Court Opinion

ID: 9297154
Source: CourtListenerOpinion
Date Created: 2022-11-29 21:03:47.785597+00
Date Added: 2024-06-11T17:13:24.359068
License: Public Domain

In the United States Court of Federal Claims
                              OFFICE OF SPECIAL MASTERS
                                  Filed: November 4, 2022

*************************
STACY GINN and JENNIFER GINN, *
parents of R.G., a minor,     *                      PUBLISHED
                              *
              Petitioners,    *                      No. 16-1466V
                              *
v.                            *                      Special Master Nora Beth Dorsey
                              *
SECRETARY OF HEALTH           *                      Ruling Awarding Pain and Suffering
AND HUMAN SERVICES,           *                      Damages; Health Insurance; Febrile
                              *                      Seizures; Epilepsy.
              Respondent.     *
                              *
*************************

Ronald Craig Homer, Conway Homer, P.C., Boston, MA, for Petitioners.
Felicia Langel, U.S. Department of Justice, Washington, DC, for Respondent.

                             RULING AWARDING DAMAGES1

       On November 7, 2016, Stacy Ginn and Jennifer Ginn (“Petitioners”), as parents of R.G.,
a minor, filed a petition for compensation under the National Vaccine Injury Compensation
Program (“Vaccine Act” or “the Program”), 42 U.S.C. § 300aa-10 et seq. (2012).2 Petitioners
alleged that R.G. suffered from epilepsy as the result of diphtheria-tetanus-acellular-pertussis
(“DTaP”), inactivated polio (“IPV”), haemophilus influenzae type b (“Hib”), measles-mumps-

1 Because this Ruling contains a reasoned explanation for the action in this case, the undersigned
is required to post it on the United States Court of Federal Claims’ website in accordance with
the E-Government Act of 2002. 44 U.S.C. § 3501 note (2012) (Federal Management an d
Promotion of Electronic Government Services). This means the Ruling will be available to
anyone with access to the Internet. In accordance with Vaccine Rule 18(b), Petitioner has 14
days to identify and move to redact medical or other information, the disclosure of which would
constitute an unwarranted invasion of privacy. If, upon review, the undersigned agrees that the
identified material fits within this definition, the undersigned will redact such material from
public access.

2The National Vaccine Injury Compensation Program is set forth in Part 2 of the National
Childhood Vaccine Injury Act of 1986, Pub. L. No. 99-660, 100 Stat. 3755, codified as amended,
42 U.S.C. §§ 300aa-10 to -34 (2012). All citations in this Ruling to individual sections of the
Vaccine Act are to 42 U.S.C. § 300aa.
rubella (“MMR”), and influenza (“flu”) vaccines administered on November 15, 2013. Petition
at 1 (ECF No. 1). On March 26, 2021, a Ruling on Entitlement issued, finding Petitioners
entitled to compensation. Ruling on Entitlement dated Mar. 26, 2021 (ECF No. 113).

        Since the Ruling on Entitlement issued, the parties have worked to resolve all relevant
items of damages but reached an impasse on future medical costs as well as the appropriate
amount for pain and suffering. Regarding future medical costs, the parties disagree about
whether R.G. should receive compensation for health insurance premiums versus the actual cost
for his projected future medical and health care needs.

        After consideration of the evidence, and for the reasons described below, the undersigned
finds that Petitioners are entitled to receive an award that includes the cost of health insurance
until R.G. reaches the age of 22. In addition, Petitioners are awarded actual pain and suffering in
the amount of $200,000.00 for R.G., and an award for future pain and suffering in the amount of
$5,000.00 per year, reduced to net present value, until R.G. reaches the age of 22.

I.     RELEVANT PROCEDURAL HISTORY

        An entitlement hearing was held on September 15, 2020, and the Ruling on Entitlement
issued on March 26, 2021. Since then, the case has been in the damages phase. Damages Order
dated Mar. 26, 2021 (ECF No. 114). The parties obtained respective life care planners and
worked to resolve all outstanding items of damages. On March 30, 2022, the parties filed a joint
status report in which they summarized the items of damages the parties agreed to, as well as
identified the disputed items. Joint Status Report, filed Mar. 30, 2022 (ECF No. 149). Because
the parties reached an impasse as to certain items of damages, they submitted those to the
undersigned for resolution.

        Petitioners filed their memorandum in support of damages on May 2, 2022. Petitioners’
Memorandum in Support of Damages (“Pet. Mem.”), filed May 2, 2022 (ECF No. 154).
Respondent filed his damages brief on May 31, 2022. Respondent’s Damages Brief (“Resp.
Br.”), filed May 31, 2022 (ECF No. 155). On August 31, 2022, Petitioners filed a supplement
brief. Petitioners’ Supplemental Damages Brief (“Pet. Supp. Br.”), filed Aug. 31, 2022 (ECF
No. 157). On October 19, 2022, Respondent filed a status report updating the Court on the
parties’ agreement as to Petitioners’ unreimbursed expenses of $22,072.33.00. Resp. Status
Report, filed Oct. 19, 2022 (ECF No. 159).

       The disputed items of damages are now ripe for adjudication.

II.    ISSUES IN DISPUTE

        In their joint status report dated March 30, 2022, the parties identified the damages items
in dispute, including pain and suffering and future medical needs. Joint Status Report, filed Mar.
30, 2022 at 2. An updated Life Care Plan was also filed, with the parties’ consolidated
recommendations for each item and identifying the items in dispute. Pet. Exhibit (“Ex.”) 35.
The two most significant disagreements are the amount of an appropriate award for past and

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future pain and suffering and whether health insurance should be awarded to cover the costs of
R.G.’s future medical and health care needs.

III.     SUMMARY OF RELEVANT MEDICAL RECORDS3

        The relevant facts are summarized in the parties’ submissions and will not be repeated
here in detail.4 A very brief chronology, however, is helpful for context.

        R.G. was born on November 11, 2009 and was healthy prior to the vaccinations at issue.
At his four-year-old well child visit on November 15, 2013, he received MMR, DTaP, IPV, Hib,
and flu vaccinations. Pet. Ex. 1 at 1; Pet. Ex. 5 at 367. Later that night, R.G.’s parents heard a
strange noise and found R.G. shaking, unresponsive, and not breathing. Pet. Ex. 10 at 2. His lips
were blue. Id. They called 911, and when emergency medical services (“EMS”) arrived, they
noted that R.G. was nonresponsive except to painful stimuli. Pet. Ex. 3 at 6. R.G. was
transported by ambulance to the hospital. Pet. Ex. 10 at 2. He was seen by a physician in the
emergency department (“ED”) who noted that R.G. likely had a febrile seizure. Pet. Ex. 7 at 5.
The ED physician documented that R.G. had received vaccinations less than 24 hours before the
seizure. Id. at 4-5.

       On January 23, 2014, R.G. had a second seizure. Pet. Ex. 7 at 23. With this seizure, R.G.
had nausea and vomiting, jerking, and loss of consciousness. Id. He was taken to the ED, where
the physician noted that he had a seizure two months before, thought to be related to fever and/or
vaccinations. Id. at 24. R.G. was referred for an electroencephalogram (“EEG”). Id.

        R.G. had the EEG on January 29, 2014. Pet. Ex. 5 at 389. The EEG was abnormal,
showing an “independent foci of spike activity in the right parieto posterior temporal occipital
and left occipital regions.” Id. The findings “indicate[d] the presence of a focal potentially
epileptogenic process in these regions.” Id. at 389-90.

        R.G.’s third seizure occurred on February 24, 2014. Pet. Ex. 10 at 5; Pet. Ex. 5 at 417.
During this seizure, he experienced jerking and shaking, and his color was ashen. Pet. Ex. 5 at
417. Afterward, he was sleepy and tired. Id. Subsequently, on February 25, 2014, R.G. saw
pediatric neurologist, Dr. Castro-Reyes, who noted that R.G.’s first seizure occurred in
November with fever after receiving vaccinations. Id. at 418. Dr. Castro-Reyes diagnosed R.G.
with “[e]pilepsy with an abnormal EEG that showed multifocal spikes.” Id. at 419. She
prescribed anti-seizure medication, Trileptal. Id.

        Although R.G. began taking Trileptal in February 2014, he continued to have seizures.
His fourth seizure occurred on March 19, 2014. Pet. Ex. 5 at 462. On April 20, 2014, R.G. had a
full body seizure, and his body stiffened into a fetal position. Id. at 472. He turned blue and had
decreased breathing. Id. After the seizure, R.G. was disoriented and confused, had slurred
speech, and he remained lethargic until the following day. Id.

3   For a more complete summary, see Ruling on Entitlement at 2-5.

4   See Pet. Mem. at 3-26; Resp. Br. at 2-3.

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        His sixth seizure occurred approximately one month later, on May 8, 2014, while
sleeping. Pet. Ex. 5 at 483. Prior to having that seizure, R.G. became very clingy and asked to
be held. Id. R.G.’s father believed that his son knew that he was about to have a seizure because
of his clingy behavior. Id.

       R.G. went approximately two years without a seizure, but, on July 6, 2016, at age six, he
had a seizure lasting about 30 seconds. Pet. Ex. 12 at 6. He was lethargic and sleepy afterward.
Id. R.G. remained on anti-seizure medication and remained seizure-free for the next two years.

       However, on August 10, 2018, at age 10, R.G. had another seizure. Pet. Ex. 19 at 2. He
was found unresponsive and blue in the kitchen at the family’s home. Id. On August 3, 2020,
R.G. was seen by Dr. Tran, who recommended that R.G. remain on medication. Pet. Ex. 25 at
58. R.G. had a consult with Dr. Kuerbitz, who observed that since 2013, R.G. had experienced
11 seizures. Id. at 32. The seizures had been less frequent since he had started oxcarbazepine
300 mg twice daily. Id.

       Since 2018, R.G. had not had a seizure, but on September 27, 2021, (sixth grade) he
experienced an aura while at school. Pet. Ex. 28 at 1-2. The school nurse administered
clonazepam. Id. Afterward, R.G. became tearful and emotional. Id.

        R.G. requires a 504 plan 5 at school due to his illness. Pet. Ex. 30 at 1. He continues to
see his neurologist every six months and remains on anti-seizure medication. See generally Pet.
Ex. 5. His neurologist, Dr. Burris, opined that R.G. will require medication and neurological
follow-up for his epilepsy until he reaches age 22. Pet. Ex. 22 at 2.

IV.    LEGAL FRAMEWORK

        Relevant here, compensation awarded pursuant to the Vaccine Act shall include “[f]or
actual and projected pain and suffering and emotional distress from the vaccine -related injury, an
award not to exceed $250,000.” § 15(a)(4).

        Additionally, compensation awarded under the Program to a Petitioner for a vaccine-
related injury shall include the following:

       Actual unreimbursable expenses incurred from the date of the judgment awarding
       such expenses and reasonable projected unreimbursable expenses which —

5 Section 504 of the Rehabilitation Act of 1973 requires schools receiving federal financial
assistance to “provide to students with disabilities appropriate educational services designed to
meet the individual needs of such students to the same extent as the needs of students without
disabilities are met.” Protecting Students with Disabilities, U.S. Dep’t Educ., Off. for C.R.,
https://www2.ed.gov/about/offices/list/ocr/504faq.html#skipnav2 (last visited Oct. 26, 2022).
This may be in the form of accommodations and/or other specialized services. Qualified
students may be those who have a “physical or mental impairment that substantially limits one or
more major life activities.” Id.

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                 (i) result from the vaccine-related injury for which the [P]etitioner seeks
                 compensation,
                 (ii) have been or will be incurred by or on behalf of the person who
                 suffered such injury, and
                 (iii)(I) have been or will be for diagnosis and medical or other remedial
                 care determined to be reasonably necessary, or
                 (II) have been or will be for rehabilitation, developmental evaluation,
                 special education, vocational training and placement, case management
                 services, counseling, emotional or behavioral therapy, residential and
                 custodial care and service expenses, special equipment, related travel
                 expenses, and facilities determined to be reasonably necessary.

§ 15(a)(1)(A).

      Importantly, a petitioner bears the burden of proof with respect to each element of
compensation requested. Brewer v. Sec’y of Health & Hum. Servs., No. 93-0092V, 1996 WL
147722, at *22-23 (Fed. Cl. Spec. Mstr. Mar. 18, 1996).

       Payment of these elements of compensation is limited by § 15(g) of the Vaccine Act,
which provides that

       Payment of compensation . . . shall not be made for any item or service to the
       extent that payment has been made, or can reasonably be expected to be made,
       with respect to such item or service (1) under any State compensation program,
       under an insurance policy, or under any Federal or State health benefits program
       . . . , or (2) by an entity which provides health services on a prepaid basis.

§ 15(g).

        When Congress created the Vaccine Program, it contemplated that compensation would
be provided “quickly, easily, with certainty and generosity.” H.R. Rep. No. 908, 99 th Cong., 2d
Sess. 3 (1986), reprinted 1986 U.S.C.C.A.N. 6287, 6344.

        There is no formula for assigning a monetary value to a person’s pain and suffering and
emotional distress. I.D. v. Sec’y of Health & Hum. Servs., No. 04-1593V, 2013 WL 2448125, at
*9 (Fed. Cl. Spec. Mstr. May 14, 2013) (“Awards for emotional distress are inherently subjective
and cannot be determined by using a mathematical formula.”); Stansfield v. Sec’y of Health &
Hum. Servs., No. 93-0172V, 1996 WL 300594, at *3 (Fed. Cl. Spec. Mstr. May 22, 1996)
(“[T]he assessment of pain and suffering is inherently a subjective evaluation.”). Factors to be
considered when determining an award for pain and suffering include: (i) awareness of the
injury; (ii) severity of the injury; and (iii) duration of the suffering. I.D., 2013 WL 2448125, at
*9 (citing McAllister v. Sec’y of Health & Hum. Servs., No. 91-1037V, 1993 WL 777030, at *3
(Fed. Cl. Spec. Mstr. Mar. 26, 1993), vacated & remanded on other grounds, 70 F.3d 1240 (Fed.
Cir. 1995)).

                                                   5
        The undersigned may look to prior pain and suffering awards to aid in the resolution of
the appropriate amount of compensation for pain and suffering in this case. See, e.g., Doe 34 v.
Sec’y of Health & Hum. Servs., 87 Fed. Cl. 758, 768 (2009) (finding that “there is nothing
improper in the chief special master’s decision to refer to damages for pain and suffering
awarded in other cases as an aid in determining the proper amount of damages in this case”).
The undersigned may also rely on her experience adjudicating similar claims. Hodges v. Sec’y
of Health & Hum. Servs., 9 F.3d 958, 961 (Fed. Cir. 1993) (noting that Congress contemplated
the special masters would use their accumulated expertise in the field of vaccine injuries to judge
the merits of individual claims). Importantly, however, it must also be stressed that pain and
suffering is not determined based on a continuum. See Graves v. Sec’y of Health & Hum.
Servs., 109 Fed. Cl. 579 (2013).

        In Graves, Judge Merow rejected the special master’s approach of awarding
compensation for pain and suffering based on a spectrum from $0.00 to the statutory
$250,000.00 cap. Graves, 109 Fed. Cl. at 580. Judge Merow noted that this constituted “the
forcing of all suffering awards into a global comparative scale in which the individual
petitioner’s suffering is compared to the most extreme cases and reduced accordingly.” Id. at
589-90. Instead, Judge Merow assessed pain and suffering by looking to the record evidence,
prior pain and suffering awards within the Vaccine Program, and a survey of similar injury
claims outside of the Vaccine Program. Id. at 595.

V.     DISCUSSION

        In determining an award in this case, the undersigned does not rely on a single decision
or case, but has reviewed all of the evidence, including the medical records, testimony, expert
reports, the Life Care Plan, medical literature, and briefs submitted by the parties. The
compensation awarded is based on the particular facts and circumstances in this case, with due
consideration given to the circumstances and damages awarded in other cases cited by the
parties, and other relevant cases, as well as knowledge and experience adjudicating similar cases.

       A.      Unreimbursable Expenses

        The foundational framework for the undersigned’s ruling rests on (1) the Vaccine Act’s
language allowing compensation for unreimbursable vaccine-related expenses for medical and
other remedial care 6 that are reasonably projected and reasonably necessary; (2) R.G.’s
significant vaccine injury—epilepsy; and (3) the fact R.G. has no health insurance available
through his parents’ employment.

        Dr. Burris, one of R.G.’s treating neurologists, opined “[i]t is more likely than not” that
R.G. will require neurological follow-up, anti-convulsant medication, and EEG and MRI studies
until he reaches the age of 22. Pet. Ex. 22 at 2. The most recent EEG, done in 2019, was
abnormal, showing “epileptiform activity in the left occipital, left centrotemporal, right center,

6Relevant here, § 15(a)(1)(A) also provides for unreimbursable expenses for “counseling,
emotional or behavioral therapy.”

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and right frontal regions” indicating “focal potentially epileptogenic processes.” Id. Dr. Burris
explained R.G. will require regular neurological visits and medication therapy, EEG testing
every two to three years, and MRI testing every five years. Id. For two to three years during
R.G.’s adolescent years, Dr. Burris recommends psychological support be provided to R.G. Id.
at 3.

       The parties do not dispute that R.G. will need health care for his epilepsy. The issue is
whether the award should be for projected actual costs or health insurance to pay for health care.
R.G. currently has no health insurance. R.G.’s father, Mr. Ginn, is the primary earner, and he is
self-employed. Accordingly, there is currently no insurance in the household afforded by his
parents’ employment.

        R.G. is 12 years old, about to turn 13, and he has a significant neurological condition.
Petitioners’ life care planner, Maureen Clancy, R.N., B.S.N., C.L.C.P., recommends that the cost
of health insurance be awarded to pay for R.G.’s future medical and health care needs. In the
Life Care Plan, Ms. Clancy states that “[d]ue to the unpredictable course that an epilepsy
diagnosis can present, particularly with [an] 11 year old [], [7] it is most prudent to recommend
health insurance through age 25.” 8 Pet. Ex. 35 at 2.

       Petitioners assert that health insurance coverage is “reasonably necessary” due to the
unpredictable nature of epilepsy, especially during the ages of puberty and adolescence. Pet.
Mem. at 29. They point out that R.G. is on medication, will require periodic diagnostic tests
(EEG and MRIs), and that the cost of specialty care, when there is no health insurance, can be
variable. Id. They believe that health insurance is “the most effective way to ensure that R.G.’s
ongoing medical care relating to his epilepsy is covered.” Id.

        In support of their position, Petitioners cite an article by Gloss et al., 9 which provides
neurology practice guidelines related to tapering and discontinuing antiseizure medication in an
epileptic patient. Pet. Mem., Tab A at 3. R.G.’s medical records show that his neurologists, in
consultation with R.G.’s parents, have discussed discontinuing his anti-seizure medication, but at
present, R.G. continues to take oxcarbazepine daily. See Pet. Ex. 35 at 5.

        In Gloss et al., the authors explain that the “purpose of prescribing an antiseizure
medication (ASM) is to render patients with epilepsy seizure-free, a task that is accomplished
approximately two-thirds of the time. When seizure freedom is achieved, there is the inevitable
question of if and when ASMs should be weaned.” Pet. Mem., Tab A at 4. Further, “[e]pilepsy
is not considered resolved until a patient is seizure-free for at least 10 years and off ASM for at

7   At the time the Life Care Plan was prepared by Ms. Clancy, R.G. was 11 years old.

8 Petitioners seek health care insurance until R.G. reaches the age of 26, when “he would
reasonably be expected to have health insurance coverage . . . through his employer or
otherwise.” Pet. Mem. at 29 n.5.
9David Gloss et al., Antiseizure Medication Withdrawal in Seizure-Free Patients: Practice
Advisory Update Summary, 97 Neurology 1072 (2021).

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least the past 5 years.” Id. The authors observe that there are many factors clinicians must
consider when recommending medication withdrawal; the decision-making process is complex
and there are associated risks. Id. at 8-9. Physicians are advised to counsel their patients of
these risks, which include seizure recurrence, that seizures may become refractory to medication,
status epilepticus,10 or death. Id. at 9.

        Respondent disagrees that R.G. should receive the cost of health insurance, and instead
recommends an award for “projected actual costs.” Resp. Br. at 4. Respondent’s position is that
actual costs are “significantly more cost effective,” health insurance premiums should not be
awarded where there is a lower cost alternative, and “projected actual costs will sufficiently deal
with future contingencies.” Id. at 4-10.

        To illustrate the costs involved, Respondent provided a chart that compares the cost of
actual projected medical care to that for health insurance. Resp. Br. at 5 tbl.1. According to
Respondent, when paid through age 25, health insurance premiums would cost $109,334.16,
whereas the actual cost of projected care would be $22,041.25, making the difference between
the two options $87,292.91. Id. The difference between the two would be less if health
insurance is paid only through age 21. Id. When paid through age 21, the cost of health
insurance premiums would be $75,692.88, the actual cost of projected care would remain
$22,041.25, and thus the difference between actual cost versus the cost of health insurance would
be reduced to $53,651.63. Id.

         Respondent’s life care planner, Laura E. Fox, M.S.N., B.S.N., R.N., C.L.C.P., noted that
R.G.’s most recent seizure was in 2018, that he is on anti-seizure medication, and that he
receives routine neurology follow-ups.11 Pet. Ex. 35 at 2. Ms. Fox also noted that R.G. is in a
regular school classroom and has “a 504-seizure action plan.” Id. Regarding insurance, Ms. Fox
explained that R.G.’s parents “do not have insurance and out of pocket expenses are provided.
Per Dr. Burris[,] [] neurology follow up is recommended through age 21.” Id. While Ms. Fox
states that actual, out-of-pocket costs have been provided, she does not offer any explanation for
this approach, or opine that health insurance is not reasonable.

        In support of his position that actual costs are appropriate, Respondent cites Huber v.
Secretary of Health & Human Services, 22 Cl. Ct. 255 (1991). Resp. Br. at 6. In Huber, Judge
Wiese held that “health insurance premiums [were] a permissible item of compensation where
the insurance can help cover those medical risks for which compensation would otherwise be
allowable under the Act and where the insurance is, in fact, a lower-cost alternative to the
funding of those risks.” Huber, 22 Cl. Ct. at 257. Judge Wiese concluded that “the allowance of

10Status epilepticus is “a prolonged series of seizures without return to full consciousness
between them[,] . . . which is life-threatening.” Status Epilepticus, Dorland’s Med. Dictionary
Online, https://www.dorlandsonline.com/dorland/definition?id=108327 (last visited Oct. 26,
2022).

11Of note, however, the medical records indicate that R.G. experienced an aura in 2021 which
required the use of a secondary medication used to treat a seizure, clonazepam.

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insurance costs meeting these requirements grants no more than the statute permits and therefore
cannot be regarded as an impermissible enlargement of the Act.” Id. While the case was
remanded back to the special master to address several issues, Judge Wiese recognized that the
cost of health insurance could be an appropriate way to address the funding of medical risks—a
concept applicable to the case at hand. Id.

        The other cases cited by Respondent on the issue of health insurance do not address the
facts and circumstances presented here. The vaccinee in Moteles was an adult, and while she
had a profound neurological injury, there was no evidence that she had a seizure disorder that
required her to see a specialist for follow up care, diagnostic testing, or that medication cessation
was contemplated. Moteles v. Sec’y of Health & Hum. Servs., No. 90-644V, 1992 WL 109068,
at *8 (Cl. Ct. May 4, 1992). The central issue in her case was the significant cost of residential
care. Id.

        In De Fazio, the vaccinee was also an adult, and his seizure disorder had resolved by the
time his case was adjudicated. De Fazio v. Sec’y of Health & Hum. Servs., No. 90-3174V, 1997
WL 383142 (Fed. Cl. Spec. Mstr. June 25, 1997), aff’d sub nom. DeFazio v. Sec’y of Health &
Hum. Servs., 40 Fed. Cl. 462 (1998). The issue was whether his depressive disorder, anxiety,
and ADHD were vaccine-related injuries, and the special master found that they were not. Id. at
*14. Thus, the question about whether to award the costs of health insurance became moot. Id.

        Lastly, in Heins, the vaccinee was a child who was covered by his mother’s health
insurance. Heins ex rel. Heins v. Sec’y of Health & Hum. Servs., No. 90-819V, 1992 WL 63272
(Cl. Ct. Mar. 10, 1992). The mother was a nurse at Yale New Haven Hospital and had health
insurance through her employer. Id. at *8. In contrast, R.G. does not have health insurance
through either of his parents’ employers.

        The relevant inquiry here is whether actual costs take into account future medical risks in
a 12-year-old child who has epilepsy, takes anti-seizure medication, and whose most recent EEG
was abnormal. While he has been seizure-free for several years on medication, R.G. did
experience an aura as recently as 2021, which required secondary medication to be administered
at school. Notably, the records show that R.G.’s neurologists have discussed medication
withdrawal. Dr. Burris opined “[i]t more likely than not” that R.G. will need medical care
through age 21. Pet. Ex. 22 at 2. Based on these facts, it is reasonable to assume that at some
point in the next several years, if R.G. remains seizure-free, R.G.’s neurologist may recommend
that R.G be taken off his anti-seizure medication. The medical literature filed by Petitioners
identifies risks associated with medication cessation.12

       Respondent suggests that the Vaccine Act does not permit compensation for “speculative
treatment” or a petitioner’s “future, unforeseeable needs.” Resp. Br. at 8. But risks attendant to
seizures themselves or to medication withdrawal are not speculative or unforeseeable. While
they may be rare, the risks are known and identifiable, and neurologists are encouraged to warn

12   See Pet. Mem., Tab A.

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parents of children with epilepsy of these potential adverse consequences. Health insurance is
the most reasonable way to address these medical risks.

       Moreover, there is no way to project the cost of medical care and treatment assuming an
adverse consequence did occur. Even if there were a way to estimate such costs, Respondent’s
projected future costs do not include a line item to reflect care that would be required for any of
the known risk factors or future contingences that could occur given R.G.’s diagnosis of
epilepsy.

        One of Respondent’s objections to awarding the cost of health insurance is that it would
pay for “non-vaccine related care.” Resp. Br. at 6-7. Health insurance limited to the specific
diagnosis of epilepsy is not available. Thus, of the options available and recommended by the
parties, actual cost or health insurance, health insurance is the most reasonable under the facts
and circumstances of this case. As Judge Wiese wrote in Huber, “the compensability of the
expense is to be evaluated in light of the injury it seeks to redress.” Huber, 22 Cl. Ct. at 257.

        Further, as noted in Petitioners’ memorandum, the cost of health insurance has been
awarded in cases where the vaccinee will lose Medicaid insurance coverage due to a Vaccine Act
award. Pet. Mem. at 34-35 (citing La Veck v. Sec’y of Health & Hum. Servs., No. 14-340V,
2015 WL 9194841 (Fed. Cl. Spec. Mstr. Sept. 11, 2015); Clement v. Sec’y of Health & Hum.
Servs., No. 16-324V, 2018 WL 1835346 (Fed. Cl. Spec. Mstr. Mar. 7, 2018); Schwartz v. Sec’y
of Health & Hum. Servs., No. 18-1454V, 2021 WL 1092923 (Fed. Cl. Spec. Mstr. Feb. 17,
2021); Master v. Sec’y of Health & Hum. Servs., No. 19-0006V, 2021 WL 966870 (Fed. Cl.
Spec. Mstr. Feb. 12, 2021)). In these situations, the health insurance likely paid for “non-vaccine
related care” but was found to be reasonable.

       It is within the discretion of the Special Master to determine that health insurance
premiums are “reasonably necessary” for medical care. Based on the facts and circumstances
present here, the undersigned agrees with Petitioner that it is reasonably necessary for R.G. to
have health insurance due to his vaccine-related injury of epilepsy. The undersigned, however,
disagrees that R.G. should be awarded the cost of health insurance until he reaches the age of 26.
Dr. Burris opined that R.G. will require neurological care and treatment until the age of 22, not
26. There is no evidence that due to his epilepsy, R.G. will need ongoing medical care once he
reaches the age of 22. The undersigned, therefore, finds that the costs of health insurance shall
be awarded until R.G. reaches the age of 22.

       B.      Pain and Suffering

       Petitioners request $220,000.00 for actual (past) pain and suffering for ages four (the age
when R.G. had his first seizure) to present, a span of approximately nine years. Pet. Mem. at 39-
40. Petitioners also requests an award of $10,000.00 per year in future pain and suffering,

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reduced to net present value. Id. at 40. The statutory cap of $250,000.0013 would thus be
reached in 2025. Id.

        Petitioners argue this award would compensate R.G. for emotional stress and
dysregulation of his life. Pet. Mem. at 38. Since 2013, R.G. has suffered from 11 seizures. Id.
at 30 n.7. Petitioners note R.G.’s fear of additional seizures and explain that his independence
has been “limited by his seizure disorder” because he is “unable to bathe or swim alone.” Id.

       Respondent recommends that R.G. be awarded $180,000.00 for past and future pain and
suffering. Resp. Br. at 1. Respondent believes this is appropriate because “each of R.G.’s
seizures lasted no more than five to ten minutes, and he has no developmental delays or
cognitive issues as a result of his epilepsy.” Id. at 13.

         As described above, the factors to be considered when determining an award for pain and
suffering include awareness of the injury, severity of the injury, and duration of the suffering.
Here, awareness of the injury is not in dispute. Although R.G. was a young child when he had
his first seizure, there is no dispute that he had the ability of a child his age to be aware of his
seizure. As the parties do not disagree that R.G. had the ability to understand his injury, the
undersigned’s analysis will focus principally on the severity and duration of his injury.

         Regarding the severity and duration, R.G. has experienced seizures since the age of four,
or, for most of his life. Seizures are dramatic and terrifying events. R.G.’s records describe the
circumstances surrounding his seizures and illustrate the suffering he experienced before, during,
and after them. During his first seizure, at four years old, he experienced wheezing and shaking,
his lips turned blue, and he became unresponsive. During his second seizure, he experienced
vomiting and jerking. He experienced jerking and shaking during his third seizure, and
afterwards, he was sleepy and tired. An EEG showed abnormalities consistent with epilepsy,
and anti-seizure medication was prescribed. In 2014, R.G. had a full body seizure, his body
stiffened into a fetal position, he turned blue, and had decreased breathing. Afterwards, he was
disoriented, confused, and had slurred speech. He remained lethargic with no appetite until the
following day. Before his sixth seizure, R.G. became clingy, and asked to be held. His father
believed that his son knew he was about to have a seizure based on this behavior.

       In August 2018, after being seizure-free for over a year, R.G., then age eight, had a
seizure at home. Again, he was described as turning blue. He continued to require medication
and received a 504 plan at school. In September 2021, at age 11, he had an aura while at school.
clonazepam was administered by the school nurse. Afterwards, he was tearful.

       R.G.’s seizures resulted in loss of control of his body, rendering him unconscious. He
has experienced a seizure and an aura while at school. R.G. is unable to enjoy activities that
other children his age are able to do independently, like bathing or swimming. Dr. Burris has
recommended psychological care during his adolescent years. Although his seizures are under

13Compensation awarded pursuant to the Vaccine Act shall include an award “[f]or actual and
projected pain and suffering and emotional distress from the vaccine-related injury . . . not to
exceed $250,000.” § 15(a)(4).

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control, he has required the use of daily medications since he was four years old. R.G. will
continue to require medical care and treatment for his epilepsy until he is 22 years old.

       The parties have cited a number of cases to support their respective positions on an
appropriate award for pain and suffering, but none of these cases are factually similar. There are
other cases involving children with seizure disorders, but generally, the injuries include
encephalopathy or developmental delays. The most analogous case is one where a 12-year-old
had post-vaccination encephalitis and seizures. Bowlds v. Sec’y of Health & Hum. Servs., No.
13-956V, 2017 WL 5378090 (Fed. Cl. Spec. Mstr. Sept. 22, 2017). The child was awarded
$195,000.00 for pain and suffering. Id. at *2. Respondent contends the child in Bowlds was
seizure-free after a year. Resp. Br. at 13. While R.G. did not have encephalitis, he has
experienced seizures for a much longer duration of time than the child in Bowlds.

        In light of all of the facts and circumstances here, the undersigned finds an award of
$200,000.00 to be reasonable and appropriate for past pain and suffering, and $5 ,000.00 per year
until R.G. reaches the age of 22, to be reasonable for future pain and suffering.

       C.      Other Items of Disputed Damages

        The undersigned’s ruling with respect to health insurance renders moot several disputed
items in the Life Care Plan pertaining to future medical care, antiepileptic drug blood level
monitoring, diagnostic testing (EEG and MRI), medications, and counseling. See Pet. Ex. 35 at
1-5, 7.

       Regarding the over-the-counter medication ibuprofen, the undersigned finds that the cost
of $4.79 per year, as recommended by Respondent is reasonable, as it is consistent with the
evidence related to R.G.’s most recent episode. See Pet. Ex. 35 at 6. The undersigned also
agrees with Respondent that the cost of Tylenol is not reasonable, as it was not prescribed for
seizures, and not mentioned during the site visit. Id. Thus, the cost for Tylenol will not be
awarded.

        The undersigned finds that the costs of an Embrace 2 smart watch and the standard
package monitoring service are reasonable and awards the costs of those items until R.G. reaches
the age of 22. This is consistent with Dr. Burris’ opinion that R.G. will need medical care for his
seizure disorder through age 21. See Pet. Ex. 35 at 8.

        Petitioners also seek the cost for a seizure animal to alert R.G. and his caregivers that he
might be having a seizure. The undersigned finds the cost for an Embrace 2 smart watch and
associated monitoring service to be more reasonable as compared to the cost for an alert dog.
Moreover, during his recent aura, R.G. recognized that he could be having a seizure, and was
able to seek medical care. The need for a seizure animal is also not reasonably necessary given
R.G.’s infrequent seizures. See Pet. Ex. 35 at 7.

        Lastly, the parties dispute mileage reimbursement for transportation to various health care
visits. Pet. Ex. 35 at 9. Mileage costs to the pediatrician for routine care will not be
compensated. Mileage costs for the neurologist, and for EEGs and MRIs are to be compensated

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through age 21. Mileage for counseling will also be awarded, to reflect the number of
counseling visits recommended by Petitioners’ life care planner, since she allows for more
frequent visits during adolescence, consistent with Dr. Burris’ opinion. Id. Thus, the
undersigned finds these costs reasonably necessary.

VI.    CONCLUSION

       The undersigned awards Petitioners the cost of health insurance until R.G. reaches the
age of 22, as well as the specific items addressed above. Further, the Petitioners shall be
awarded $200,000.00 in compensation for R.G.’s actual (past) pain and suffering for ages four to
present, and $5,000.00 per year until R.G. reaches the age of 22, reduced to net present value.

       If the parties are unable to agree on the amount of the net present value of the future pain
and suffering award, the undersigned will use a one percent net discount. See Dillenbeck v.
Sec’y of Health & Hum. Servs., No. 17-428V, 2019 WL 4072069, at *15 (Fed. Cl. July 29,
2019), aff’d in part and remanded, 147 Fed. Cl. 131 (2020).

       The parties are to file a joint status report by Monday, December 5, 2022, (1)
converting the undersigned’s award of future pain and suffering to its net present value, (2)
providing an updated LCP reflecting all items of damages agreed to as well as those
awarded consistent with this Ruling, and (3) a list of all other items of damages agreed to
by the parties. Thereafter, a damages decision will issue.

       IT IS SO ORDERED.

                                                     s/Nora Beth Dorsey
                                                     Nora Beth Dorsey
                                                     Special Master

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