Court Opinion

ID: 4703166
Source: CourtListenerOpinion
Date Created: 2021-07-13 16:04:28.820615+00
Date Added: 2024-06-11T08:06:29.943338
License: Public Domain

In the United States Court of Federal Claims
                                   OFFICE OF SPECIAL MASTERS
                                           No. 19-0633V
                                          UNPUBLISHED

    T. E.,                                                      Chief Special Master Corcoran

                         Petitioner,                            Filed: May 7, 2021
    v.
                                                                Special Processing Unit (SPU);
    SECRETARY OF HEALTH AND                                     Decision Awarding Damages; Pain
    HUMAN SERVICES,                                             and Suffering; Unreimbursable
                                                                Expenses; Influenza (Flu) Vaccine;
                         Respondent.                            Shoulder Injury Related to Vaccine
                                                                Administration (SIRVA)

Carol L. Gallagher, Carol L. Gallagher, Esquire, LLC, Somers Point, NJ, for Petitioner.

James Vincent Lopez, U.S. Department of Justice, Washington, DC, for Respondent.

                                 DECISION AWARDING DAMAGES1

       On April 30, 2019, T. E. filed a petition for compensation under the National
Vaccine Injury Compensation Program, 42 U.S.C. § 300aa-10, et seq.2 (the “Vaccine
Act”). Petitioner alleges that she suffered left shoulder injuries related to vaccine
administration (“SIRVA”) as a result of an influenza (“flu”) vaccine administered on
September 28, 2018. Petition at 1. The case was assigned to the Special Processing Unit
of the Office of Special Masters.

     For the reasons described below, I find that Petitioner is entitled to an award of
damages in the amount $70,203.12, representing compensation in the amount of

1
   Because this unpublished decision contains a reasoned explanation for the action in this case, I am
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 and Promotion of Electronic
Government Services). This means the decision 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, I agree that the identified material fits within this definition, I will redact such material from
public access.
2
 National Childhood Vaccine Injury Act of 1986, Pub. L. No. 99-660, 100 Stat. 3755. Hereinafter, for ease
of citation, all section references to the Vaccine Act will be to the pertinent subparagraph of 42 U.S.C.
§ 300aa (2012).
$70,000.00 for actual pain and suffering, and $203.12 for past unreimbursable
expenses.

    I.      Relevant Procedural History

       Petitioner filed Exhibits 1-12 containing medical records and an affidavit (ECF No.
6-7). On May 28, 2020, Petitioner filed Ex. 13 (ECF No. 25). On August 3, 2020,
Respondent filed his Rule 4(c) Report conceding that Petitioner was entitled to
compensation (ECF No. 29). On August 5, 2020, a ruling on entitlement was issued, and
the parties began damages discussions (ECF Nos. 30-31).

       On August 27, 2020, Petitioner filed a status report (ECF No. 34). Petitioner
reported that the parties had reached an impasse on damages and requested guidance
on how to proceed. On October 20, 2020, a telephonic status conference was held to
discuss how to proceed regarding damages. The parties reported that they were still
trying to come to an agreement on damages, but requested that I set a schedule for
damages briefs. Scheduling Order, issued Oct. 20, 2020 (ECF No. 39).

       On January 6, 2021, Petitioner filed her damages brief (“Br.”) (ECF No. 41).
Respondent filed his brief (“Opp.”) on March 1, 2021 (ECF No. 43). Petitioner filed
additional medical records as Ex. 14 on March 2, 2021 (ECF No. 44). On March 4, 2021,
Petitioner filed a reply (“Reply”) to Respondent’s damages brief (ECF No. 46).

        On March 18, 2021, Petitioner filed a joint status report (ECF No. 48), confirming
that Petitioner sought only past pain and suffering and past unreimbursable damages,
and reported that the parties were amenable to an expedited hearing (to be held on April
30, 2021) to resolve damages. The case was set for a Motions Day slot for the end of
April (ECF No. 49).

        On April 8, 2021, a pre-hearing telephonic status conference was held. Order,
issued Apr. 8, 2021 (ECF No. 50). The parties confirmed that they were in agreement that
Petitioner was entitled to $203.123 in unreimbursed expenses, but disagreed on damages
for pain and suffering and a mattress. Id. Petitioner’s counsel stated that she had
requested but not yet received a letter of medical necessity for the mattress. Id. Counsel
were advised that they were not limited to discussing cases cited in the damages briefs.
Id. However, they were cautioned that their discussion of other cases should be limited
to information in public decisions. Id.

3
 Petitioner requested $213.00 for “incurred co-pays” in her brief. Br. at 12. However, during the April 8,
2021 conference, counsel for both parties agreed that the correct amount was $203.12 (ECF No. 50).

                                                    2
       On April 30, 2021, an expedited hearing was held to resolve damages. This written
decision memorializes the decision that I issued orally at the conclusion of the hearing.4

    II.      Legal Standard
        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.” Section 15(a)(4). Additionally, a petitioner may recover
“actual unreimbursable expenses incurred before the date of judgment award such
expenses which (i) resulted from the vaccine-related injury for which petitioner seeks
compensation, (ii) were incurred by or on behalf of the person who suffered such injury,
and (iii) were for diagnosis, medical or other remedial care, rehabilitation . . . determined
to be reasonably necessary.” Section 15(a)(1)(B). The 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).

       There is no mathematic 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) (“[a]wards 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) (“the assessment of pain and suffering is
inherently a subjective evaluation”). Factors to be considered when determining an award
for pain and suffering include: 1) awareness of the injury; 2) severity of the injury; and 3)
duration of the suffering. I.D., 2013 WL 2448125, at *9 (quoting McAllister v. Sec’y of
Health & Hum. Servs., No 91-1037V, 1993 WL 777030, at *3 (Fed. Cl. Spec. Mstr. Mar.
26, 1993), vacated and remanded on other grounds, 70 F.3d 1240 (Fed. Cir. 1995)).

       I may also consider prior pain and suffering awards to aid my 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.”). And, of course, I may rely on my own experience (along with my

4
  At the end of the hearing, I issued an oral ruling from the bench on damages in this case. That ruling is
set forth fully in the transcript from the hearing, which is yet to be filed with the case’s docket. The transcript
from the hearing is, however, fully incorporated into this Decision.

                                                        3
predecessor Chief Special Masters) adjudicating similar claims.5 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).

       Although pain and suffering in the past was often determined based on a
continuum, as Respondent argues, that practice was cast into doubt by the Court several
years ago. In Graves, Judge Merrow rejected a 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. Judge Merrow maintained that do so resulted in “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.” Graves, 109
Fed. Cl. at 590. Instead, Judge Merrow 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. Under this
alternative approach, the statutory cap merely cuts off higher pain and suffering awards
– it does not shrink the magnitude of all possible awards as falling within a spectrum that
ends at the cap.

    III.    Appropriate Compensation in this SIRVA Case

            A. Pain and Suffering

       There is no dispute about Petitioner’s awareness of her injury, leaving only severity
and duration to be considered. In determining an appropriate award, I have reviewed the
complete record in this case, as well as prior awards. My determination is based on the
specific circumstances of this case.

         Petitioner requests a pain and suffering award of $125,000.00. Br. at 12. In support
of this request, Petitioner cites a number of prior SIRVA decisions, including three in which
petitioners received pain and suffering awards exceeding $100,000.00, Cates,6 Collado,7

5
  From July 2014 until September 2015, the SPU was overseen by former Chief Special Master Vowell.
For the next four years, until September 30, 2019, all SPU cases, including the majority of SIRVA claims,
were assigned to former Chief Special Master Dorsey, now Special Master Dorsey. In early October 2019,
the majority of SPU cases were reassigned to me as the current Chief Special Master.
6
 Cates v. Sec’y of Health & Hum. Servs., No. 18-0275V, 2020 WL 3751072 (Fed. Cl. Spec. Mstr. June 5,
2020) (awarding $108,000.00 for actual pain and suffering).
7
 Collado v. Sec’y Health & Hum. Servs., No. 17-0225V, 2018 WL 3433352 (Fed. Cl. Spec. Mstr. June 6,
2018) (awarding $120,000.00 for actual pain and suffering and $772.53 for actual unreimbursable
expenses).

                                                   4
and Cabansag,8 as well as others with lower awards, Bartholomew,9 Bordelon,10 Dagen,11
Dhanoa,12 and Dirksen.13 Br. at 5-11. Petitioner’s counsel conceded at argument that the
cases cited in her brief with six-figure awards involved petitioners who underwent surgical
repair of their injuries, while she did not.

       Respondent argues that the pain and suffering award should be no more than
$55,000.00. Opp. at 1. Petitioner sustained a relatively mild injury that required less than
six months of treatment. Id. at 9. Respondent also argues that Petitioner’s injury was
conservatively managed with a cortisone injection, seven physical therapy (“PT”)
sessions, and a topical anti-inflammatory. Id. Petitioner’s case is not comparable to the
cases she cites that involved surgery. Id. Although surgery may have been discussed as
a treatment option, it never occurred, and therefore awards in which it was taken into
account are inapposite. Id. at 10. Respondent asserts that Petitioner’s case is more
comparable to Rayborn,14 Knauss,15 and Dagen – all non-surgery cases.

       A number of facts from this case suggest the pain and suffering award should not
be as high as some of Petitioner’s proposed comparable cases. Petitioner’s last treatment
for her shoulder injury was on March 25, 2019, just under six months after vaccine

8
   Cabansag v. Sec’y of Health & Hum. Servs., No. 16-475V, 2016 WL 6496277 (Fed. Cl. Spec. Mstr. Aug.
23, 2016). The public decision in this case (which was a settled matter after Respondent’s proffer) contains
little information about the petitioner’s injury or treatment, and thus details about those matters are not
included in this Decision.
9
 Bartholomew v. Sec’y of Health & Hum. Servs., No. 18-1570V, 2020 WL 3639805 (Fed. Cl. Spec. Mstr.
June 5, 2020) (awarding $67,000.00 for actual pain and suffering).
10
  Bordelon v. Sec’y of Health & Hum. Servs., No. 17-1892V, 2019 WL 2385896 (Fed. Cl. Spec. Mstr. Apr.
24, 2019) (awarding $75,000.00 for actual pain and suffering).
11
  Dagen v. Sec’y of Health & Hum. Servs., No. 18-0442V, 2019 WL 7187335 (Fed. Cl. Spec. Mstr. Nov. 6,
2019) (awarding $65,000.00 for actual pain and suffering and $2,080.14 for actual unreimbursable
expenses).
12
  Dhanoa v. Sec’y Health & Hum. Servs., No. 15-1011V, 2018 WL 1221922 (Fed. Cl. Spec. Mstr. Feb. 1,
2018) (awarding $85,000.00 for actual pain and suffering, $9,900.99 for projected pain and suffering, and
$862.15 for actual unreimbursable expenses).
13
  Dirksen v. Sec’y Health & Hum. Servs., No. 16-1461V, 2018 WL 6293201 (Fed. Cl. Spec. Mstr. Oct. 18,
2018) (awarding $85,000.00 for actual pain and suffering and $1,784.56 for actual unreimbursable
expenses).
14
  Rayborn v. Sec’y Health & Hum. Servs., No. 18-0226V, 2020 WL 5522948 (Fed. Cl. Spec. Mstr. Aug. 14,
2020) (awarding $55,000.00 for actual pain and suffering and $619.60 for actual unreimbursable expenses).
15
  Knauss v. Sec’y Health & Hum. Servs., No. 16-1372V, 2018 WL 3432906 (Fed. Cl. Spec. Mstr. May 23,
2018) (awarding $60,000.00 for actual pain and suffering and $170.00 for actual unreimbursable expenses).

                                                     5
administration.16 Ex. 4 at 40. Her affidavit, which asserts that she continued “to experience
excruciating pain” in her left shoulder and arm, is dated April 23, 2019, less than seven
months after vaccination. Ex. 2 at ¶ 27. The only record evidence documenting any
shoulder issues beyond this point is from a September 20, 2019 gynecologist
appointment where Petitioner reported “shoulder pain/decreased range of motion after flu
shot last year. May need to have surgery.” Ex. 13 at 123. It does not appear that an
examination or treatment was sought or performed at this appointment. And though
Petitioner asserts in her brief that she continued to experience significant pain fifteen
months after vaccine administration (Br. at 5), there is no evidence in the record to support
this assertion.

        From the above, I conclude there is objective, medical record evidence supporting
a finding that Petitioner’s symptoms continued for at least six months, and I credit her
affidavit a month later indicating that the pain continued for some time after. However, the
fall 2019 gynecologist record does not provide objective evidence of continuing shoulder
symptoms, nor does the record contain other objective evidence documenting symptoms
beyond seven months. Thus, I find that the preponderance of the evidence would support
a finding that Petitioner’s symptoms continued for approximately seven months.

        As to the intrusiveness of treatment and other interventions, the record establishes
that Petitioner was treated with one cortisone injection, from which she did not obtain
relief. She attended two short courses of physical therapy for a total of seven sessions.
Ex. 7.17 And she experienced mild to moderate restrictions in her range of motion and
pain with motion. Ex. 3 at 19; Ex. 7 at 5, 9, 11, 15, 20. This, plus the absence of surgery,
all further supports a slightly below-median award.

       In response, Petitioner offers an explanation for the absence of surgery. She
maintains that she did not undergo surgery due to a risk of developing adhesive capsulitis,
her history of severe anxiety, and her fear of contracting COVID. Br. at 3-4, 7, 9-10.
However, the record does not permit me to conclude that these factors were the
predominant reason she did not undergo surgery.

       First, while the record documents that surgery was discussed, it does not appear
to have been Petitioner’s physician’s recommended treatment. At her March 25, 2019
appointment with Dr. Kuntz, for example, the record states that Dr. Kuntz discussed with
her “recent literature that suggest equivalent outcomes with surgical and nonoperative
treatment, but an increased risk of developing adhesive capsulitis following surgical

16
     The first treatment for her shoulder injury was 18 days after vaccination. Ex. 5 at 10-13.
17
  Petitioner attended five PT sessions between November 8-19, 2018, Ex. 7 at 5-21, and two PT sessions
between February 18-25, 2019, Ex. 7 at 25-31.

                                                        6
treatment.” Ex. 4 at 45. This record goes on to indicate that she:

       has tried everything, but as it turns out she has not been doing her exercises
       at home. We talked about pre-simple phase I range of motion exercises and
       phase I strengthening exercises. She is agreeable to trying these at home
       on her own. She will try to cut back on some of her painful activities as well.
       Ultimately though, if she has persistent symptoms and feels that the
       potential benefits of surgery outweigh the risks, then she will return to further
       discuss surgical treatment.

       Ex. 4 at 45-46 (emphasis added). This suggests that Petitioner’s physician
recommended that she first try home exercises - and if her symptoms persisted, she could
return to discuss the risks and benefits of surgery. There are no further records
documenting evaluation or treatment of her shoulder, and no evidence that surgery was
recommended more firmly. Thus, the preponderance of the evidence reflects that surgery
was discussed only as a possible option to consider at a later time if home exercises were
unsuccessful, but not her physician’s recommended treatment.

      Second, while Petitioner documented a pre-existing anxiety and panic disorder, I
cannot conclude from the record that this condition explains her failure to undergo
surgery. The record documents that Petitioner attended 15-minute medication
management appointments at four to five month intervals. Ex. 11. It appears that only the
February 8, 2019 record includes anything about her shoulder, and indicates simply that
she hoped to avoid surgery. Ex. 11 at 21. Thus, the preponderance of the evidence would
not support a finding that Petitioner’s shoulder injury was severe enough to require
surgery, or that her pre-existing anxiety condition precluded surgery.

        The pain levels reported in Petitioner’s medical records varied greatly. Initially,
she reported pain levels ranging from 2-5. Ex. 5 at 10; 3 at 31, 39, 40. From the period of
mid-October to late November 2018, a period of approximately six weeks, Petitioner
reported pain levels in the moderate to high range for the most part. At five consultations
during this time, on October 19 and November 14, 16, 19, and 30, she reported pain at a
level of 9 or 10 on a scale of 0-10. Ex. 6 at 4, 10, 24; Ex. 7 at 5, 11, 13, During this same
period of time, on three occasions she reported mild or no pain at all, or a pain level
between 2-5 on a scale of 0-10. Ex. 7 at 9 (November 15, 2018 physical therapy (“PT”)
record indicating she felt “ok” prior to treatment and reported pain at a level of 5/10 after
treatment); 7 at 17 (November 8, 2018 PT record noting no pain prior to treatment and
mild pain after treatment); 7 at 15 (November 12, 2018 PT record noting no pain prior to
treatment and after treatment she was “numb from ice”). In February and March 2019,
Petitioner reported pain levels of 0, 10 or simply “a lot.” Ex. 7 at 28, 23; Ex. 4 at 40. The
preponderance of the evidence thus supports a finding that Petitioner’s pain levels were

                                             7
not consistently high enough to justify the pain and suffering damages component
requested by Petitioner.

        Petitioner underwent two MRIs and an ultrasound. Ex. 12. The first MRI, on
October 30, 2018, was of poor quality and showed tendinosis and minimal subacromial
subdeltoid fluid, but no rotator cuff tear. Id. at 1-2. Petitioner’s January 11, 2019
ultrasound noted a high-grade partial-thickness tear of the supraspinatus tendon at its
insertion. Ex. 12 at 3. Dr. Kuntz ordered a repeat MRI to confirm whether there was a
tear. Ex. 4 at 28. The second MRI report indicated findings of tendinopathy with partial
tears. Ex. 12 at 6. However, Dr. Kuntz reviewed the MRI and stated, “I actually do not see
any signs of a high-grade partial thickness tear.” Ex. 4 at 37.

      Overall, this case presents evidence of a mild to moderate SIRVA. After six
months, Petitioner did not seek further evaluation or treatment. I acknowledge that this
does not necessarily mean that she was completely asymptomatic by this time, but it does
suggest that she was able to manage any remaining symptoms on her own without formal
treatment.

        I find that two of the cases cited by Petitioner, Bordelon and Dagen, are the most
similar to this case, and set the appropriate range in which Petitioner’s award should fall.
In both Bordelon and Dagen, the petitioners did not require surgery, had one cortisone
injection, and underwent physical therapy. Both injuries also continued for a similar
duration -- eight months in Bordelon and seven months in Dagen, with similar ranges in
pain levels. And while the petitioners in Bordelon and Dagen obtained better results from
physical therapy, they also attended more sessions: sixteen each in Bordelon and Dagen
versus seven in this case.

       In Dagen, the petitioner was awarded $65,000.00 for pain and suffering, and in
Bordelon the award was $75,000.00. I find that a slightly higher award than Dagen is
warranted in this case, because the evidence suggests that Petitioner in this case had
less relief from her treatment. Dagen, 2019 WL 7187335, at *4. However, a slightly lower
award than Bordelon is also appropriate, as the Petitioner in that case was assessed with
potential early adhesive capsulitis and axillary nerve injury, and underwent formal
treatment for two months longer than Petitioner in this case. Bordelon, 2019 WL 2385896,
at *7-8. I therefore award Petitioner $70,000.00 for pain and suffering.

       B. Unreimbursable Expenses

      The parties agree that Petitioner is entitled to $203.12 for past unreimbursable
expenses, and I award this amount.

                                             8
      In addition, Petitioner requests $1,971.48 for a sleep number modular base
mattress set. Br. at 12. Petitioner’s brief asserts that this “better enables her to release
pressure on her shoulder while sleeping.” Id.

     Respondent argues that this expense should not be reimbursed. Opp. at 15.
Respondent asserts:

           Petitioner references no medical opinion recommending she purchase a
           sleep number bed. Petitioner does not cite reports made to her medical
           provider regarding an inability to sleep, which coincided with the purchasing
           of this mattress. Absent evidence showing that the purchasing of this bed is
           ‘reasonably necessary,’ as required by Section 15(a)(1)(A) of the Vaccine
           Act, compensation for this bed is not warranted.

Opp. at 15.

       I find that an expense of this type could, conceivably, be eligible for reimbursement
under Section 15(a)(1)(A). Certainly it is in the ballpark of reasonability. However, in this
case, Petitioner has not provided objective corroboration as to the need for the bed, such
as a doctor’s recommendation, or the amount of the expense. Due to the absence of
substantiating evidence, this expense is denied.

     IV.      Conclusion

       For all of the reasons discussed above and based on consideration of the record
as a whole, I find that $70,000.00 represents a fair and appropriate amount of
compensation for Petitioner’s actual pain and suffering.18 I also find that Petitioner
is entitled to $203.12 in actual unreimbursable expenses.

       Based on the record as a whole and arguments of the parties, I award Petitioner
a lump sum payment of $70,203.12 in the form of a check payable to Petitioner. This
amount represents compensation for all damages that would be available under Section
15(a).

18
  Since this amount is being awarded for actual, rather than projected, pain and suffering, no reduction to
net present value is required. See § 15(f)(4)(A); Childers v. Sec’y of Health & Hum. Servs., No. 96-0194V,
1999 WL 159844, at *1 (Fed. Cl. Spec. Mstr. Mar. 5, 1999) (citing Youngblood v. Sec’y of Health & Hum.
Servs., 32 F.3d 552 (Fed. Cir. 1994)).

                                                    9
       The clerk of the court is directed to enter judgment in accordance with this
decision.19

IT IS SO ORDERED.

                                         s/Brian H. Corcoran
                                         Brian H. Corcoran
                                         Chief Special Master

19
  Pursuant to Vaccine Rule 11(a), entry of judgment can be expedited by the parties’ joint filing of notice
renouncing the right to seek review.

                                                    10