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Hopkins v. Berryhill

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

December 5, 2018

ROCKY T. HOPKINS, Plaintiff,
v.
NANCY A. BERRYHILL, ACTING COMMISSIONER OF THE SOCIAL SECURITY ADMINISTRATION, Defendant.

          OPINION AND ORDER

          THERESA L. SPRINGMANN CHIEF JUDGE

         The Plaintiff, Rocky T. Hopkins, seeks review of the final decision of the Commissioner of the Social Security Administration denying his application for Disability Insurance Benefits. The Plaintiff argues that the Commissioner erred by: (1) failing to include limitations from all impairments in her hypothetical to the vocational expert; and (2) failing to properly weigh the opinion evidence of the consultative examiner. For the reasons set forth below, the Court REVERSES and REMANDS this case for further proceedings in accordance with this Opinion and Order.

         BACKGROUND

         On March 14, 2014, 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 December 6, 2012. (R. 208-20.) His claims were denied initially on May 23, 2014, and upon reconsideration on August 21, 2014. (R. 125-32, 138-44.) An administrative law judge (ALJ) conducted a video hearing on February 9, 2016, during which the Plaintiff-who was represented by an attorney-and a vocational expert (VE) testified. (R. 16-55.) On April 15, 2016, the ALJ issued a partially favorable decision, finding that the Plaintiff was disabled for purposes of Supplemental Security Income beginning on April 26, 2014, but that he was not disabled prior to that date for purposes of Disability Insurance Benefits through December 31, 2013, the date last insured. (R. 109-20.) On March 1, 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 May 4, 2017 [ECF No. 1].

         THE ALJ'S FINDINGS

         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). With respect to a Title II claim for Disability Insurance Benefits, a claimant must also meet the insured status requirements of the Social Security Act. In this case, the ALJ determined that the “claimant has acquired sufficient quarters of coverage to remain insured through December 31, 2013.” (R. 109.)

         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 of December 6, 2012. (R. 112.)

         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). The ALJ determined that, since the alleged onset date of December 6, 2012, the Plaintiff had severe impairments of chronic obstructive pulmonary disease, emphysema, loss of vision in the right eye, and left knee pain status-post tibial plateau fracture. (R. 112.) However, the ALJ found that the Plaintiff's anxiety and history of alcohol abuse were 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 assessed the Plaintiff's RFC based on two separate time periods-prior to and post April 26, 2014, the date the ALJ determined the Plaintiff became disabled. Prior to April 26, 2014, the ALJ determined that the Plaintiff had the RFC to perform “medium work as defined in 20 CFR 404.1567(c) and 416.967(c), with an additional limitation, meaning he was limited to jobs that could be performed with monocular vision.” (R. 114.) Beginning on that date, however, the ALJ found that the Plaintiff had the RFC to perform:

light work as defined in 20 CFR 404.1567(b) and 416.967(b) with additional limitations meaning, only occasional climbing ladders, ropes, or scaffolds, only occasional ramps or stairs, and only occasional stooping, crouching, kneeling, crawling. He should avoid concentrated exposure to environmental irritants, and he is limited to jobs that can be performed with monocular vision.

(R. 116.)

         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 the alleged symptoms but that the Plaintiff's statements concerning the intensity, persistence, and limiting effects of the symptoms were not fully supported prior to April 26, 2014. (R. 114.) While the ALJ acknowledged that the Plaintiff had severe impairments prior to that date, she indicated that the doctors had “generally reported normal observations.” (Id.) For example, on December 18, 2012, the Plaintiff underwent surgery for repair of his left tibial plateau fracture. (R. 115.) The ALJ noted that a January 29, 2013, x-ray revealed that the bony fragments in the Plaintiff's knee were in “good alignment” with evidence of healing and minimal degenerative changes. (Id.) She pointed to a follow-up visit on February 19, 2013, where he self-reported that he was “doing fine” and the doctor noted that he was doing well post-fracture.[1] (R. 115.) Several days prior to that visit, a doctor observed that the Plaintiff had normal respiration, normal musculature with no skeletal tenderness or joint deformity, and no edema or cyanosis. (Id.) Approximately one year later, a physician noted that the Plaintiff had no cyanosis, clubbing, or edema.[2] (Id.) According to the ALJ, these observations along with the Plaintiff's assertion that he was “doing fine” called into question the severity of the Plaintiff's allegations regarding his left knee impairment.[3] (Id.)

         Additionally, the ALJ described the record as containing “inconsistencies” prior to April 26, 2014, with regard to the Plaintiff's breathing impairments. (Id.) She noted that on February 15, 2014, the Plaintiff visited the Jasper County Hospital for exertional dyspnea that had been present for approximately one week; according to the ALJ, the doctor observed that the Plaintiff was “only in mild respiratory distress, ” and he “diagnosed an acute COPD exacerbation.”[4] (Id.) The ALJ also acknowledged that the Plaintiff was diagnosed with emphysema, [5] but she found his admission that he had been “smoking a lot” undermined the severity of the Plaintiff's allegations pertaining to his breathing impairments. (Id.)

         Conversely, the ALJ found that the Plaintiff's allegations regarding his symptoms were consistent with the evidence beginning on April 26, 2014; in making this determination, the ALJ relied primarily on the Consultative Examination performed by Andrew J. Koerber, M.D. (Dr. Koerber) on that date. (R. 116.) Dr. Koerber noted that the Plaintiff complained of shortness of breath due to COPD and leg pain, and, upon examination, he observed an antalgic gait and shortness of breath upon exertion. (Id.) Dr. Koerber diagnosed the Plaintiff with COPD/emphysema, left leg fracture, and decreased visual acuity in his right eye. (Id.) The ALJ noted that the Plaintiff was diagnosed with a cataract in his right eye as a child and could only see shadows out of it; vision in his left eye was good with the use of glasses. (Id.)

         With regard to the opinion evidence, the ALJ afforded Dr. Koerber's opinion that the Plaintiff could sit and stand for no more than two hours at a time and up to five hours in a workday “significant, but not great weight” because the ALJ did not “precisely” adopt it. (R. 117.) The ALJ noted that she “agree[d] that the claimant is limited with standing throughout an 8-hour workday, ” but did not expand upon the precise limitation she believed was warranted. (Id.) The ALJ also gave the state agency physicians “significant, but not great weight, ” noting that as of April 26, 2014, she agreed that the “evidence supports light work activity” but that she considered additional evidence including the Plaintiff's testimony and did not “precisely” adopt the state agency opinions either. (Id.)

         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 ALJ found that the Plaintiff had past relevant work as a construction worker (heavy per the DOT but medium as performed), a heating and air-conditioning installer-servicer helper (heavy per the DOT and as performed), a maintenance mechanic (heavy per the DOT and as performed), and a house repairer (medium per the DOT but light/medium as performed). (R. 118.) The ALJ concluded that the Plaintiff was able to perform his past relevant work as a construction worker I (DOT 869.664-014) and a house repairer (DOT 869.381-010) prior to April 26, 2014, because the findings were “supported by the testimony of the vocational expert at [the] hearing.” (Id.) However, beginning on that date, the ALJ determined that the Plaintiff's RFC prevented him from being able to perform any past relevant work because the demands of those jobs exceeded the post-April 26, 2014, RFC; additionally, based on the VE's testimony, the ALJ found that the Plaintiff did not have any transferable skills. (R. 118-19.)

         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 “[s]ince April 26, 2014, considering the claimant's age, education, work experience, and residual functional capacity, there are no jobs that exist in significant numbers in the national economy that the claimant can perform.” (R.119.) Thus, the ALJ found that the Plaintiff was not disabled prior to April 26, 2014, but became disabled on that date; the ALJ also found that the Plaintiff was not under a disability within the meaning of the Social Security Act at any time through December 31, 2013, the date he was last insured.

         STANDARD OF REVIEW

         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 “such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” Richardson v. Perales, 402 U.S. 389, 401 (1971) (quoting Consol. Edison Co. v. NLRB, 305 U.S. 197, 229 (1938)); Henderson v. Apfel, 179 F.3d 507, 512 (7th Cir. 1999).

         It is the duty of the ALJ to weigh the evidence, resolve material conflicts, make independent findings of fact, and dispose of the case accordingly. Richardson, 402 U.S. at 399- 400. The reviewing court reviews the entire record; however, it does not substitute its judgment for that of the Commissioner by reconsidering facts, reweighing evidence, resolving conflicts in evidence, or deciding questions of credibility. See Diaz, 55 F.3d at 608. A court will “conduct a critical review of the evidence, ” considering both the evidence that supports, as well as the evidence that detracts from, the Commissioner's decision, and “the decision cannot stand if it lacks evidentiary support or an adequate discussion of the issues.” Lopez ex rel. Lopez v. Barnhart, 336 F.3d 535, 539 (7th Cir. 2003) (internal quotations omitted).

         When an ALJ recommends the denial of benefits, the ALJ must first “provide a logical bridge between the evidence and [his] conclusions.” Terry v. Astrue, 580 F.3d 471, 475 (7th Cir. 2009) (internal quotation marks and citation omitted). Though the ALJ is not required to address every piece of evidence or testimony presented, “as with any well-reasoned decision, the ALJ must rest its denial of benefits on adequate evidence contained in the record and must explain why contrary evidence does not persuade.” Berger v. Astrue, 516 F.3d 539, 544 (7th Cir. 2008). However, if substantial evidence supports the ALJ's determination, the decision must be affirmed even if “reasonable minds could differ concerning whether [the claimant] is disabled.” Elder v. Astrue, 529 F.3d 408, 413 (7th Cir. 2008).

         ANALYSIS

         As noted above, the Plaintiff argues that the Commissioner erred by: (1) failing to include limitations from all impairments in her hypothetical to the VE; and (2) failing to properly weigh the opinion evidence of Dr. Koerber. Specifically of relevance, the Plaintiff contends that the ALJ elicited no testimony and/or evidence from the VE that an individual limited to a medium exertional level and monocular vision could perform the Plaintiff's past relevant work and did not adequately explain why additional exertional limitations related to the Plaintiff's COPD were required on April 26, 2014, but not before that date. The Government, on the other hand, contends that the ALJ properly relied on the VE's testimony that the Plaintiff could return to his past relevant work and that the RFC findings were supported by substantial evidence. The Government is mistaken.

         A. The ALJ's Step Four Analysis

         “RFC is an assessment of an individual's ability to do sustained work-related physical and mental activities in a work setting on a regular and continuing basis.” SSR 96-8p. In crafting a particular RFC for a claimant, an ALJ must first identify that person's restrictions and/or functional limitations. Id. In doing so:

the ALJ must consider all of the relevant evidence in the record, even limitations that are not severe, and may not dismiss a line of evidence contrary to the ruling. However, a determination need not contain a ...

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