VICP Registry Case Source Bundle
Canonical URL: https://vicp-registry.org/case/USCOURTS-cofc-1_21-vv-00107
Package ID: USCOURTS-cofc-1_21-vv-00107
Petitioner: Fanny Rivera
Filed: 2021-01-05
Decided: 2024-07-23
Vaccine: Tdap
Vaccination date: 2019-12-15
Condition: Shoulder Injury Related to Vaccine Administration (SIRVA)
Outcome: compensated
Award amount USD: 51688

AI-assisted case summary:
Fanny Rivera filed a petition for compensation under the National Vaccine Injury Compensation Program, alleging she suffered a Shoulder Injury Related to Vaccine Administration (SIRVA) after receiving a Tdap vaccination on or about December 15, 2019. She claimed the SIRVA occurred within the Table's timeframe and that she experienced residual effects for more than six months. Respondent denied that Rivera sustained a SIRVA Table injury, denied that the vaccine caused her injury, and denied that her condition was a sequela of a vaccine-related injury. Despite these denials, the parties filed a joint stipulation agreeing that a decision should be entered awarding compensation. The Chief Special Master adopted the stipulation, awarding Rivera a lump sum of $50,000.00 for all damages and an additional $1,687.99 to reimburse a Medicaid lien for services rendered by the Commonwealth of Pennsylvania. This award represents a settlement of liability and damages.

Theory of causation field:
Table

Public staged source text:

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DOCUMENT 1: USCOURTS-cofc-1_21-vv-00107-0
Date issued/filed: 2024-07-23
Pages: 8
Docket text: PUBLIC DECISION (Originally filed: 06/20/2024) regarding 41 DECISION Stipulation/Proffer. Signed by Chief Special Master Brian H. Corcoran. (tlf) Service on parties made.
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Case 1:21-vv-00107-UNJ Document 45 Filed 07/23/24 Page 1 of 8
In the United States Court of Federal Claims
OFFICE OF SPECIAL MASTERS
No. 21-107V
FANNY RIVERA, Chief Special Master Corcoran
Petitioner, Filed: June 20, 2024
v.
SECRETARY OF HEALTH AND
HUMAN SERVICES,
Respondent.
Jeffrey S. Pop, Jeffrey S. Pop & Associates, Beverly Hills, CA, for Petitioner.
Felicia Langel, U.S. Department of Justice, Washington, DC, for Respondent.
DECISION ON JOINT STIPULATION1
On January 5, 2021, Fanny Rivera 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 a shoulder injury related to vaccine
administration (“SIRVA”) after receiving a tetanus, diphtheria, acellular pertussis (“Tdap’)
vaccination on or about December 15, 2019. Petition at 1; Stipulation, filed at June 18,
2024, ¶¶ 2-4. Petitioner further alleges she sustained the SIRVA within the time period
set forth in the Table and that she experienced the residual effects of her alleged injury
for more than six months. Stipulation at ¶¶ 4. “Respondent denies that petitioner
sustained a SIRVA Table injury; denies that the Tdap vaccine caused petitioner’s alleged
shoulder injury, or any other injury or condition; and denies that her current condition is a
sequela of a vaccine-related injury. ” Stipulation at ¶ 6.
1 Because this Decision contains a reasoned explanation for the action taken in this case, it must be made
publicly accessible and will be posted on the United States Court of Federal Claims' website, and/or
at https://www.govinfo.gov/app/collection/uscourts/national/cofc, in accordance with the E-Government
Act of 2002. 44 U.S.C. § 3501 note (2018) (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 (2018).

Case 1:21-vv-00107-UNJ Document 45 Filed 07/23/24 Page 2 of 8
Nevertheless, on June 18, 2024, the parties filed the attached joint stipulation,
stating that a decision should be entered awarding compensation. I find the stipulation
reasonable and adopt it as my decision awarding damages, on the terms set forth therein.
Pursuant to the terms stated in the attached Stipulation, I award the following
compensation:
1) A lump sum of $50,000.00 in the form of a check payable to Petitioner.
Stipulation at ¶ 8. This amount represents compensation for all items of
damages that would be available under Section 15(a). Id.; and
2) A lump sum of $1,687.99 in the form of a check payable jointly to
Petitioner and the Department of Human Services. Id. This amount
represents reimbursement of a Medicaid lien for services rendered to petitioner
by the Commonwealth of Pennsylvania.
I approve the requested amount for Petitioner’s compensation. In the absence of
a motion for review filed pursuant to RCFC Appendix B, the Clerk of Court is directed to
enter judgment in accordance with this decision.3
IT IS SO ORDERED.
s/Brian H. Corcoran
Brian H. Corcoran
Chief Special Master
3 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.
2

Case 1:21-vv-00107-UNJ Document 45 Filed 07/23/24 Page 3 of 8
IN THE UNITED ST ATES COURT OF FEDERAL CLAIMS
OFFICE OF SPECIAL MASTERS
FANNY RIVERA,
Petitioner,
v. No. 21-107V
Chief Special Master Corcoran
SECRETARY OF HEAL TH AND ECF
HUMAN SERVICES,
Respondent.
STIPULATION
The parties hereby stipulate to the following matters:
I. Fanny Rivera ("petitioner''), filed a petition for vaccine compensation under the
National Vaccine Injury Compensation Program, 42 U.S.C. §§ 300aa-l Oto -34 ("Vaccine
Program"). The petition seeks compensation for injuries allegedly related to petitioner's receipt
of the tetanus, diphtheria, acellular pertussis ("Tdap") vaccine, which is contained in the Vaccine
Injury Table ("Table"), 42 C.F .R. § 100.3(a).
2. Petitioner received the Tdap vaccine on or about December 15, 2019.
3. The vaccine was administered within the United States.
4. Petitioner alleges that she sustained a Shoulder Injury Related to Vaccine
Administration ("SIRVA") within the time period set forth in the Table, or in the alternative, that
her alleged injury was caused-in-fact by the Tdap vaccine. Petitioner further alleges that she
experienced the residual effects of her alleged injury for more than six months.
5. Petitioner represents that there has been no prior award or settlement of a civil action
for damages as a result of her condition.

Case 1:21-vv-00107-UNJ Document 45 Filed 07/23/24 Page 4 of 8
6. Respondent denies that petitioner sustained a SIRVA Table injury; denies that the
Tdap vaccine caused petitioner's alleged shoulder injury, or any other injury or condition; and
denies that her current condition is a sequela of a vaccine-related injury.
7. Maintaining their above-stated positions, the parties nevertheless now agree that the
issues between them shall be settled, and that a decision should be entered awarding the
compensation described in paragraph 8 of this Stipulation.
8. As soon as practicable after entry of judgment reflecting a decision consistent with the
terms of this Stipulation, and after petitioner has filed an election to receive compensation
pursuant to 42 U .S.C. § 300aa-2 I (a)( I), the Secretary of Health and Human Services will issue
the following vaccine compensation payments:
a. A lump sum of $50,000.00 in the form of a check payable to petitioner; and
b. A lump sum of$1,687.991 representing reimbursement ofa Medicaid lien for services
rendered to petitioner by the Commonwealth of Pennsylvania, in the form of a check
payable jointly to petitioner and Department of Human Services.
Petitioner agrees to endorse this check to the Department of Human Services and mail
it to:
Department of Human Services
ATTN: Gregory Martin
Re: CIS #590166516
Bureau of Program Integrity
Commonwealth Towers
303 Walnut Street, 7th Floor
Harrisburg, PA 17101
1 This amount represents full satisfaction of any right of subrogation, assignment, claim, lien, or
cause of action the Commonwealth of Pennsylvania may have against any individual as a result
of any Medicaid payments the Commonwealth of Pennsylvania has made to or on behalf of
petitioner as a result of her alleged injury relating to a vaccine administered on December 15,
2019 under Title XIX of the Social Security Act, see 42 U.S.C. § 300aa-15(g), (h).
2

Case 1:21-vv-00107-UNJ Document 45 Filed 07/23/24 Page 5 of 8
These amounts represent compensation for all damages that would be available
under 42 U.S.C. § 300aa-l 5{a).
9. As soon as practicable after the entry of judgment on entitlement in this case, and after
petitioner has filed both a proper and timely election to receive compensation pursuant to
42 U.S.C. § 300aa-21(a)(l) and an application, the parties will submit to further proceedings
before the special master to award reasonable attorneys' fees and costs incurred in proceeding
upon this petition.
I 0. Petitioner and her attorney represent that they have identified to respondent all
known sources of payment for items or services for which the Vaccine Program is not primarily
liable under 42 U.S.C. § 300aa-l 5(g), including State compensation programs, insurance
policies, Federal or State health benefits programs (other than Title XIX of the Social Security
Act), or entities that provide health services on a pre-paid basis.
11. Payments made pursuant to paragraph 8 of this Stipulation, and any amount awarded
pursuant to paragraph 9, will be made in accordance with 42 U.S.C. § 300aa-l 5(i) and subject to
the availability of sufficient statutory funds.
12. The parties and their attorneys further agree and stipulate that, except for any award
for attorneys' fees and litigation costs and past unreimbursable expenses, the money provided
pursuant to this Stipulation will be used solely for the benefit of petitioner as contemplated by a
strict construction of 42 U.S.C. § 300aa-l S(a) and (d), and subject to the conditions of 42 U.S.C.
§ 300aa-I 5(g) and (h).
13. In return for the payments described in paragraph 8, and any amount awarded
pursuant to paragraph 9, petitioner, in her individual capacity and on behalf of her heirs,
executors, administrators, successors, and/or assigns, does forever irrevocably and
3

Case 1:21-vv-00107-UNJ Document 45 Filed 07/23/24 Page 6 of 8
unconditionally release, acquit, and discharge the United States and the Secretary of Health and
Human Services from any and all actions or causes of action (including agreements, judgments,
claims, damages, loss of services, expenses, and all demands of whatever kind or nature) that
have been brought, could have been brought, or could be timely brought in the Court of Federal
Claims under the Vaccine Program on account of, or in any way growing out of, any and all
known or unknown, suspected or unsuspected personal injuries to, or death of, petitioner
resulting from, or alleged to have resulted from, the Tdap vaccine administered on or about
December 15, 2019, as alleged by petitioner in a petition for vaccine compensation filed on or
about January 5, 2021, and as amended by petitioner on May 20, 202 I, in the United States
Court of Federal Claims as petition No. 2l-107V.
14. If petitioner should die prior to entry ofj udgment, this agreement shall be voidable
upon proper notice to the Court of Federal Claims on behalf of either or both of the parties.
15. If the special master fails to issue a decision in complete conformity with the terms
of this Stipulation, or if the Court of Federal Claims fails to enter judgment in conformity with a
decision that is in complete conformity with the terms of this Stipulation, then the parties'
settlement and this Stipulation shall be voidable at the sole discretion of either party.
16. This Stipulation expresses a full and complete negotiated settlement of liability and
damages claimed under the National Childhood Vaccine Injury Act of 1986, as amended, except
as otherwise noted in paragraph 9 above. There is absolutely no agreement on the part of the
parties hereto to make any payment, or do any act or thing, other than is herein expressly stated
and clearly agreed to. The parties further agree and understand that the award described in this
Stipulation may reflect a compromise of the parties' respective positions as to liability and/or
4

Case 1:21-vv-00107-UNJ Document 45 Filed 07/23/24 Page 7 of 8
amount of damages, and, further, that a change in the nature of the injury or condition, or in the
items of compensation sought, is not grounds to modify or revise this agreement.
17. This Stipulation shall not be construed as an admission by the United States or the
Secretary of Health and Human Services that petitioner sustained a SIRVA Table injury; that the
Tdap vaccine caused any other injury or condition; or that her current condition is a sequela of a
vaccine-related injury.
I 8. All rights and obligations of petitioner hereunder shall apply equally to petitioner's
heirs, executors, administrators, successors, and/or assigns.
END OF STIPULATION
5

Case 1:21-vv-00107-UNJ Document 45 Filed 07/23/24 Page 8 of 8
Respectfully submitted,
PETITIONER:
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ATIORNEYOFRECORDFOR
AUTHORIZED REPRESENTATIVE
PETJTIONER:
OF TIIE ATTORNEY GENERAL:
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JEFFREY S. POP & ASSOCIATES Deputy Director
91 SO Wilshire Boulevard, Suite 241 Torts Branch
Beverly Hills, CA 90212
Civil Division
jpop@popJawyer.com
U.S. Department of Justice
P.O. Box 146
Benjamin Franklin Station
Washington, D.C. 20044-0146
AUTHORIZED REPRESENTATIVE ATIORNEYOFRECORDFOR
OF THE SECRETARY OF HEALTH RESPONDENT:
AND HUMAN SERVICES:
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Je Olgltally signed by Jeffrey
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CDR GEORGE REED GRJMES, MD, MPH FELICIA D:·tANGEL
Director, Division of Injwy Trial Attorney
Compensation Programs Torts Branch
Health Systems Bureau Civil Division
Health Resources and Services U.S. Department of Justice
Administration P.O. Box 146
U.S. Department of Health Benjamin Franklin Station
and Hwnan Services Washington, D.C. 20044-0146
5600 Fishers Lane, 08W-25A felicia.d.langcl@usdoj.gov
Rockville, MD 20857
6