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Renfree v. Commissioner of Social Security

United States District Court, N.D. Indiana, Fort Wayne Division

September 8, 2017




         The Plaintiff, Christopher Lee Renfree, seeks review of the final decision of the Commissioner of the Social Security Administration denying his application for Disability Insurance Benefits and Supplemental Security Income. The Plaintiff's application was denied initially and upon reconsideration. In September of 2014, an administrative law judge (ALJ) held a hearing on the Plaintiff's application. On December 18, 2014, the ALJ issued a Decision holding that the Plaintiff was not entitled to benefits because he was not disabled under the relevant provisions of the Social Security Act. On June 2, 2016, the Appeals Council denied review of the ALJ's decision, thereby making the ALJ's decision the final decision of the Commissioner. The Plaintiff subsequently filed suit pursuant to 42 U.S.C. § 405(g) and § 1383(c)(3).


         The Plaintiff was born on August 23, 1964. (R. at 155, ECF No. 10.) He has at least a high school education. (Id.) The Plaintiff has a work history that includes working as a groundskeeper, bar back, and warehouse worker. (R. at 155.)

         In the present case, the Plaintiff claims to have become disabled on July 9, 2008, due to multiple physical and mental impairments, including a history of bilateral leg fractures due to a motor vehicle accident in 1988; post-traumatic arthritis in the left knee, right ankle, and foot; contracture and/or stress fracture; degenerative disc disease (spondylosis); hepatitis C; hyperlipidemia; major depressive disorder; dysthymia secondary to physical problems; a history of polysubstance abuse; chronic pain syndrome; polyarthralgia; thoracolumbar scoliosis; a right hip/proximal femur bone formation problem; and foot problems including verruca plantaris, fasciitis, tendonitis, metatarsalgia, and hammertoe. (Pl. Br. 4-5, ECF No. 17.)


         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 be found disabled, a claimant must demonstrate that his physical or mental limitations prevent him from doing not only his previous work, but also any other kind of gainful employment that exists in the national economy, considering his age, education, and work experience. § 423(d)(2)(A).

         An ALJ conducts a five-step inquiry in deciding whether to grant or deny benefits. 20 C.F.R. § 404.1520. The first step is to determine whether the claimant no longer engages in substantial gainful activity (SGA). Id. In the case at hand, the ALJ determined that the Plaintiff did not engaged in SGA since the alleged onset of disability and thus, the Plaintiff satisfied the step one inquiry. (R. at 146.) In step two, the ALJ determines whether the claimant has a severe impairment limiting the ability to do basic work activities pursuant to § 404.1520(c). Here, the ALJ determined that the Plaintiff's impairments, including a “history of bilateral leg fractures due to [a] remote motor vehicle accident in 1988, posttraumatic arthritis in [the] left knee, right ankle/foot arthritis/contracture/stress fracture/status post-crash [sic] injury, degenerative disc disease/spondylosis” were severe impairments because they significantly limited his ability to perform basic work activities. (Id.) The ALJ did not find that the Plaintiff's diagnoses of major depressive disorder and dysthymia secondary to physical problems were severe. (Id.). Step three requires the ALJ to “consider the medical severity of [the] impairment” to determine whether the impairment “meets or equals one of [the] listings in appendix 1 . . . .” § 404.1520(a)(4)(iii). If a claimant's impairment(s), considered singly or in combination with other impairments, rises to this level, he earns a presumption of disability “without considering [his] age, education, and work experience.” § 404.1520(d). But, if the impairment(s), either singly or in combination, falls short, an ALJ must move to step four and examine the claimant's “residual functional capacity” (RFC)-the types of things he can still do physically, despite his limitations-to determine whether he can perform this “past relevant work, ” § 404.1520(a)(4)(iv), or whether the claimant can “make an adjustment to other work” given the claimant's “age, education, and work experience.” § 404.1520(a)(4)(v).

         In the case at hand, the ALJ determined that the Plaintiff's impairments, either singly or in combination, do not meet or equal any of the listings in Appendix 1 and that the Plaintiff has the RFC to perform light work, as defined by § 404.1567(b). (R. at 147.) However, the ALJ held that the Plaintiff is limited to occasional climbing of ramps and stairs, balancing, stooping, kneeling, crouching, and crawling. (Id.) Additionally, he requires a sit/stand option, which will allow him to alternate between sitting and standing up to every 30 minutes, if needed, but will not render him off task. (Id.) The Plaintiff can never climb ladders, ropes, or scaffolds, should avoid concentrated exposure to extreme cold and vibration, and avoid even moderate exposure to hazards such as moving machinery, unprotected heights, and slippery, uneven, or moving surfaces. (Id.)

         In arriving at the RFC, the ALJ determined that the Plaintiff's medically determinable impairments could reasonably be expected to cause his alleged symptoms, “however, the claimant's statements concerning the intensity, persistence, and limiting effects of these symptoms are not entirely credible . . . .” (R. at 148). The ALJ examined both the Plaintiff's physical impairments and his mental impairments.

         A. Physical Impairments

         The ALJ began by examining the Plaintiff's claim that he is disabled due to his left knee and right foot, which cause him pain and result in an irregular walking pattern. The ALJ noted that the Plaintiff's problems began with an automobile accident in 1988, though in 2007, a CT scan revealed healed fractures. (R. at 148-49.) The ALJ also noted that though the Plaintiff claims that the primary issue is pain as a result of the injury, the Plaintiff nevertheless continues to walk for long periods of time, has had no diagnosis of decreased muscle strength, responded well to pain medications, returned to work after sustaining the injuries, takes care of his elderly mother (including cooking, pushing her in a wheelchair, and performing household chores), is able to travel out of town for periods of time while on pain medication, has failed to follow up with a foot surgeon (stating that he needs to care for his mother and cannot be off his feet for that long), and is able to perform daily activities. (R. at 151-52.) Accordingly, the ALJ found the Plaintiff not fully credible, (R. at 151.), also holding that he “does not find the record supports the intensity of pain reported by the claimant.” (R. at 152.)

         In reaching his conclusion, the ALJ detailed the Plaintiff's October 2010 initial consultation by Dr. Winifred Lau, M.D., who referred the Plaintiff for pain management treatment resulting from chronic pain syndrome. (R. at 149.) However, the ALJ noted that less than a month later, the Plaintiff reported to Dr. Lau requesting new inserts for his shoes because he had been walking frequently. (Id.). The ALJ additionally reviewed the Plaintiff's treatment by Dr. Patricia Stewart, M.D., beginning in 2011, who determined that the Plaintiff showed signs of sclerosis, but otherwise had no major problems. (Id.) Upon further examination by Dr. Nicole Arcand, M.D., the Plaintiff appeared to have mild issues, but no major movement concerns. (Id.) Though in 2012 the Plaintiff was found to have a lesion and pain in his foot, an abnormal gait, and minimal swelling (R. at 150-51), the ALJ detailed the 2013 examination by Karim Moshref, P.C., who determined that the Plaintiff's physical examination was generally normal. (R. at 151.) The ALJ gave little weight to Jenna Purdell, who opined that the Plaintiff would be suited for a job that does not require physical labor or a lot of walking, because the ALJ held it was unknown in what capacity Purdell treated the Plaintiff. (R. at 153.) Additionally, the ALJ determined that he likely incorporated Purdell's opinion when holding that the Plaintiff is limited to light work with a sit/stand option. (Id.) The ALJ also gave little weight to the state agency medical consultants from the Plaintiff's prior intimal application because the doctors' opinions were not based on a complete medical record. (R. at 155.) Nevertheless, the ALJ held that he generally accounted for their recommendations. (Id.) The ALJ gave great weight to the opinion of M. Brill, M.D., a state agency medical consultant, who opined regarding the limitations of the Plaintiff, which the ALJ ultimately incorporated in the RFC determination. (R. at 154.)

         B. Mental Impairments

         Because the Plaintiff had no limitations in his activities of daily living, mild limitations in social functioning, no limitations in concentration, persistence, or pace, and no episodes of decomposition, the ALJ determined that the Plaintiff's major depressive disorder and dysthymia were not severe. (R. at 146.) Moreover, the ALJ noted that the Plaintiff did not seek or receive ongoing ...

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