United States District Court, N.D. Indiana, Fort Wayne Division
PATRICIA S. MATHIAS, Plaintiff,
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.
OPINION AND ORDER
William C. Lee, Judge
matter is before the court for judicial review of a final
decision of the defendant Commissioner of Social Security
Administration denying Plaintiff's application for
Disability Insurance Benefits (DIB), as provided for in the
Social Security Act. Section 205(g) of the Act provides,
inter alia, "[a]s part of his answer, the [Commissioner]
shall file a certified copy of the transcript of the record
including the evidence upon which the findings and decision
complained of are based. The court shall have the power to
enter, upon the pleadings and transcript of the record, a
judgment affirming, modifying, or reversing the decision of
the [Commissioner], with or without remanding the case for a
rehearing." It also provides, "[t]he findings of
the [Commissioner] as to any fact, if supported by
substantial evidence, shall be conclusive. . . ." 42
provides that an applicant for DIB must establish an
"inability to engage in any substantial gainful activity
by reason of any medically determinable physical or mental
impairment which can be expected to last for a continuous
period of no less than 12 months. . . ." 42 U.S.C.
§416(i)(1); 42 U.S.C. §423(d)(1)(A). A physical or
mental impairment is "an impairment that results from
anatomical, physiological, or psychological abnormalities
which are demonstrable by medically acceptable clinical and
laboratory diagnostic techniques." 42 U.S.C.
§423(d)(3). It is not enough for a plaintiff to
establish that an impairment exists. It must be shown that
the impairment is severe enough to preclude the plaintiff
from engaging in substantial gainful activity. Gotshaw v.
Ribicoff, 307 F.2d 840 (7th Cir. 1962), cert. denied,
372 U.S. 945 (1963); Garcia v. Califano, 463 F.Supp.
1098 (N.D.Ill. 1979). It is well established that the burden
of proving entitlement to disability insurance benefits is on
the plaintiff. See Jeralds v. Richardson, 445 F.2d
36 (7th Cir. 1971); Kutchman v. Cohen, 425 F.2d 20
(7th Cir. 1970).
the foregoing framework, "[t]he question before [this
court] is whether the record as a whole contains substantial
evidence to support the [Commissioner's] findings."
Garfield v. Schweiker, 732 F.2d 605, 607 (7th Cir.
1984) citing Whitney v. Schweiker, 695 F.2d 784, 786
(7th Cir. 1982); 42 U.S.C. §405(g). "Substantial
evidence is defined as 'more than a mere scintilla. It
means such relevant evidence as a reasonable mind might
accept as adequate to support a conclusion.'"
Rhoderick v. Heckler, 737 F.2d 714, 715 (7th Cir.
1984) quoting Richardson v. Perales, 402 U.S. 389,
401, 91 S.Ct. 1410, 1427 (1971); see Allen v.
Weinberger, 552 F.2d 781, 784 (7th Cir. 1977). "If
the record contains such support [it] must [be] affirmed, 42
U.S.C. §405(g), unless there has been an error of
law." Garfield, supra at 607; see
also Schnoll v. Harris, 636 F.2d 1146, 1150 (7th Cir.
present matter, after consideration of the entire record, the
Administrative Law Judge (“ALJ”) made the
1. The claimant meets the insured status requirements of the
Social Security Act through December 31, 2019.
2. The claimant has not engaged in substantial gainful
activity since September 12, 2014, the alleged onset date (20
CFR 404.1571 et seq.).
3. The claimant has the following severe impairments:
fibromyalgia; chronic pain syndrome; lumbar spondylosis;
spondylosis and degenerative disc disease in the cervical
spine; cervical radiculopathy; status-post right C5-6
laminotomy and foraminotomy for decompression of the nerve
root; right shoulder impingement syndrome; subacromial
bursitis and SLAP tear; chrondromalacia of both patellae;
obesity; major depressive disorder; and anxiety disorder (20
4. The claimant does not have an impairment or combination of
impairments that meets or medically equals the severity of
one of the listed impairments in 20 CFR Part 404, Subpart P,
Appendix 1 (20 CFR 404.1520(d), 404.1525 and 404.1526).
5. After careful consideration of the entire record, the
undersigned finds that the claimant has the residual
functional capacity to perform light work as defined in 20
CFR 404.1567(b) except no overhead reaching bilaterally. She
is limited to frequent handling, fingering and feeling
bilaterally. She is limited to occasional climbing of ramps
and stairs, balancing, stooping, kneeling, crouching and
crawling. She cannot climb ladders, ropes or scaffolds. She
must avoid unprotected heights, moving mechanical parts and
operating a motor vehicle. She can tolerate occasional
exposure to extreme cold and heat, and humidity. She can
tolerate exposure to moderate noise in the work environment.
She is limited to performing simple, routine and repetitive
tasks but not at a production-rate pace (e.g. assembly-line
work). She is limited to simple work-related decisions. She
is limited to occasional interaction with supervisors and
coworkers. She cannot interact with the public but can be in
proximity with the public. She is limited to tolerating
occasional changes in a routine work setting.
6. The claimant is unable to perform any past relevant work
(20 CFR 404.1565).
7. The claimant was born on May 17, 1969 and was 45 years
old, which is defined as a younger individual age 18-49, on
the alleged disability onset date (20 CFR 404.1563).
8. The claimant has at least a high school education and is
able to communicate in English (20 CFR 404.1564).
9. Transferability of job skills is not material to the
determination of disability because using the
Medical-Vocational Rules as a framework supports a finding
that the claimant is “not disabled, ” whether or
not the claimant has transferable job skills (See SSR 82-41
and 20 CFR Part 404, Subpart P, Appendix 2).
10. Considering the claimant's age, education, work
experience, and residual functional capacity, there are jobs
that exist in significant numbers in the national economy
that the claimant can perform (20 CFR 404.1569 and
11. The claimant has not been under a disability, as defined
in the Social Security Act, from September 12, 2014, through
the date of this decision (20 CFR 404.1520(g)).
upon these findings, the ALJ determined that Plaintiff was
not entitled to disability insurance benefits. The ALJ's
decision became the final agency decision when the Appeals
Council denied review. This appeal followed.
filed her opening brief on December 20, 2018. On February 7,
2019 the defendant filed a memorandum in support of the
Commissioner's decision to which Plaintiff replied on
March 11, 2019. Upon full review of the record in this cause,
this court is of the view that the ALJ's decision should
step test has been established to determine whether a
claimant is disabled. See Singleton v. Bowen, 841
F.2d 710, 711 (7th Cir. 1988); Bowen v. Yuckert, 107
S.Ct. 2287, 2290-91 (1987). The United States Court of
Appeals for the Seventh Circuit has summarized that test as
The following steps are addressed in order: (1) Is the
claimant presently unemployed? (2) Is the claimant's
impairment "severe"? (3) Does the impairment meet
or exceed one of a list of specific impairments? (4) Is the
claimant unable to perform his or her former occupation? (5)
Is the claimant unable to perform any other work within the
economy? An affirmative answer leads either to the next step
or, on steps 3 and 5, to a finding that the claimant is
disabled. A negative answer at any point, other than step 3,
stops the inquiry and leads to a determination that the
claimant is not disabled.
Nelson v. Bowen, 855 F.2d 503, 504 n.2 (7th Cir.
1988); Zalewski v. Heckler, 760 F.2d 160, 162 n.2
(7th Cir. 1985); accord Halvorsen v. Heckler, 743
F.2d 1221 (7th Cir. 1984). From the nature of the ALJ's
decision to deny benefits, it is clear that Step 5 was the
was born on May 17, 1969, and was considered a “younger
person” as of the date she alleged her disability
began. (Tr. 220). She has a bachelor's degree in
accounting. (Tr. 160, 337). Ms. Ringenberg classified
Plaintiff's past work as that of a paralegal, gas station
cashier, press operator, and automobile assembler. (Tr. 195).
testified that she had not worked or applied for work since
September 12, 2014. (Tr. 160-161). She reported that earnings
from TI Group received in the first quarter of 2015 were for
short-term disability. (Tr. 160-161).
March 2015, state agency medical consultant, J.V. Corcoran,
M.D. reviewed Plaintiff's claim at the initial level of
review and projected a residual functional capacity for a
limited range of light work with environmental, postural and
manipulative limitations as of December 2015, which is 12
months after Plaintiff underwent surgery on her right
shoulder. (Tr. 225- 229, 518-519). In April 2015, state
agency psychological consultant, Kari Kennedy, Psy.D.
reviewed Plaintiff's claim regarding her psychological
impairments and concluded that her mental impairments were
not severe and resulted in mild restriction of activities of
daily living, social functioning, and in maintaining
concentration, persistence or pace. (Tr. 223-224). Upon
reconsideration, in July 2015, another state agency medical
consultant, M. Brill, M.D., affirmed without change the prior
projected residual functional capacity assessment. (Tr.
238-240). Another state agency psychological consultant,
Joelle Larsen, Ph.D. affirmed without change the assessment
and finding of Dr. Kennedy who indicated that the
Plaintiff's mental impairments were not severe.
April 6, 2015, Plaintiff presented to Candace Martin, Psy.D.
for a consultative psychological evaluation at the request of
the Indiana DDB. (Tr. 596-600). At the exam, Plaintiff
reported that she was filing for disability due to her
physical complaints, though Dr. Martin noted that Plaintiff
had an extensive mental health history and reported being
molested by her father, raped by a boyfriend, and a history
of inpatient treatment for an eating disorder and outpatient
mental health treatment. (Tr. 596). Plaintiff reported that
she had worked as a paralegal from 1997 to 2009 but quit that
job because of the stress. (Tr. 597). She also reported
working in a factory for three years. (Id.). Dr.
Martin noted that Plaintiff seemed quite lethargic and
uninterested in interacting in an appropriately social
manner. She was slow to respond to questions, and her
attention and concentration seemed marginal. (Tr. 597-598).
Her mood seemed discouraged and apathetic. (Tr. 598).
Martin concluded that Plaintiff evidenced signs of depression
in the form of disturbance in sleep, appetite, anhedonia, and
lethargy. Her weakness in cognitive functioning seemed to be
evidence of her depression and social withdrawal rather than
intellectual deficit. (Tr. 599). Dr. Martin diagnosed
Plaintiff with major depressive disorder. (Id.).
before the state agency included an October 2012 psychiatric
evaluation from the Bowen Center. Plaintiff's diagnoses
included major depressive disorder, recurrent, and
“rule-out” diagnoses of post-traumatic stress
disorder and eating disorder. (Tr. 429-434). At a follow-up
appointment in November she was instructed to continue Celexa
and to start therapy.
Health Physician Group records reflect that Plaintiff
presented to the office of Phillip Corbin, M.D. in 2014
regarding anxiety and depression. (Tr. 436-443). On August
25, 2014, she presented to her doctor's office with
excessive worry, irritability, muscle tension and
nervous/anxious behavior and was diagnosed with anxiety and
given a prescription for Ativan and Prozac (Tr. 436-437). She
felt a great deal of her tension and muscle pain was related
to stress and anxiety. (Tr. 436). She was placed on leave
from work through August 29, 2014. (Tr. 438). At a follow-up
appointment in September 2014, Plaintiff reported that her
anxiety and stress were slowly improving with medication.
September 17, 2014, Plaintiff presented to Dr. Corbin's
office regarding neck and shoulder numbness radiating down
her right arm after presenting to the emergency room with arm
pain on September 12, 2014. (Tr. 444, 462-466). She was
tearful, anxious, worried about her job, and in obvious
discomfort. (Id.). An examination showed decreased
right grip strength with weakness and strength reduced to 3/5
in the right upper extremity. (Tr. 445). She was instructed
to take Tylenol #3 for severe pain and placed on leave from
work. (Tr. 446). A September 2014 MRI of the cervical spine
showed small disc protrusions at ¶ 5-6 and C6-7. (Tr.
447). Dr. Corbin diagnosed shoulder strain and paresthesia
secondary to nerve irritation and recommended prednisone, a
muscle relaxer, and therapy. (Tr. 451). Plaintiff returned in
October and reported that she was experiencing no significant
improvement of her symptoms with therapy and medication. (Tr.
454). She was instructed to remain off work. (Tr. 455).
shoulder MRI from November 2014 showed mild cystic
degeneration of the humeral head and fraying or rounding of
the anterior labrum. (Tr. 469). Jason Hanna, M.D. with Fort
Wayne Orthopaedics diagnosed right shoulder impingement
syndrome and possible bicep tendinopathy. (Tr. 548-549). On
December 24, 2014, Plaintiff underwent a right shoulder
subacromial decompression and debridement. (Tr. 518-519).
Following surgery she participated in occupational therapy
with a goal of returning to work. (Tr. 493).
February 2015, Plaintiff presented as a new patient to Kevin
Rahn, M.D. at Fort Wayne Orthopaedics and reported numbness
and tingling in the arms and hands. (Tr. 544). Dr. Rahn noted
that a MRI of the cervical spine from September 2014 showed a
C5-6 disc bulge and C6-7 stenosis. (Id.). Dr. Rahn
also noted that an EMG from Dr. Mark Zolman in December 2014
showed radiculopathy of C6. (Tr. 487, 544).
March 2015, Plaintiff presented to Dr. Corbin and reported
that she was doing worse and had fallen on ice. (Tr. 528). In
March 2015, Plaintiff also presented for a consultation with
T.J. Curfman, M.D., and his impression was carpal tunnel,
weakness, and depression. (Tr. 587-589). Dr. Curfman noted in
April 2015 that ...