyalgia. (R. 879).
At the hearing with the ALJ on October 25, 2017, Ms. Roberts testified that she had problems with her hips and that it hurt for her to sit because her lower back had herniated discs and degenerative discs. (R. 61). She told the ALJ that after being diagnosed with fibromyalgia, she was unable to take the prescribed medication for fibromyalgia because they made her feel sick and gave her headaches. (R. 64). Ms. Roberts stated that the pain caused by her back and hips prevented her from sleeping and that prescription medications do not help her. (R. 68). After hearing testimony from Ms. Roberts and the Vocational Expert, the ALJ made the following residual functional capacity finding:
After careful consideration of the entire record, I find that the claimant had the residual functional capacity to perform light work as defined in 20 CFR 404.1567(b) and 416.967(b) except the claimant can occasionally climb ramps and stairs, but can never climb ladders, ropes or scaffolds. She can occasionally balance,stoop, kneel, crouch and crawl. She should avoid concentrated exposure to extreme heat, extreme cold, moving machinery, unprotected heights, and wet slippery surfaces. The claimant can occasionally reach in all directions, including overhead, bilaterally; She can frequently handle/finger bilaterally, and can frequently push/pull and operate foot controls bilaterally. . . . Last, the claimant can occasionally adapt to rapid changes in the workplace.
(R. 24-25). The ALJ ultimately found that Ms. Roberts was not disabled. The Appeals Council declined review, and Ms. Roberts filed this action seeking judicial review of the Commissioner's decision.
Because the Appeals Council denied review, the Court evaluates the ALJ's decision as the final word of the Commissioner of Social Security. Schomas v. Colvin, 732 F.3d 702, 707 (7th Cir. 2013). This Court will affirm the Commissioner's findings of fact and denial of benefits if they are supported by substantial evidence. Craft v. Astrue, 539 F.3d 668, 673 (7th Cir. 2008). Substantial evidence consists of "such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Richardson v. Perales, 402 U.S. 389, 401 (1971). This evidence must be "more than a scintilla but may be less than a preponderance." Skinner v. Astrue, 478 F.3d 836, 841 (7th Cir. 2007). Even if "reasonable minds could differ" about the disability status of the claimant, the Court must affirm the Commissioner's decision as long as it is adequately supported. Elder v. Astrue, 529 F.3d 408, 413 (7th Cir. 2008).
The ALJ has the duty to weigh the evidence, resolve material conflicts, make independent findings of fact, and dispose of the case accordingly. Perales, 402 U.S. at 399-400. In evaluating the ALJ's decision, the Court considers the entire administrative record but does not reweigh evidence, resolve conflicts, decide questions of credibility, or substitute the Court's own judgment for that of the Commissioner. Lopez ex rel. Lopez v. Barnhart, 336 F.3d 535, 539 (7th Cir. 2003). Nevertheless, the Court conducts a "critical review of the evidence" beforeaffirming the Commissioner's decision. Id. An ALJ must evaluate both the evidence favoring the claimant as well as the evidence favoring the claim's rejection and may not ignore an entire line of evidence that is contrary to his or her findings. Zurawski v. Halter, 245 F.3d 881, 887 (7th Cir. 2001). The ALJ must provide a "logical bridge" between the evidence and the conclusions. Terry v. Astrue, 580 F.3d 471, 475 (7th Cir. 2009).
Disability benefits are available only to those individuals who can establish disability under the terms of the Social Security Act. Estok v. Apfel, 152 F.3d 636, 638 (7th Cir. 1998). Specifically, the claimant must be unable "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). The Social Security regulations create a five-step process to determine whether the claimant qualifies as disabled. 20 C.F.R. § 404.1520(a)(4)(i)-(v). The steps are to be used in the following order:
1. Whether the claimant is currently engaged in substantial gainful activity;
2. Whether the claimant has a medically severe impairment;
3. Whether the claimant's impairment meets or equals one listed in the regulations;
4. Whether the claimant can still perform relevant past work; and
5. Whether the claimant can perform other work in the community.
See Dixon v. Massanari, 270 F.3d 1171, 1176 (7th Cir. 2001).
At step two, an impairment is severe if it significantly limits a claimant's ability to do basic work activities. 20 C.F.R. § 404.1522(a). At step three, a claimant is deemed disabled if the ALJ determines that the claimant's impairment or combination of impairments meets or equals an impairment listed in the regulations. 20 C.F.R. § 404.1520(a)(4)(iii). If not, the ALJ must thenassess the claimant's residual functional capacity, which is defined as the most a person can do despite any physical and mental limitations that may affect what can be done in a work setting. 20 C.F.R. § 404.1545. The ALJ uses the residual functional capacity to determine whether the...
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