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Munsey v. Berryhill

United States District Court, N.D. Indiana, LaFayette Division

November 9, 2018




         The Plaintiff, Stephen Francis Munsey, 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 argues that the Commissioner erred by: (1) failing to properly evaluate the opinion of the Plaintiff's treating physician; and (2) failing to properly include the use of a cane in the residual functional capacity determination. For the reasons set forth below, the Court REVERSES and REMANDS this case for further proceedings in accordance with this Opinion and Order.


         In September 2013, the Plaintiff filed an application for Disability Insurance Benefits under Title II of the Social Security Act, 42 U.S.C. § 423(d), as well as an application for Supplemental Security Income under Title XVI of the Social Security Act, 42 U.S.C. § 1382c(a)(3), alleging disability beginning January 31, 2001. (R. 179-91.) His claims were denied initially on December 13, 2013, and upon reconsideration on April 3, 2014. (R. 51-101.) An administrative law judge (ALJ) conducted a video hearing on September 1, 2015, during which the Plaintiff-who was represented by an attorney-and a vocational expert (VE) testified. (R. 25-50.) On March 2, 2016, the ALJ denied the Plaintiff's application, finding that he was not entitled to benefits. (R. 11-19.) On February 9, 2017, the ALJ's decision became the final decision of the Commissioner when the Appeals Council denied the Plaintiff's request for review. (R. 1-6.) The Plaintiff filed this claim in federal court against the Acting Commissioner of the Social Security Administration on April 14, 2017 [ECF No. 1].


         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), 1382c(a)(3)(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), 1382c(a)(3)(B).

         An ALJ conducts a five-step inquiry in deciding whether to grant or deny benefits. 20 C.F.R. §§ 404.1520, 416.920. 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 found that the Plaintiff had not engaged in SGA since his alleged onset date, January 31, 2001. (R. 13.)

         At step two, the ALJ determines whether the claimant has a severe impairment or combination of impairments that limit his ability to do basic work activities under §§ 404.1520(c) and 416.920(c). With regard to the instant Title II claim, the ALJ determined that the Plaintiff was insured for purposes of benefits through September 30, 2006, but found that the Plaintiff did not meet the requirements of Title II disability because the record lacked “any treatment, diagnosis, or evidence of any impairments prior to the claimant's date last insured . . . .” (R. 13.) Thus, the Plaintiff's Title II claim was denied at step 2, and the remainder of the ALJ's decision focused solely on the Plaintiff's Title XVI claim. (R. 13-14.)[1] The ALJ determined that the Plaintiff had severe impairments of degenerative disc disease, anxiety, and obesity. (R. 14.) However, the ALJ found that the Plaintiff's diabetes was non-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), 416.920(a)(4)(iii). If a claimant's impairment(s), considered singly or in combination with other impairments, rise to this level, there is a presumption of disability “without considering [the claimant's] age, education, and work experience.” §§ 404.1520(d), 416.920(d). But, if the impairment(s), either singly or in combination, fall short, the ALJ must proceed 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 “past relevant work, ” §§ 404.1520(a)(4)(iv), 416.920(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), 416.920(a)(4)(v). Here, the ALJ determined that the Plaintiff's impairments did not meet or equal any of the listings in Appendix 1 and that he had the RFC to perform light work, as defined in 20 C.F.R. §§ 404.1567(b) and 416.967(b), but modified as follows:

[T]he claimant lifts or carries 20 pounds occasionally and 10 pounds frequently, stands or walks for six of eight hours during the workday, and sits for six of eight hours during the workday. The claimant can occasionally climb, balance, stoop, kneel, crouch, and crawl. The claimant can frequently reach overhead bilaterally. The claimant must avoid a concentrated exposure to extreme cold, wetness, and vibration. The claimant can have no exposure to slippery, uneven surfaces. The claimant can perform simple to mildly complex work with brief, superficial interactions with others.

(R. 15.)

         In doing so, the ALJ evaluated the objective medical evidence and the Plaintiff's subjective symptoms and found that the Plaintiff's medically determinable impairments could reasonably be expected to cause some of the alleged symptoms but that his statements concerning the intensity, persistence, and limiting effects of the symptoms were not entirely credible to the extent they were inconsistent with the aforementioned RFC assessment. (R. 18.) For example, the ALJ described the Plaintiff as having “good functioning despite the claimant's abnormalities.” (R. 16.) He noted lumbar and thoracic x-rays showing moderate degenerative changes in January 2013, a spine scan showing “grade I anterolisthesis of L5 on S1, and severe bilateral foraminal stenosis at the L5-S1 disc” in February 2013, and an MRI showing “grade I spondylosis, mild L5-S1 stenosis, and possible nerve root compression” in April 2013; yet, despite these results and the fact that the Plaintiff had a “positive straight leg raise test, ” the ALJ pointed out that he had “full strength, and a normal gait without an assistive device” during a consultative examination in December 2013. (Id.) The ALJ found the Plaintiff's hearing testimony-that he could only stand for fifteen minutes at a time, sit for ten minutes at a time, and walk one-hundred-fifty feet with a cane-to be contradicted by the related medical evidence from that consultative examination where he “walked unassisted and normally.” (R. 16-17.) The ALJ also referenced cervical x-rays in December 2014 that showed “moderate C5-C6 degenerative changes, ” a lumbar MRI from January 2015 that he described as “unchanged, ” and a cervical MRI from July 2015 that he described as “overall unchanged.” (R. 16.) The ALJ concluded that the Plaintiff's lumbar and cervical imaging “did not show significant worsening.” (R. 17.) Finally, the ALJ determined that the Plaintiff is “able to perform activities of daily living” because he can drive, shop by computer, pay bills, “mow the yard in small spurts, ” and “complete small household repairs.” (Id.)

         With regard to the opinion evidence, the ALJ afforded the opinions of the state agency medical consultants-who opined that the Plaintiff was capable of performing light work in accordance with the above RFC determination-“great weight” because their opinions were “consistent with the claimant's normal functioning during his consultative examination” and because they were “supported by spinal imaging that did not show worsening.” (Id.) As to the Plaintiff's treating physician, Scott Carrington, M.D. (Dr. Carrington), the ALJ stated in full:

[Dr. Carrington] found that the claimant could lift 10 pounds, stand or walk 30 minutes at a time, stand or walk only two hours total during the day, sit only two hours, could rarely stoop, will have pain that interferes with attention and concentration, and will likely miss more than four days of work per month (Exhibit 15F/1). However, his opinion is contradicted by evidence that the claimant has full strength and walks normally (Exhibit 13F). His opinion is contradicted by spinal imaging that did not show worsening (exhibit 18F). Therefore, his opinion is granted little weight.


         At step four, the ALJ must determine whether the claimant has the RFC to perform his past relevant work. §§ 404.1520(f), 416.920(f). In this case, the Plaintiff has past relevant work as a material handler and mechanic, which the ALJ found he was not able to perform. (R. 18.)

         Finally, at the last step of the sequential analysis, the ALJ must determine whether the claimant is able to make an adjustment to any other work. §§ 404.1520(g), 416.920(g). Relying on the VE's testimony, the ALJ concluded that “[c]onsidering the claimant's age, education, work experience, and residual functional capacity, the claimant is capable of making a successful adjustment to other work that exists in significant numbers in the national economy.” (Id.) Thus, the ALJ found that the Plaintiff was not disabled as defined in the Social Security Act from January 31, 2001, through the date the decision was issued on March 2, 2016. (R. 19.)


         The decision of the ALJ is the final decision of the Commissioner when the Appeals Council denies a request for review. Liskowitz v. Astrue, 559 F.3d 736, 739 (7th Cir. 2009). The Social Security Act establishes that the Commissioner's findings as to any fact are conclusive if supported by substantial evidence. See Diaz v. Chater, 55 F.3d 300, 305 (7th Cir. 1995). Thus, the Court will affirm the Commissioner's finding of fact and denial of disability benefits if substantial evidence supports them. Craft v. Astrue, 539 F.3d 668, 673 (7th Cir. 2009). Substantial evidence is defined as ‚Äúsuch relevant evidence as a reasonable mind might accept as adequate to support a ...

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