Davison v. Commissioner of Social SecurityDavison v. Commissioner of Social Security
DALY, Magistrate Judge:
In accordance with
Procedural History
Plaintiff applied for disability insurance benefits and supplemental security income in 2022, alleging a disability onset date of July 15, 2022. (Tr. 4). He alleged a variety of physical and mental conditions, including depression, anxiety, and Meniere‘s disease. (Tr. 248). Plaintiff failed to prove disability at the initial and reconsideration levels and requested a hearing before an ALJ, which was held in July 2024. (Tr. 4, 38). On August 30, 2024, the ALJ found Plaintiff not disabled, and the Appeals Council denied Plaintiff‘s request for review, thereby making the ALJ‘s decision the final decision of the Commissioner. (Tr. 4–21, 27).12
Plaintiff raises the following issues:
- Whether the ALJ‘s assessment of the psychological consultative examiner‘s opinion violated
20 C.F.R. § 404.1520c and the logical bridge requirement; - Whether the ALJ‘s symptom evaluation violated SSR 16-3p; and
- Whether the ALJ‘s Residuаl Functional Capacity (“RFC“) Assessment Violated SSR 96-8p.
Applicable Legal Standards
To qualify for DIB, a claimant must be disabled within the meaning of the applicable statute.3 Under the Social Security Act, a person is disabled if she has an “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.”
To determine whether a plaintiff is disabled, the ALJ considers the following five questions in order: (1) Is the plaintiff presently unemployed? (2) Does the plaintiff have a severe impairment? (3) Does the impairment meet or medically equal one of a list of specific impairments enumerated in the regulations? (4) Is the plaintiff unable to perform her former occupation? and (5) Is the plaintiff unable to perform any other work?
An affirmative answer at either step 3 or step 5 leads to a finding that the plaintiff is disabled. A negative answer at any step, other than at step 3, precludes a finding of disability. The
Importantly, the Court‘s scope of review is limited. “The findings of the Commissioner of Social Security as to any fact, if supported by substantial evidence, shall be conclusive. . . .”
In reviewing for “substantial evidence,” the entire administrative record is taken into consideration, but the Court does not reweigh evidence, resolve conflicts, decide questions of credibility, or substitute its own judgment for that of the ALJ. Burmester v. Berryhill, 920 F.3d 507, 510 (7th Cir. 2019). However, while judicial review is deferential, it is not abject; this Court does not act as a rubber stamp for the Commissioner. See Parker v. Astrue, 597 F.3d 920, 921 (7th Cir. 2010), as amended on reh‘g in part (May 12, 2010), and cases cited therein.
The Decision of the ALJ
The ALJ followed the five-step analytical framework described above. The ALJ found that Plaintiff had severe cervical degenerative disc disease with radiculopathy, psoriasis/psoriatic arthritis, diabetes mellitus with peripheral neuropathy, obesity, Meniere‘s disease, major
light work as defined in
20 CFR 404.1567(b) and416.967(b) , except he should never climb ladders, ropes, of scaffolds, but he can occasionally climb ramps and stairs, balance, stoop, kneel, crouch, and crawl. He should avoid concentrated exposure to vibrations and hazards as they are defined in the Selected Characteristics of Occupations (SCO) of the Dictionary of Occupational Titles (DOT). He is further limited to working in no more than a class III moderate noise environment. The claimant can understand, remember, and carry out detailed but not complex tasks. He can deal with occasional interactions with the public, coworkers, and supervisors.
(Tr. 11). The ALJ concluded that Plaintiff had not been under a disability, as a significant number of jobs existed in the national economy that he could perform, at positions including marker, garment sorter, and laundry classifier. (Tr. 20).
The Evidentiary Record
The Court has reviewed and considered the entire evidentiary record in formulating this Memorandum and Order. The following summary is directed to the points raised by Plaintiff. Additional relevant records are also detailed in the Court‘s discussion of the ALJ‘s decision.
1. Plaintiff‘s Agency Forms and Testimony
Plaintiff testified via video at a hearing before the ALJ on July 11, 2024. (Tr. 40-79). Plaintiff is currently married and lives with his spouse in а rental home. (Id.; Tr. 11). He has a driver‘s license, but he rarely drives and only for short distances due to dizziness. (Id.). He has health insurance. (Id.). He has not worked for two years due to complications with his physical and mental health after an injury and a mental health episode requiring hospitalization (Id.).
He reported doing “light housework,” such as cooking, dishes, or sweeping, three days a week when he is able, but one day per week he cannot get out of bed beyond going to the bathroom. (Tr. 63, 272). He testified that when he does those chores he “can spend 30 minutes and then take an hour long break . . . to sit down and recover.” (Tr. 63). He “tri[es] to cook dinner as part of [his] light housework, usually something simple,” four to five times a week, which takes him over an hour even for simple meals. (Tr. 273). Further, on bad days, he needs help from his wife to bathe and dress due to dizziness. (Tr. 272). Plaintiff testified that he drives “very rarely and short distance,” because he is scared to drive due to his dizziness. (Tr. 50-51). In those rare cases, he drives “a couple blocks down a back road to the grocery store.” (Id.). He testified that the farthest he walked the year before the hearing was “maybe a quarter mile” to his local Dollar General to get groceries. (Tr. 62). He added that once he arrived there, he had to take a ten-minute break outside, do the shopping, and then walk back. (Id.).
Mentally, Plaintiff testified he struggles with depression that worsens his anxiety and insomnia. (Tr. 11; 40-79). It can affect his sleep and focus. (Id.). He has constant ruminating
He takes Effexor and Wellbutrin for his depression and Gabapentin for his anxiety and neuropathy (Id.). He has a prescription for Valium that he takes when he is having a panic attack. (Id.). He takes 800 milligrams of Ibuprofen for pain, and occasionally uses cannabis to help manage his pain and anxiety. (Id.).
2. Medical Opinions
In June 2023, Plaintiff underwent a psychiatric evaluatiоn with Ana A. Gil, M.D. (Tr. 772-77.) Dr. Gil observed that Plaintiff‘s affect was sad and restricted and his mood was moderately depressed. (Tr. 774). Dr. Gil opined that Plaintiff had moderate to severe impairment in socially interacting with others and in adapting to changes in his environment. (Tr. 776-77).
At the initial level in July 2023, non-examining State agency psychological consultant Margaret DiFonso, Psy.D., opined that Plaintiff had moderate limitations in carrying out detailed instructions, maintaining attention аnd concentration for extended periods, interacting appropriately with the general public, and accepting instructions and responding appropriately to criticism from supervisors. (Tr. 87.) He was capable of simple as well as more than simple but not complex duties with modified social demands. (Tr. 87.) Moderate social limitations were recommended. (Tr. 87.) Reviewer Robert Vautrain, M.D. also opined in July 2023 thаt Plaintiff could lift 50 pounds occasionally and 25 pounds frequently and could sit, stand, and walk for six hours out of the workday. (Tr. 86.) At the reconsideration level in January 2024, Steven Fritz, Psy.D., affirmed Dr. Difonso‘s opinion. (Tr. 108.) Jennifer Western, M.D. affirmed Dr. Vautrain‘s opinion. (Tr. 106.)
Plaintiff challenges several aspects of the ALJ‘s decisions. Having reviewed the record, the Court finds that remand is warranted at least as to the ALJ‘s assessment of Plaintiff‘s symptoms related to dizziness and unbalance and the formulation of Plaintiff‘s RFC on that ground. Accordingly, the Court will not need to discuss the remaining grounds for reversal.
An ALJ‘s assessment of a claimant‘s reports regarding the “intensity, persistence, and limiting effects of” her subjective symptoms will not be disturbed unless it is “patently wrong,” meaning that it “lacks any explanation or support.” Weber v. Kijakazi, No. 20-2990, 2021 WL 3671235, at *5 (7th Cir. Aug. 19, 2021) (citation and internal quotation marks omitted). At the same time, when that assessment rests on “objective factоrs or fundamental implausibilities rather than subjective considerations,” such as the demeanor of the claimant, the court has “greater freedom to review” that assessment. Clifford v. Apfel, 227 F.3d 863, 872 (7th Cir. 2000), as amended (Dec. 13, 2000) (citation and internal quotation marks omitted). An ALJ must “adequately explain” whether the claimant‘s report of subjective symptoms is persuasive or not and discuss “specific reasons supported by the record.” Pepper v. Colvin, 712 F.3d 351, 367 (7th Cir. 2013); SSR 16-3p, 2016 WL 1119029 (Mar. 16, 2016) (superseding SSR 96-7p). Although an ALJ dоes not need “to address every piece of evidence,” some legitimate reason must be articulated to establish an “accurate and logical bridge from the evidence to [the] conclusion.” Clifford, 227 F.3d at 872 (citation omitted).
Here, the ALJ found:
The claimant testified that currently he is unable to work due to significant dizziness and balance issues caused by his Meniere‘s disease. He said he has several days a
week that are so bad he is unable to move and thаt he has “drop down” episodes 1-2 times a month where he blacks out and falls over (Hearing Testimony). However, the claimant does not relate this level of extreme limitation to his own treating physicians and has not presented with any sequelae of falls. He reports increasing dizziness in October 2023 and was prescribed Meclizine and referred to an ENT, who apparently put the claimant on a diuretic he was unable to continue taking. Despite suggesting that stopping the diuretic increased his dizziness, he never followed up with his ENT, strongly suggesting the symptoms were not as severe as alleged, and he never mentions his dizziness being so bad he is incapable of functioning or is blacking out (See Exs. 20F; 21F). Moreover, the claimant suggests this dizziness occurs daily, but he is still able to cook and complete household chores. He is able to walk to the Dollar General and somеtimes drive (Hearing Testimony). He informed Dr. Gil in June 2023 that he spent much of his time on the computer playing video games and talking with friends (Ex. 9F). Dr. Feinerman does not observe any balance issues on examination, and the claimant‘s own medical sources, including the neurologist, have not observed balance issues. His gait was normal at his May 2024 neurology consultation (Ex. 20F). The undersigned acknowledges the positive finding on Rinne Testing at the claimant‘s consultative examination, and his diagnosis for Meniere‘s, and has limited the claimant‘s exposure to ladders, ropes, or scaffolds, his postural activity, including balance, and his exposure to hazards as a precautionary measure against his complaints of dizziness. However, greater limitation is not supported by the objective evidence, which fails to back up the claimant‘s extreme subjective complaints, and grеater limitation is not consistent with his demonstrated ability to engage in a wide variety of daily activities.
(Tr. 17-18). Accordingly, the ALJ relied on the following evidence to assess Plaintiff‘s subjective reports related to Meniere‘s disease: (a) lack of support by the medical records as to the severe reported impairments; (b) failure to comply with treatment or follow up with his ENT; (c) inconsistency with ability to engage in wide variety of dаily activites; and (d) lack of objective medical evidence. The Court finds that the ALJ misrepresented the record on many of those categories, and that the compound effect of those misrepresentations warrants remand.
First, the ALJ was only partially correct in his conclusion that Plaintiff did not relay to his providers the reported severe impairments associated with Meniere‘s disease, dizziness, and
The ALJ acknowledged Plaintiff‘s reports in June 2024 of increased dizziness and imbalance that made it hard for him to stand, drive, or function. (Tr. 965, 980). He also noted that Plaintiff was thereafter referred to an ENT who put the claimant on a diuretic to address his dizziness. (Tr. 16). Yet, the ALJ completely discredited that evidence because thereafter Plaintiff discontinued the diuretic due to nausea and vomiting but failed to follow up with his ENT despite reporting intensified dizziness without the medication. He concluded that Plaintiff‘s failure to follow up “strongly suggest[ed] the symptoms were not as severe as alleged.” (Tr. 16). This is speculative and even more problematic as the Seventh Circuit has repeatedly cautioned against drawing any inferences as to a claimant‘s symptoms from a lack of care unless the ALJ explores
Here, as Plaintiff correctly points out, the record shows that due to his mental health issues, he struggled to call back and reschedule medical appointments and that, in the past, he had struggled with the motivation to follow up with his providers. (Tr. 66). The record shows that in 2022, he reported that leaving home made him very anxious, and he was out of medications for four days as he felt unable to call for refills. (Tr. 595). Further, in January 2023, Plaintiff reported not returning to his counselor as he had trouble with his finances and transportation. (Tr. 837). Yet, the ALJ did not consider those reasons when he concluded that Plaintiff‘s failure to follow up with his ENT “strongly suggest[ed the] symptoms were not as severe as alleged.” This not only goes against the Seventh Circuit‘s established precedent but also contravenes the agency‘s regulations. See SSR 16-3p (directing SSA to not find a claimant‘s symptoms inconsistent with the record without considering possible reasons for treatment noncompliance, and requiring the SSA to “consider and address reasons for not pursuing treatment that are pertinent to an individual‘s case” and “explain how [it] considered the individual‘s reasons in evaluation of the individual‘s symptoms).
The Commisioner counters that any such error was harmless because the ALJ also relied on other forms of evidence in assessing Plaintiff‘s reported symptoms. (Doc. 21, p. 21, n.4, citing Kittelson v. Astrue, 362 F. App‘x 553, 558 (7th Cir. 2010); Nicholson v. Astrue, 341 F. App‘x 248, 252 (7th Cir. 2009)). While this is correct, as already indicated and will be further detailed below, the ALJ‘s assessment of Plaintiff‘s Meniere‘s disease-related symptoms contained several errors
The ALJ‘s discussion of Plaintiff‘s reported daily activities to discredit his reports as to the severity of his dizziness is also erroneous in that the ALJ failed to assess the qualifications of Plaintiff‘s daily activities. “An ALJ cannot disregard a claimant‘s limitations in performing household activities.” Moss v. Astrue, 555 F.3d 556, 562 (7th Cir. 2009) (citing Craft, 539 F.3d at 680; Mendez v. Barnhart, 439 F.3d 360, 362 (7th Cir. 2006)).
Here, the ALJ noted that despite Plaintiff‘s reports of daily dizziness, he is “still able to cook and complete household chores,“[h]e is able to walk to the Dollar General and sometimes drive,” and “in June 2023 that he spent much of his time on the computer playing video games and talking with friends.” (Tr. 17). But Plaintiff stated that he did ”light housework,” such as cooking, dishes, or sweeping, three days a week when he had the ability, but one day per week he could not get out of bed beyond going to the bathroom. (Tr. 63, 272). He testified that when he does those chores he “cаn spend 30 minutes and then take an hour long break . . . to sit down and recover.” (Tr. 63). He “tri[es] to cook dinner as part of [his] light housework, usually something simple,” four to five times a week, which takes him over an hour even for simple meals. (Tr. 273). Further, on bad days, he needed help from his wife to bathe and dress due to dizziness. (Tr. 272). Plaintiff testified that he drives “very rarely and short distance,” because he is scared to drive due to his dizziness. (Tr. 50-51). In those rare cases, he drivеs “a couple blocks down a back road to the grocery store.” He testified that the farthest he walked within a year from the hearing was “maybe a quarter mile” to his local Dollar General to get groceries. (Tr. 62). He added that once he arrived there, he had to take a ten-minute break outside, do the shopping, and then walk back. (Id.).
Overall, the ALJ materially mischaracterized Plaintiff‘s daily activities. Taking into account the reported qualifications, those activities are not necessarily inconsistent with Plaintiff‘s reports of daily dizziness: Plaintiff nеver reported constant dizziness throughout the day. He explained that he has good and bad days, with his symptoms on the good days being limited “to a bit of stumbling.” (Tr. 12). Likewise, the ALJ did not explain why sitting at his computer was inconsistent with Plaintiff‘s dizziness-related symptoms on his good days. See Bauer v. Astrue, 532 F.3d 606, 608 (7th Cir. 2008) (noting that ALJs need to assess evidence of periods of good and poor functionality); Danniel W. B. v. Comm‘r of Soc. Sec., 2021 WL 4290771, at *8 (S.D. Ill. Sept. 21, 2021) (“Once again, the ALJ has improperly focused on the records that reflect Plaintiff‘s goоd days“).
Contrary to the Commissioner‘s assertion, this is not a harmless error. Based on the above discussion, the only possible articulation left to support the ALJ‘s assessment of Plaintiff‘s dizziness-related symptoms was the lack of objective findings. Yet, the fact that the medical providers did not observe unbalance or observed normal gait during their examinations is not inherently inconsistent with Plaintiff‘s report of his more limited symptoms during good days. Further, the ALJ еmphasized his consideration of Plaintiff‘s “ability to engage in a wide variety of daily activities” in formulating his RFC and rejecting the need for “greater limitations” relating to Plaintiff‘s dizziness. (Tr. 17; see also Tr. 16, noting that [t]he claimant‘s testimony and reports
Because remand under those grounds is warranted, the Court does not need to reach Plaintiff‘s remaining arguments. On remand, the ALJ should consider all arguments raised afresh, taking into account the entire record.
Conclusion
The Commissioner‘s final decision denying Plaintiff‘s application for disability insurance benefits and supplemental security income is REVERSED and REMANDED to the Commissioner for rehearing and consideration of the evidence, pursuant to sentence four of
IT IS SO ORDERED.
DATED: September 1, 2026
Hon. Reona J. Daly
United States Magistrate Judge