UNITED STATES DISTRICT COURT 

NORTHERN DISTRICT OF INDIANA 

FORT WAYNE DIVISION

CHRISTOPHER LEE RENFREE, ) 

 ) 

 Plaintiff, ) 

 ) 

 v. ) CAUSE NO.: 1:16-CV-271-TLS 

 ) 

COMMISSIONER OF SOCIAL SECURITY, ) 

 ) 

 Defendant. ) 

OPINION AND ORDER 

 The Plaintiff, Christopher Lee Renfree, 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’s application was denied 

initially and upon reconsideration. In September of 2014, an administrative law judge (ALJ) held 

a hearing on the Plaintiff’s application. On December 18, 2014, the ALJ issued a Decision 

holding that the Plaintiff was not entitled to benefits because he was not disabled under the 

relevant provisions of the Social Security Act. On June 2, 2016, the Appeals Council denied 

review of the ALJ’s decision, thereby making the ALJ’s decision the final decision of the 

Commissioner. The Plaintiff subsequently filed suit pursuant to 42 U.S.C. § 405(g) and 

§ 1383(c)(3). 

EVIDENCE OF RECORD

 The Plaintiff was born on August 23, 1964. (R. at 155, ECF No. 10.) He has at least a 

high school education. (Id.) The Plaintiff has a work history that includes working as a 

groundskeeper, bar back, and warehouse worker. (R. at 155.) 
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 In the present case, the Plaintiff claims to have become disabled on July 9, 2008, due to 

multiple physical and mental impairments, including a history of bilateral leg fractures due to a 

motor vehicle accident in 1988; post-traumatic arthritis in the left knee, right ankle, and foot; 

contracture and/or stress fracture; degenerative disc disease (spondylosis); hepatitis C; 

hyperlipidemia; major depressive disorder; dysthymia secondary to physical problems; a history 

of polysubstance abuse; chronic pain syndrome; polyarthralgia; thoracolumbar scoliosis; a right 

hip/proximal femur bone formation problem; and foot problems including verruca plantaris, 

fasciitis, tendonitis, metatarsalgia, and hammertoe. (Pl. Br. 4–5, ECF No. 17.) 

THE ALJ’S HOLDING

 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). 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). 

An ALJ conducts a five-step inquiry in deciding whether to grant or deny benefits. 20 

C.F.R. § 404.1520. 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 determined that the Plaintiff 

did not engaged in SGA since the alleged onset of disability and thus, the Plaintiff satisfied the 

step one inquiry. (R. at 146.) In step two, the ALJ determines whether the claimant has a severe 

impairment limiting the ability to do basic work activities pursuant to § 404.1520(c). Here, the 
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ALJ determined that the Plaintiff’s impairments, including a “history of bilateral leg fractures 

due to [a] remote motor vehicle accident in 1988, posttraumatic arthritis in [the] left knee, right 

ankle/foot arthritis/contracture/stress fracture/status post-crash [sic] injury, degenerative disc 

disease/spondylosis” were severe impairments because they significantly limited his ability to 

perform basic work activities. (Id.) The ALJ did not find that the Plaintiff’s diagnoses of major 

depressive disorder and dysthymia secondary to physical problems were 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). If a 

claimant’s impairment(s), considered singly or in combination with other impairments, rises to 

this level, he earns a presumption of disability “without considering [his] age, education, and 

work experience.” § 404.1520(d). But, if the impairment(s), either singly or in combination, falls 

short, an ALJ must move 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 this “past relevant work,” § 404.1520(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). 

 In the case at hand, the ALJ determined that the Plaintiff’s impairments, either singly or 

in combination, do not meet or equal any of the listings in Appendix 1 and that the Plaintiff has 

the RFC to perform light work, as defined by § 404.1567(b). (R. at 147.) However, the ALJ held 

that the Plaintiff is limited to occasional climbing of ramps and stairs, balancing, stooping, 

kneeling, crouching, and crawling. (Id.) Additionally, he requires a sit/stand option, which will 

allow him to alternate between sitting and standing up to every 30 minutes, if needed, but will 

not render him off task. (Id.) The Plaintiff can never climb ladders, ropes, or scaffolds, should 
4 

avoid concentrated exposure to extreme cold and vibration, and avoid even moderate exposure to 

hazards such as moving machinery, unprotected heights, and slippery, uneven, or moving 

surfaces. (Id.) 

 In arriving at the RFC, the ALJ determined that the Plaintiff’s medically determinable 

impairments could reasonably be expected to cause his alleged symptoms, “however, the 

claimant’s statements concerning the intensity, persistence, and limiting effects of these 

symptoms are not entirely credible . . . .” (R. at 148). The ALJ examined both the Plaintiff’s 

physical impairments and his mental impairments. 

A. Physical Impairments 

 The ALJ began by examining the Plaintiff’s claim that he is disabled due to his left knee 

and right foot, which cause him pain and result in an irregular walking pattern. The ALJ noted 

that the Plaintiff’s problems began with an automobile accident in 1988, though in 2007, a CT 

scan revealed healed fractures. (R. at 148–49.) The ALJ also noted that though the Plaintiff 

claims that the primary issue is pain as a result of the injury, the Plaintiff nevertheless continues 

to walk for long periods of time, has had no diagnosis of decreased muscle strength, responded 

well to pain medications, returned to work after sustaining the injuries, takes care of his elderly 

mother (including cooking, pushing her in a wheelchair, and performing household chores), is 

able to travel out of town for periods of time while on pain medication, has failed to follow up 

with a foot surgeon (stating that he needs to care for his mother and cannot be off his feet for that 

long), and is able to perform daily activities. (R. at 151–52.) Accordingly, the ALJ found the 

Plaintiff not fully credible, (R. at 151.), also holding that he “does not find the record supports 

the intensity of pain reported by the claimant.” (R. at 152.) 
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 In reaching his conclusion, the ALJ detailed the Plaintiff’s October 2010 initial 

consultation by Dr. Winifred Lau, M.D., who referred the Plaintiff for pain management 

treatment resulting from chronic pain syndrome. (R. at 149.) However, the ALJ noted that less 

than a month later, the Plaintiff reported to Dr. Lau requesting new inserts for his shoes because 

he had been walking frequently. (Id.). The ALJ additionally reviewed the Plaintiff’s treatment by 

Dr. Patricia Stewart, M.D., beginning in 2011, who determined that the Plaintiff showed signs of 

sclerosis, but otherwise had no major problems. (Id.) Upon further examination by Dr. Nicole 

Arcand, M.D., the Plaintiff appeared to have mild issues, but no major movement concerns. (Id.) 

Though in 2012 the Plaintiff was found to have a lesion and pain in his foot, an abnormal gait, 

and minimal swelling (R. at 150–51), the ALJ detailed the 2013 examination by Karim Moshref, 

P.C., who determined that the Plaintiff’s physical examination was generally normal. (R. at 151.) 

The ALJ gave little weight to Jenna Purdell, who opined that the Plaintiff would be suited for a 

job that does not require physical labor or a lot of walking, because the ALJ held it was unknown 

in what capacity Purdell treated the Plaintiff. (R. at 153.) Additionally, the ALJ determined that 

he likely incorporated Purdell’s opinion when holding that the Plaintiff is limited to light work 

with a sit/stand option. (Id.) The ALJ also gave little weight to the state agency medical 

consultants from the Plaintiff’s prior intimal application because the doctors’ opinions were not 

based on a complete medical record. (R. at 155.) Nevertheless, the ALJ held that he generally 

accounted for their recommendations. (Id.) The ALJ gave great weight to the opinion of M. Brill, 

M.D., a state agency medical consultant, who opined regarding the limitations of the Plaintiff, 

which the ALJ ultimately incorporated in the RFC determination. (R. at 154.) 
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B. Mental Impairments 

Because the Plaintiff had no limitations in his activities of daily living, mild limitations in 

social functioning, no limitations in concentration, persistence, or pace, and no episodes of 

decomposition, the ALJ determined that the Plaintiff’s major depressive disorder and dysthymia 

were not severe. (R. at 146.) Moreover, the ALJ noted that the Plaintiff did not seek or receive 

ongoing treatment for these mental impairments, and with medication, the Plaintiff’s symptoms 

improved. (R. at 146–47.) 

When determining the Plaintiff’s RFC, the ALJ continued to review the Plaintiff’s mental 

impairments.1

 The ALJ found that in 2006, the Plaintiff was diagnosed with major depressive 

disorder, (R. at 148), but he had not sought treatment upon his diagnosis. (R. at 149). In October 

2010, the Plaintiff was seen at Sound Community Services and was diagnosed with depressive 

disorder, and the diagnosis was changed to major depressive disorder a month later. (Id.) The 

Plaintiff subsequently began treatment by Rama Goyal, M.D., which he continued for one year 

before moving out of state. (R. at 150.) The ALJ ultimately gave no weight to Dr. Goyal’s 

opinion that the Plaintiff would have an obvious to slight problem in areas of social interaction 

and performing basic work activities because the ALJ determined that the opinion is vague as it 

is unknown what an “obvious to slight” problem is. (R. at 153.) Moreover, the ALJ held that Dr. 

Goyal’s evaluation was a result of answers provided by the Plaintiff and thus, the evaluation was 

a subjective report by the Plaintiff. (Id.) 

In April 2011, the ALJ noted that Sound Community Services determined that the 

Plaintiff had normal mental status, and Dr. Lau’s notes indicated that the Plaintiff had no 

 

1

 “In making a proper RFC determination, the ALJ must consider . . . the combined effect of all of a 

claimant’s impairments, both severe and non-severe.” Keenan v. Colvin, 2016 WL 4735157, at * 8 (N.D. 

Ind. Sept. 12, 2016); see also Parker v. Astrue, 597 F.3d 920, 923 (7th Cir. 2010). Here, the ALJ correctly 

continued to review the Plaintiff’s mental impairments when developing the RFC. 
7 

symptoms of depression (R. at 150.) The Plaintiff was subsequently seen by Dr. Yunus 

Pothiawala, M.D., and the ALJ found that though Dr. Pothiawala diagnosed the Plaintiff with 

dysthymia, the Plaintiff had an appropriate and cooperative affect and engaged in regular 

activities of daily living including normal socialization. (Id.) In March 2013, the Plaintiff was 

seen by Dr. Wayne Von Barger, PhD, who found that the Plaintiff reported taking care of his 

mother, engaging in daily activities, and did not have any difficulties with recall or 

concentration. (R. at 151.) In November 2013, the Plaintiff was prescribed Elavil for depression, 

though the ALJ noted that the Plaintiff presented in a cooperative and pleasant manner. (Id.) 

The ALJ gave great weight to some of the state agency psychological consultants, who 

opined that the Plaintiff had only mild limitations in social functioning, but no limitations in his 

daily activity, because the ALJ concurred that the Plaintiff had not continued to follow up with a 

therapist or psychologist and did not report ongoing limitations due to mental impairments. (R. at 

154.) However, the ALJ gave little weight to the state agency psychological consultants who 

opined that the Plaintiff had mild limitations in all areas of functioning, specifically noting that 

these consultants failed to account for the fact that the Plaintiff completed activities of daily 

living and assisted his mother. (R. at 154–55.) The ALJ also gave little weight to the state agency 

medical consultants from the Plaintiff’s prior applications, holding that these consultants did not 

have an opportunity to examine the entire medical record. (R. at 155.) 

The ALJ further examined the Plaintiff’s Global Assessment Functioning (GAF) scores, 

which ranged from 36 to 55, and ultimately gave them no weight. (R. at 153–54.) In 2009, the 

Plaintiff had a GAF Score of 37, indicating severe impairments. (R. at 149.) The ALJ determined 

that this score and the Plaintiff’s previous score of 36 were not reliable because they were more 

than five years old (at the time of the ALJ’s decision), the Plaintiff’s mental issues appeared to 
8 

stem from an ongoing court case at the time, and the Plaintiff presented with a normal mental 

status examination. (R. at 153.) In 2010, Dr. Goyal gave the Plaintiff a GAF score of 41, also 

indicating a major impairment in functioning. (R. at 149, 153.) The ALJ held that the record did 

not support this score because the Plaintiff had a stable mood, no delusions, and the score was 

more than two years old. (R. at 153.) In 2013, the Plaintiff’s GAF score was 55, indicating 

moderate limitations; however, the ALJ again noted that the Plaintiff appeared cooperative and 

had an intact memory. (R. at 151, 153–54.) 

Additionally, the ALJ analyzed the Plaintiff’s polysubstance abuse. The ALJ noted that 

the Plaintiff presented to the emergency room on multiple occasions requesting detox and was 

diagnosed on numerous occasions with alcohol dependence. (R. at 148–49.) Though the Plaintiff 

entered treatment for opiate and alcohol detox, (id.), the ALJ found that “the claimant has been 

noted to leave against medical advice and cancel appointments.” (R. at 152.) Moreover, the 

Plaintiff’s drug and alcohol abuse did not result in a period of decomposition. (R. at 146.) 

Accordingly, the ALJ determined “that the record evidence fails to demonstrate that the 

claimant’s history of alcohol abuse constitutes a contributing factor material to the determination 

of disability.” (R. at 152–53.) Moreover, the ALJ found that the Plaintiff’s testimony regarding 

his pain levels and dependence issues was vague and evasive because the Plaintiff did not clarify 

how long he could stand or what “overdoing it” was. (R. at 152.) 

 At the final step of the evaluation, the ALJ determined that the Plaintiff cannot perform 

any past relevant work. (R. at 155.) However, because of the Plaintiff’s age, education, work 

experience, and RFC, the ALJ found that there are a significant number of jobs in the national 
9 

economy that the Plaintiff could perform. (Id.) These jobs include small products assembler, 

cashier, and electrical accessories assembler. (R. at 156.) 

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). A 

court will affirm the Commissioner’s findings of fact and denial of disability benefits if they are 

supported by substantial evidence. Craft v. Astrue, 539 F.3d 668, 673 (7th Cir. 2008). 

Substantial evidence is “such relevant evidence as a reasonable mind might accept as adequate to 

support a conclusion.” Richardson v. Perales, 402 U.S. 389, 401 (1971). 

It is the duty of the ALJ to weigh the evidence, resolve material conflicts, make 

independent findings of fact, and resolve the case accordingly. Richardson, 402 U.S. at 399–400. 

In a substantial-evidence determination, the Court considers the entire administrative record but 

does not reweigh evidence, resolve conflicts, decide questions of credibility, or substitute the 

Court’s own judgment for that of the Commissioner. Lopez ex rel. Lopez v. Barnhart, 336 F.3d 

535, 539 (7th Cir. 2003). In other words, the Court conducts a “critical review of the evidence” 

before affirming the Commissioner’s decision, and the decision cannot stand if it lacks 

evidentiary support or an inadequately discusses the issues. Id.

When an ALJ recommends that the Agency deny benefits, the ALJ must “provide a 

logical bridge between the evidence and [her] 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 
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explain why contrary evidence does not persuade.” Berger v. Astrue, 516 F.3d 539, 544 (7th Cir. 

2008). Where conflicting evidence would allow reasonable minds to differ as to whether the 

claimant is disabled, it is the ALJ’s responsibility to resolve those conflicts. Elder v. Astrue, 529 

F.3d 408, 414 (7th Cir. 2008). Conclusions of law are not entitled to such deference, however, so 

where the ALJ commits an error of law, the Court must reverse the decision regardless of the 

volume of evidence supporting the factual findings. Binion v. Chater, 108 F.3d 780, 782 (7th Cir. 

1997). 

ANALYSIS

On appeal to this Court, the Plaintiff presents the following faults with the ALJ’s 

decision: the ALJ improperly over emphasized the Plaintiff’s daily activities, the ALJ did not 

properly consider the impact of the Plaintiff’s inability to afford treatment, and the ALJ 

improperly identified and weighted the opinion of the Plaintiff’s treating psychiatrist. 

A. The Plaintiff’s Daily Activities 

 The Plaintiff finds fault with the ALJ’s analysis equating the Plaintiff’s daily activities, 

including care for his elderly mother, with his ability to do work. Specifically, the ALJ held: 

Additionally, the claimant provides care for his elderly mother, including cooking for [her,] 

putting on her shoes, pushing her in her wheelchair, and performing household chores. 

These are not activities of someone who would be unable to perform light work with a 

sit/stand option. 

(R. at 152.) 

The Seventh Circuit has acknowledged that care for the family does not automatically 

equate to the ability to work. In Beardsley v. Colvin, the Seventh Circuit held: 
11 

As we have said, it is proper for the Social Security Administration to consider a claimant’s 

daily activities in judging disability, but we have urged caution in equating these activities 

with the challenges of daily employment in a competitive environment, especially when 

the claimant is caring for a family member. 

758 F.3d 834, 838 (7th Cir. 2014); see also Gentle v. Barnhart, 430 F.3d 865, 867 (7th Cir. 

2005) (“The administrative law judge’s casual equating of household work to work in the labor 

market cannot stand.”). This is because “[t]he critical differences between activities of daily 

living and activities in a full-time job are that a person has more flexibility in scheduling the 

former than the latter, can get help from other persons . . . and is not held to a minimum standard 

of performance, as [he] would be by an employer. The failure to recognize these differences is a 

recurrent, and deplorable feature of opinions by administrative law judges in social security 

disability cases.” Bjornson v. Astrue, 671 F.3d 640, 647 (7th Cir. 2012); see also Gentle, 430 

F.3d at 867 (holding that a Plaintiff may have to take care of family or else abandon them to 

foster care and thus, household work is not equitable to employment). 

Accordingly, the ALJ may review the Plaintiff’s daily activities, including his 

undertaking of household chores and taking care of his mother, when analyzing his symptoms 

and severity of his alleged disability. However, the ALJ should not equate the Plaintiff’s ability 

to engage in household chores and care for his mother with the ability to take on a full time job. 

For the ALJ to have made this later determination was error and constitutes grounds for reversal. 

B The Plaintiff’s Inability to Afford Treatment 

The Plaintiff also argues that the ALJ did not properly analyze why the Plaintiff was 

unable to afford to follow through with foot surgery. 

In his analysis of why the Plaintiff was not credible, the ALJ held that the Plaintiff “has 

been referred for foot surgery, however he has failed to follow up with a foot surgeon, stating 

that he cares for his mother and is unable to be off his feet for that long.” (R. at 152.) According 
12 

to the Plaintiff, the ALJ overlooked in his decision that the Plaintiff’s health insurance at the time 

was the type of Medicaid that required a spend down, and thus, the Plaintiff was unable to obtain 

the surgery until the spend down had been exhausted. (see R. at 877 (“chronic leg pain in his 

legs—in another spend down right now—can’t have surgery until the spend down is done.”), 878 

(“awaiting surgery—on a spend down now.”).) Therefore, the Plaintiff argues that the ALJ 

improperly held the Plaintiff’s “failure” to obtain surgery against his credibility. (R. at 152.) 

The Court affirms that an ALJ “must not draw any inferences about an individual’s 

symptoms and their functional effects from a failure to seek or pursue regular medical treatment 

without first considering any explanations that the individual may provide.” Moss v. Astrue, 555 

F.3d 556, 562 (7th Cir. 2009) (citation omitted). “ALJs have a duty to consider factors like 

inability to travel, mental illness, or economic constraints that may have prevented claimants 

from seeking [or] receiving medical care.” Orienti v. Astrue, 958 F. Supp. 2d 961, 977 (N.D. Ill. 

2013). 

In this case, though the ALJ noted that the Plaintiff’s complaints of foot pain were both 

vague and unsupported by the record, (R. at 152), the Court remands this case to the ALJ to the 

extent that the ALJ predicated her adverse credibility determination on the Plaintiff’s failure to 

obtain surgical treatment without analyzing whether the Plaintiff’s failure to obtain an expensive 

surgery was due to factors such as his economic constraints. 

C. The Plaintiff’s Treating Psychiatrist 

 Finally, the Plaintiff argues that the ALJ erred when giving little weight to Dr. Goyal’s 

opinion. First, the Plaintiff points out that the ALJ did not engage in a discussion concerning the 

length of the treating relationship, frequency of examination, nature of the treatment relationship, 

and the extent of the treatment relationship. see 20 C.F.R. § 404.1527. Moreover, the Plaintiff 
13 

argues that the ALJ’s primary reason for rejecting Dr. Goyal’s opinion is because Dr. Goyal 

circled “obvious problem” with one area of social functioning on the Connecticut Department of 

Disability Determination Services (DDDS) Mental Impairment Questionnaire, and “slight 

problem” with another area of social functioning. (R. at 910.) The ALJ held, “it is unknown what 

a slight problem or obvious problem is.” (R. at 153.) The Plaintiff argues that Dr. Goyal had to 

circle one of these options on the DDDS Questionnaire and thus, it is incorrect for the ALJ to 

reject Dr. Goyal’s opinions due to his filling out of a pre-printed form. 

 The Court finds that the ALJ was incorrect in discrediting Dr. Goyal’s opinion on the 

basis that he circled “obvious” and “slight” problem on a preprinted social security form. That 

these terms are vague to the ALJ is a complaint by the ALJ to the makers of the questionnaire—

the Connecticut DDDS. It should not be held against Dr. Goyal’s opinion. However, the ALJ 

provided another reason why he discredited Dr. Goyal’s opinions: “These opinions are not based 

on observations but are rather based on the claimant’s subjective reports.” (R. at 153.) In fact, 

Dr. Goyal himself wrote: “All answers were provided by the [patient] to above questions.” (R. at 

910.) Dr. Goyal did not write anything else in the comments section, including why he marked 

“obvious” and “slight” problems. Accordingly, the ALJ had an appropriate basis to provide 

controlling weight to Dr. Goyal’s opinion, and the Court declines to remand on this point. 

 However, “[i]f an ALJ does not give a treating physician's opinion controlling weight, the 

regulations require the ALJ to consider the length, nature, and extent of the treatment 

relationship, frequency of examination, the physician’s specialty, the types of tests performed, 

and the consistency and supportability of the physician’s opinion.” Moss, 555 F.3d at 561 

(citation omitted). It may very well be that “many of these considerations favor crediting [Dr. 

Goyal’s] assessment: [Dr. Goyal] is a psychiatrist (not a psychologist), []he saw [the Plaintiff] on 
14 

a monthly basis, and the treatment relationship lasted for over a year. It is not apparent that the 

ALJ considered any of these factors. Based on these shortcomings,” the Court concludes that the 

ALJ’s consideration of Dr. Goyal’s evaluation is unsatisfactory and requires remand. Scott, 647 

F.3d at 740. 

CONCLUSION 

 For the reasons stated above, the Court REVERSES the Commissioner’s decision and 

REMANDS to the ALJ for further proceedings consistent with this Opinion. 

 SO ORDERED on September 8, 2017. 

 s/ Theresa L. Springmann 

 CHIEF JUDGE THERESA L. SPRINGMANN 

 UNITED STATES DISTRICT COURT