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UNITED STATES DISTRICT COURT 

NORTHERN DISTRICT OF INDIANA 

HAMMOND DIVISION 

Sheila Lucas, 

 

 Plaintiff, 

 v. Case No. 3:13-CV-258-JVB 

Carolyn Colvin, 

Acting Commissioner of Social Security 

Administration, 

 

 Defendant. 

OPINION AND ORDER 

 Plaintiff Sheila Lucas seeks judicial review of the decision of Defendant Carolyn Colvin, 

the Acting Commissioner of Social Security. The Social Security Administration denied her 

petitions for both Disability Insurance Benefits and Supplemental Security Income benefits 

under the Social Security Act. For the reasons stated below, the Court remands this case to the 

Social Security Administration for further proceedings consistent with this Opinion. 

A. Procedural Background 

 Plaintiff applied for Supplemental Security Income disability benefits on May 24, 2010, 

and Disability Insurance Benefits on June 11, 2010, alleging that she became disabled in January 

2008. (R. at 154–162.) Her claims were denied. (R. at 82–95.) Plaintiff requested a hearing in 

front of an Administrative Law Judge (“ALJ”). (R. at 96–97.) Her hearing was held on October 

3, 2011. (R. at 37–66.) On December 16, 2011, the ALJ determined that Plaintiff was not 

disabled under the Social Security Act. (R. at 18–36.) The Appeals Council denied Plaintiff’s 

request for review, making the ALJ’s opinion final. (R. at 1–7.) 
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B. Factual Background

(1) Plaintiff’s Background and Testimony 

 Plaintiff was born in January 1967. (R. at 154.) Plaintiff graduated high school with a 

GED, followed by an associate’s degree in general studies. (R. at 57.) Before applying for 

disability in May 2010, she was a certified nursing assistant from 2007 to 2008. (R. at 39, 191.) 

While caring for her client, Plaintiff occasionally lifted up to eighty pounds and frequently lifted 

and carried twenty-five pounds. (R. at 191.) 

Before that, from 1998 to 2004, Plaintiff was a claims service representative for an 

insurance company. (R. at 190.) This required her to sit for about seven hours per shift, 

answering phone calls and typing insurance claims. (R. at 192.) She only stood or walked 

during breaks. (R. at 192.) 

From 2004 to 2006, Plaintiff worked as a library assistant, where she sat for about two 

hours of her shift and stood/walked for the remaining three hours of her shift. (R. at 193.) 

Although she only occasionally lifted fifty pounds, she routinely lifted and carried twenty-five 

pounds, while lifting between five and fifteen pounds daily. (R. at 193.) 

From 2006 to 2007, Plaintiff worked as a site coordinator for the Second Harvest Food 

Bank. (R. at 55, 194.) She walked and stood most of the day, with only brief periods of sitting. 

(R. at 194.) Plaintiff occasionally lifted up to sixty pounds, but lifted and carried between 

twenty-five to thirty pounds daily. (R. at 194.) 

 Plaintiff stopped working in January 2008 when her client passed away. (R. at 39.) 

Plaintiff testified that even if her client hadn’t passed away, she thought that she wouldn’t have 

been able to continue to do the job for much longer. (R. at 40.) 
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 Plaintiff testified at the December 2011, hearing, that she can do housework, but 

suggested that she is not a dependable employee because “some days it’s very hard just to get out 

of bed and do mundane things around the house.” (R. at 45.) Plaintiff also testified that, 

although she can lift a gallon of milk, she could not sit for more than fifteen to twenty minutes 

because her legs will go numb. (R. at 45–46.) Plaintiff can push herself to stand and walk for 

more than fifteen or twenty minutes, but if she does, she’s unable to get out of bed for the next 

two days in order to recover. (R. at 52.) Plaintiff also testified that she is unable to hold on and 

grasp things, and typically will drop dishes while washing them. (R. at 53.) Plaintiff also 

testified that she gets migraines usually once or twice a month, and after taking medication is 

typically bedridden until they are better. (R. at 54.) A trip to the hospital is sometimes necessary 

if the medication fails to work. (R. at 54.) Plaintiff also has asthma that is triggered by extreme 

cold or heat, wetness, and humidity. (R. at 57.) 

(2) Medical Evidence 

 Plaintiff claimed she has diabetes, fibromyalgia, osteo-arthritis, asthma, soregensons 

disease, high blood pressure, irritable bowel syndrome, depression, migraines, and allergies. (R. 

at 176.) 

 On May 4, 2010, Plaintiff had an x-ray that demonstrated degenerative changes in her 

right knee, indicating arthritis. (R. at 246, 289.) Plaintiff has been seeing Dr. Tran since May 

2010, who suggested that she may be suffering from an undifferentiated connective tissue 

disorder. (R. at 246–47, 514–33.) However, another rheumatologist, Dr. Tahir, questioned Dr. 

Tran’s diagnoses of a connective tissue disorder, mentioning a history of the disease, but 

concluding that currently Plaintiff “does not have many features to suggest CTD [connective 
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tissue disorder].” (R. at 553–54.) Plaintiff has undergone a few physical and occupational 

therapy appointments in June 2010 for the osteoarthritis in her knee. (R. at 246, 422–36.) Also 

in June 2010, Plaintiff underwent a polysomnogram which indicated that she had mild 

obstructive sleep apnea and signs of sleep deprivation. (R. at 246, 290.) 

In July 2010, Plaintiff was also seen by Dr. Krier for a mental examination, which 

revealed major depressive and anxiety disorders (R. at 246, 442–44.) In August 2010, Plaintiff 

was seen by Dr. Wa’el Bakdash at the request of the Indiana Disability Determination Bureau. 

(R. at 246, 445–47.) He diagnosed her with fibromyalgia, type II diabetes, osteoarthritis in the 

right knee with a slight restriction on movement, asthma, high blood pressure, irritable bowel 

syndrome, depression, migraines, allergic rhinitis, and obesity. (R. at 246, 445–47.) In June 

2011, Dr. Hirisadarahally assessed Plaintiff, noting uncontrolled diabetes mellitus type II, 

thyroid nodules, and Hashimoto’s thyroiditis. (R. at 247, 544.) 

On August 24, 2010, Joseph A. Pressner completed a mental residual functional capacity 

(“RFC”) assessment. (R. at 462–65.) He determined Plaintiff was moderately limited in her 

ability to understand, remember, and carry out detailed instructions. (R. at 462.) She was also 

moderately limited in her ability to complete a normal workday, interact appropriately with the 

general public, and travel to unfamiliar places or use public transportation. (R. at 462.) 

 Medical consultant and state agency reviewing physician, Dr. J. Sands, then completed 

Plaintiff’s physical RFC. (R. at 473–80.) He determined that Plaintiff could occasionally lift or 

carry up to twenty pounds; frequently lift or carry up to ten pounds; stand or walk, with normal 

breaks, up to roughly six hours of an eight hour workday; sit for roughly six hours of an eight 

hour workday; is unlimited in her ability to push or pull; frequently balance, stoop, kneel, 

crouch, or crawl; occasionally climb ramps and stairs; and never climb ladders, ropes, or 
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scaffolds. (R. at 474–75.) Plaintiff had no manipulative, visual, or communicative limitations 

but should avoid concentrated exposure to any environmental conditions involving wetness or 

hazards such as machinery or heights. (R. at 476–77.) 

 A year later on October 2011, treating physician Dr. Berghofer in his RFC of Plaintiff, 

stated that she is incapable of low stress jobs; that she can sit or stand for no more than twenty 

minutes; sit or stand for less than two hours in an eight hour workday; must walk for ten minutes, 

every ten minutes during an eight hour work day; should never lift more than twenty pounds and 

rarely lift less than ten pounds; can occasionally look down and turn her head right or left and 

can hold her head in a static position while rarely looking up; should never stoop, crouch/squat, 

climb ladders and should rarely twist or climb stairs; has significant limitations with reaching, 

handling, or fingering; and would likely be absent from work for more than four days per month. 

(R. at 623–25.) 

 Plaintiff’s medications include Lipitor, Fentanyl, Hydrocodone-Acetaminophen, 

Tramadol, Cyclobenzaprine, Metformin HCL, Januvia, Lisinopril, Levothyroxine, Celebrex, 

Sertraline, Estradiol, Singulair, Proair, Hydroxychloroquine, Loratadine, Fluticasone propionate, 

doxycycline hyclate, and Nitrofur-macr. (R. at 240.) 

 (3) Vocational Expert’s Testimony 

 Vocational expert Stephanie Archer (“VE”) testified at Plaintiff’s hearing before the ALJ. 

(R. at 59–66.) The ALJ provided the VE with a hypothetical, using information from Dr. Sand’s 

physical RFC, as well as Plaintiff’s age, education, and work experience. (R. at 59.) However, 

he failed to incorporate the RFC from Plaintiff’s treating physician, Dr. Berghofer. The VE 

stated that she would not be able to return to her nursing assistance position due to the lifting 
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requirements. (R. at 60.) The VE also stated that Plaintiff would not be able to return to her 

work as a claims service representative. (R. at 61.) 

 The ALJ then provided a second hypothetical introducing the results from Plaintiff’s 

mental examination. (R. at 62.) He also included her ability to “perform simple, unskilled 

work” that would limit her interactions to routine and superficial, that she should not engage in 

fast-paced production work, and that she should be given breaks at least every two hours. (R. at 

62.) The VE said Plaintiff could not return to previous work due to her mental restrictions. (R. at 

62.) The VE suggested that Plaintiff could work as an assembler (2,400 existing jobs in Indiana) 

and as a packer (1,200 existing jobs in Indiana). (R. at 63.) 

(4) ALJ’s Decision

 The ALJ found that Plaintiff was not disabled from January 24, 2010, through the date of 

the decision. (R. at 21.) The ALJ determined Plaintiff has the following severe impairments: 

fibromyalgia, obesity, osteoarthritis in her right knee, and affective disorder. (R. at 23.) 

However, Plaintiff does not have an impairment that meets the impairments listed in 20 C.F.R. § 

404, Subpart P, Appendix 1. (R. at 24.) 

 The ALJ further found Plaintiff’s impairments are reasonably expected to have caused 

her symptoms, including stiffness and pain. (R. at 26.) However, her statements were 

inconsistent with Dr. Sands’s RFC. (R. at 26.) The ALJ found that Plaintiff’s claim that the 

severity of her symptoms made her unable to work is unpersuasive. (R. at 28.) Rather, she can 

perform limited work activities. (R. at 28.) Thus, the ALJ concluded Plaintiff is capable of 

making an adjustment to other work which exists in the national economy in large numbers. (R. 

at 30.) 
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C. Standard of Review

 Under the Social Security Act, an individual is allowed judicial review of a final decision 

by the Commissioner of Social Security. 42 U.S.C. § 405(g). When under review, this Court 

must determine that ALJ’s decision was supported substantial evidence and made under the 

correct legal standard. Briscoe ex rel. Taylor v. Barnhart, 425 F.3d 345, 351 (7th Cir. 2005); 

Lopez v. Barnhart, 336 F.3d 535, 539 (7th Cir. 2003). Substantial evidence is defined as 

including relevant evidence that a reasonable mind might then accept as adequate to support a 

conclusion. Richardson v. Perales, 402 U.S. 389, 390 (1971). It is the duty of the ALJ, and not 

this Court, to consider facts and the credibility of witnesses, weigh evidence, resolve evidence 

conflicts, or substitute its own judgment for that of the ALJ. Perales, 402 U.S. at 399–400; 

Boiles v. Barnhard, 395 F.3d 421, 425 (7th Cir. 2005); Cannon v. Apfel, 213 f.3d 970, 974 (7th 

Cir. 2000). Judicial review by this Court will ensure that the ALJ has built an accurate and 

logical bridge between the evidence and his conclusion, as well as make certain that the agency’s 

findings were accurate in order to provide Plaintiff with meaningful judicial review. Scott v. 

Barnhart, 297 F.3d 589, 595 (7th Cir. 2002); Clifford v. Apfel, 227 F.3d 863, 872 (7th Cir. 2000). 

D. Disability Standard

 To qualify for Disability Insurance Benefits or Supplemental Security Income, an 

individual claimant must establish that he or she suffers from and meets a disability listed within 

the Social Security Act. A disability is “an 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 
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than 12 months.” 42 U.S.C. § 423(d)(1)(A). The Social Security Administration established a 

five-step inquiry to evaluate whether a claimant qualifies for disability benefits. A successful 

claimant must show: 

(1) he is not presently employed; (2) his impairment is severe; (3) his impairment 

is listed or equal to a listing in 20 C.F.R. § 404, Subpart P, Appendix 1; (4) he is 

not able to perform her past relevant work; and (5) he is unable to perform any 

other work within the national and local economy. 

Scheck v. Barnhart, 357 F.3d 697, 699–700 (7th Cir. 2004). An affirmative answer leads to 

either the next step, or on steps three and give, to a finding that the claimant is disabled. 

Zurawski v. Halter, 245 F.3d 881, 886 (7th Cir. 2001). A negative answer at any point other than 

step three stops the inquiry and leads to a finding that the claimant is not disabled. Id. The 

burden of proof lies with the claimant at every step except the fifth, where it then shifts to the 

Commissioner. Clifford, 227 F.3d at 868. 

E. Analysis 

 Plaintiff has two primary contentions upon appeal: (1) the ALJ erred in his assessment of 

Plaintiff’s RFC; and (2) the ALJ erred when relying on the testimony of the vocational expert. 

(Pl. Brief at 15.) For the reasons explained below, this Court remands this case to the SSA for 

further proceedings consistent with this Opinion. 

(1) The ALJ erred in his assessment of Plaintiff’s RFC

 Plaintiff claims that the ALJ legally erred when he assessed an RFC that was not 

supported by substantial evidence because the ALJ (1) improperly dismissed the opinion of 

Plaintiff’s treating physician Dr. Berghofer; (2) failed to incorporate Plaintiff’s connective tissue 

disorder; and (3) improperly dismissed Plaintiff’s testimony. (Pl. Brief at 15–24.) The Court 
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finds that the ALJ properly justified his decision regarding Plaintiff’s connective tissue disorder, 

but contrary to law, did not take Plaintiff’s testimony into account nor explained his reasoning 

behind the dismissal of treating physician Dr. Berghofer’s opinion and RFC. Therefore, the ALJ 

must address on remand why he did not fully consider Plaintiff’s testimony or assessed Dr. 

Berghofer’s opinion as inconsistent with the evidence as a whole. 

(a) The ALJ did not base his RFC conclusion on substantial evidence

 Plaintiff’s claim that the ALJ improperly dismissed treating physician Dr. Berghofer’s 

opinion requires remand. “A treating physician’s opinion is entitled to more weight because of 

his longitudinal perspective.” Hofslien v. Barnhart, 439 F.3d 375, 376 (7th Cir. 2006). The ALJ 

must consider the length, nature, and extent of the relationship, frequency of examination, and 

consistency and supportability of the physician’s opinion. Id. at 377. “An ALJ can reject an 

examining physician’s opinion only for reasons supported by substantial evidence in the record; 

a contradictory opinion of a non-examining physician does not, by itself, suffice.” Gudgel v. 

Barnhart, 345 F.3d 467, 470 (7th Cir. 2003). The ALJ needs to justify his decision with 

substantial evidence, which is “’more than a scintilla’ but less than a preponderance of the 

evidence. Wood v. Thompson, 246 F.3d 1026, 1029 (7th Cir. 2001) (citations omitted). 

Evidence is “inadequate” if it is ambiguous, outdated, or insufficient in quantity or detail. Sutton 

v. Barnhart, 183 Fed. Appx. 555, 560 (7th Cir. 2006). 

 Here, this Court cannot determine what evidence the ALJ found to discount the treating 

physician because he says no more than “Dr. Berghofer’s opinion is given little weight as it is 

not supported by and is not consistent with exam records.” (R. at 28.) He then states that the 

contrasting opinion of Dr. J. Sands was given “significant weight because it is supported with 
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references to the exam record and is consistent with treatment provided.” (R. at 28). The ALJ 

also placed great weight on the consultative exam of Dr. Wa’el Bakdash and his exam in August 

2010. (R. at 26.) However, there is no “accurate and logical bridge” from the evidence of 

contrasting RFCs to the ALJ’s conclusion as to why one deserves and receives more weight than 

the other. Cf. Scott, 297 F.3d at 595 (requiring an ALJ to build this bridge from evidence to 

conclusion so that the reviewing court “may assess the validity of the agency’s ultimate 

findings”). 

 The RFC assessments by Dr. Berghofer and Dr. Sands are opposite, in that Dr. 

Berghofer, in his October 2011 RFC, given over a year after Dr. Sands’s RFC, indicated that 

Plaintiff is “incapable of even ‘low stress’ jobs.’” (R. at 623.) The opinions of Dr. Sands and Dr. 

Bakdash, received in 2010, stated Plaintiff had no manipulative limitations and no tenderness in 

her joints. (R. at 26, 28.) Further opinions by Doctors Tran and Tahir, in 2011, indicate that 

either Plaintiff’s disease has progressed since the 2010 examinations or demonstrate a drastic 

difference in opinion between doctors. (R. at 27.) There is explanation provided for the 

diagnoses by Doctors Tran and Tahir in the ALJ’s decision, but he provides no explanation for 

his failure to take into account their more recent exams of Plaintiff as compared to the 2010 

exam of Dr. Bakdash. (R. at 26–27.) Without a demonstration of evidence otherwise, the ALJ 

cannot say for certain that the opinion of Dr. Berghofer is inconsistent, and upon remand must 

explain with sufficient evidence his reasoning. 

(b) The ALJ failed to take into account Plaintiff’s testimony

 When assigning an RFC, the ALJ must consider not just the objective medical evidence 

and opinion from medical sources, but also Plaintiff’s testimony. 20 C.F.R. § 404.1545(3). 
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Plaintiff claims that the ALJ erred when he failed to confer what weight he gave to Plaintiff’s 

testimony. (Pl. Brief at 20.) 

The Seventh Circuit has criticized Social Security Administration’s ALJs for employing 

language that is filled with “opaque” and “meaningless” boilerplate language that fails to provide 

the necessary facts to make a proper decision. Bjornson v. Astrue, 671 F.3d 640, 644 (7th Cir. 

2012). Boilerplate language gives “no clue to what weight the trier of fact gave the testimony.” 

Bjornson, 671 F.3d at 645. Although boilerplate language by itself does not make the ALJ’s 

determination invalid, it is the failure by the ALJ to then explain and provide evidence from the 

record that makes the decision invalid. Punzio v. Astrue, 630 F.3d 704, 709 (7th Cir. 2011). 

 “Because the ALJ is in the best position to observe witnesses, [the Court] will not disturb 

[their] credibility determinations as long as they find some support in the record.” Dixon v. 

Massanari, 270 F.3d 1171, 1178–79 (7th Cir. 2001). Courts will “reverse an ALJ’s credibility 

determination only if the claimant can show it was ‘patently wrong.’” Powers v. Apfel, 207 F.3d 

431, 435 (7th Cir. 2000) (citation omitted). However, “patently wrong” is a high burden, and an 

ALJ’s credibility determination does not have to be flawless. Turner v. Astrue, 390 Fed. Appx. 

581, 587 (7th Cir. 2010); Adams v. Astrue, 880 F. Supp. 2d 895, 905 (N.D. Ill. 2012) (citing 

Similia v. Astrue, 573 F.3d 503, 516 (7th Cir. 2008)). Only when there is a completely failure by 

the ALJ to provide any explanation for his credibility determination that a court will declare the 

decision to be patently wrong and worthy of a reversal. Elder v. Astrue, 529 F.3d 408, 413–414 

(7th Cir. 2008) (citations omitted). 

 Here, the ALJ determined that Plaintiff had the RFC to perform certain sedentary work 

with a list of exceptions. (R. at 25.) The ALJ followed this with his credibility findings using 

the following boilerplate language: 
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After careful consideration of the evidence, the undersigned finds that the 

claimant’s medically determinable impairments could reasonably be expected to 

cause the alleged symptoms; however, the claimant’s statements concerning the 

intensity, persistence, and limiting effects of these symptoms are not credible to 

the extent that they are inconsistent with the above residual functional capacity 

assessment. 

(R. at 26.) The ALJ spends most of his decision discussing Plaintiff’s medical records, her list of 

impairments, and what Plaintiff testified she is capable of doing. However, beyond the 

boilerplate language listed above, he never explains why he discredited her testimony. He 

instead uses the opinion of Dr. Bakdash as evidence to show Plaintiff is not suffering like she 

testified. (R. at 26.) 

 The ALJ does not take into account Plaintiff’s testimony that she cannot perform 

sedentary work because she “would [not] be reliable,” “can’t [sit for] longer than like 15 or 20 

minutes because [her] legs will go numb,” but that when she “push[es] herself further . . . [she’s] 

pretty much shot for the next day, sometimes two days.” (R. at 45–46, 52.) She also discussed 

pain in her hands daily and yet the vocational expert and the ALJ determined that she is able to 

perform the jobs of packer or assemblers, which require nearly constant hand manipulation. (R. 

at 53, 63.) The ALJ used the exams by Dr. Bakdash and Dr. Sands to discredit Plaintiff because 

her testimony does not match with the doctors’ opinions. (R. at 26.) However, like the 

inconsistency with the RFCs of Dr. Sands and Dr. Berghofer, the ALJ failed to take into account 

any exams in 2011. It is in 2011 that Plaintiff received updated results on her aliments, which 

indicate that her conditions may have worsened over time. (infra at 9–10.) 

 In summary, the ALJ’s boilerplate language when determining Plaintiff’s credibility was 

unacceptable as although he makes note of her testimony, he fails to fully address why he 

discredits it beyond the use of outdated medical exams. Upon remand, the ALJ must fill in the 

explanatory gaps regarding Plaintiff’s testimony, her inability to perform certain tasks, and her 
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pain level. He must also address his reasoning for using outdated medical exams as explanation 

and instead provide sufficient, substantial evidence as reasoning for his failure to take Plaintiff’s 

credibility into account. 

(c) The ALJ properly disregarded the connective tissue diagnosis

 The ALJ did not err in not using Plaintiff’s diagnosis of a connective tissue disorder in 

his listing of her impairments. In his opinion, the ALJ mentions that Plaintiff’s disorder was 

diagnosed by Dr. Tran, one of Plaintiff’s rheumatologists. (R. at 27.) However, he notes a 

second opinion by another rheumatologist, Dr. Tahir, who agreed with Dr. Tran’s diagnosis of 

fibromyalgia, but disagreed with the connective tissue disorder diagnosis. (R. at 27, 553–54.) 

None of the other doctors mentioned in the records suggest this diagnosis, not even her treating 

physician, Dr. Berghofer. Plaintiff did not list the connective tissue disorder as one of her 

ailments when she filed for disability. (R. at 23, 176.) Other complaints by Plaintiff are 

included but the ALJ indicates that “there is no objective medical evidence to show that these 

impairments are more than transient or that they cause significant vocational limitations.” (R. at 

23.) There is a logical bridge that if one doctor tentatively diagnoses Plaintiff with a connective 

tissue disorder and another doctor states she is no longer showing signs of the disease, that the 

disease is nothing more than a transient impairment. 

 Because the Court finds that the ALJ finding of the RFC is flawed, the second issue 

raised by plaintiff in this appeal--- whether the ALJ erred when relying on the testimony of the 

vocational expert---is moot. 

F. Conclusion
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 This Court finds that the ALJ failed to properly build an accurate and logical bridge from 

the evidence to his conclusions, thereby precluding this Court from meaningfully reviewing the 

decision. The ALJ is directed to revisit his decision and fill in the missing explanations, as stated 

above. 

 The Court remands this case to the Social Security Administration for further proceedings 

consistent with this Opinion. 

SO ORDERED on September 30, 2014. 

 S/ Joseph S. Van Bokkelen 

 JOSEPH S. VAN BOKKELEN 

 UNITED STATES DISTRICT JUDGE