United States District Court, N.D. Indiana, South Bend Division
YVETTE N. McCLINTON, Plaintiff,
NANCY A. BERRYHILL, Acting Commissioner of the Social Security Administration, Defendant.
OPINION AND ORDER
P. SIMON, JUDGE
McClinton appeals the Social Security Administration's
decision to deny her applications for disability insurance
benefits and supplemental security income under Title II and
XVI of the Social Security Act. McClinton suffers from
several medical issues including degenerative joint disease
of the hip, diabetic neuropathy, and obesity. [Tr.
An administrative law judge found that McClinton was not
disabled and that she had the residual functional capacity
(RFC) to perform light work with some restrictions.
alleges five claims of error by the ALJ but I will limit my
discussion to one: whether the ALJ failed to properly weigh
the medical opinion evidence. Because I find the ALJ's
analysis of the medical opinion evidence is flawed, I will
REVERSE the ALJ's decision and
REMAND on this issue.
start by looking at the legal framework. My role is not to
determine from scratch whether or not McClinton is disabled.
Rather, I only need to determine whether the ALJ applied the
correct legal standards and whether the decision is supported
by substantial evidence. See 42 U.S.C. §
405(g); Shideler v. Astrue, 688 F.3d 306, 310 (7th
Cir. 2012); Castile v. Astrue, 617 F.3d 923, 926
(7th Cir. 2010); Overman v. Astrue, 546 F.3d 456,
462 (7th Cir. 2008). My review of the ALJ's decision is
deferential. This is because the “substantial
evidence” standard is not particularly demanding. In
fact, the Supreme Court announced long ago that the standard
is even less than a preponderance-of-the-evidence standard.
Richardson v. Perales, 402 U.S. 389, 401 (1971). Of
course, there has to be more than a “scintilla”
of evidence. Id. This means that I cannot
“simply rubber-stamp the Commissioner's decision
without a critical review of the evidence.”
Clifford v. Apfel, 227 F.3d 863, 869 (7th Cir.
2000). Nonetheless, the review is a light one and the
substantial evidence standard is met “if a reasonable
person would accept it as adequate to support the
conclusion.” Young v. Barnhart, 362 F.3d 995,
1001 (7th Cir. 2004).
found that McClinton had the severe impairments of moderate
degenerative joint disease changes of the right hip, mild
degenerative joint disease of the left hip, osteoarthritis,
insulin-dependent diabetes, diabetic neuropathy, obesity,
patellar hypertrophy of the right knee, and an adjustment
disorder with depressed mood. [Tr. 14.] McClinton suffers
from multiple other non-severe impairments, including
gastritis, small hiatal hernia, irritable bowel syndrome,
hypertension, early endplate spurring of the thoracic spine,
and back pain. [Tr. 15.] The ALJ determined that McClinton
had the RFC:
to perform light work as defined in 20 CFR 404.1567(b) and
416.967(b) where the claimant can sit for six hours of an
eight-hour workday, and stand and/or walk for two hours of an
eight-hour workday. The claimant can occasionally lift 20
pounds, and frequently lift 10 pounds. The claimant requires
an assistive device to walk, but not to stand. The claimant
can carry with the non-cane bearing arm. The claimant must
avoid climbing ladders, ropes, and scaffolds. The claimant
can occasionally balance, stoop, kneel, crouch, and crawl.
The claimant is precluded from concentrated exposure to
hazardous conditions. The claimant is limited to simple
repetitive tasks performed in non-public settings with no
more than occasional contact with coworkers and supervisors.
analyzing whether this RFC is proper, my focus will be on the
ALJ's handling Dr. John Kelly, McClinton's long-time
treating physician. First, I will briefly review the medical
evidence in the record, concentrating on those facts
particularly pertinent to Dr. Kelly's opinion. In
November 2015, Dr. Kelly drafted a medical source statement.
By that point in time, Dr. Kelly had been treating McClinton
for nearly seven years. [Tr. 492-99.] Dr. Kelly checked boxes
on the relevant form, but he also wrote a significant amount
of handwritten notes on it as well. Dr. Kelly opined that
McClinton was limited to lifting 10 pounds or less
occasionally, that she could sit no more than 4 hours in a
workday with sitting at one time for 45-60 minutes, and that
she could stand/walk at least two hours in a workday and with
10-15 minutes at one time with a cane to stabilize her gait.
made the following two main comments about Dr. Kelly's
medical source statement:
I give Dr. Kelly's opinion some weight, but not great
weight, as it is inconsistent with the totality of the
evidence. I recognize that the claimant requires a cane but
do not agree that she is limited to lifting only 10 pounds
from waist level as a 10 pound restriction is not supported
by the objective findings. . . . As for the opinion evidence,
I grant little weight to the opinion of Dr. John Kelly, who
completed a medical source statement. (Ex. 8F). His opinion
is not generally consistent with the medical evidence of
record, including the evaluation of Dr. Gillespie in March
2017. (Ex. 17F/5).
[Tr. 19-20, 22.]
are a few problems with this lean assessment of Dr.
Kelly's opinion. First, the ALJ does not describe
how Dr. Gillespie's evaluation on March 14,
2017, is inconsistent with Dr. Kelly's opinion. Dr.
Gillespie's notes state that McClinton reported that she
has had joint pain for 10 years and she was “in extreme
pain now.” [Tr. 922.] McClinton told Dr. Gillespie that
her knees pop in and out of their sockets, her hands spasm,
her feet turn out, she has noticed swelling in her feet and
hands, she reports morning stiffness that lasts 30 minutes,
her worst areas of pain include her knees, feet and hands,
she has tried Indocin without relief, she has numbness and
tingling in her hands and feet, and she has been diabetic for
the past 13 years. [Id.] Dr. Gillespie also recorded
that McClinton's symptoms included “nausea with
vomiting 1 x per day” and GERD. [Id.] Dr.
Gillespie's exam included a musculoskeletal exam that
showed full range of motion in the upper extremities with no
swollen or tender joints in her hands or feet. [Tr. 924.] But
it also showed left SI joint tenderness, decreased external
rotation at hips worse on the right, and mild crepitus at the
Gillespie arrived at the following assessment:
“[McClinton] has neuropathic symptoms in her hands and
feet. . . . I think her symptoms are more consistent with
neuropathy than arthritis. However, she does have some hip
and knee pain.” [Tr. 924.] Dr. Gillespie then
recommended imaging her most symptomatic joints and the
joints that were not functioning normally. [Id.] She
also noted that x-rays showed osteoarthritis changes in both
hips, and right medial joint space narrowing of the knee and
patella hypertrophy on ...