VICP Registry Case Source Bundle
Canonical URL: https://vicp-registry.org/case/USCOURTS-cofc-1_21-vv-00677
Package ID: USCOURTS-cofc-1_21-vv-00677
Petitioner: Sandy Jubran
Filed: 2021-01-12
Decided: 2024-12-02
Vaccine: influenza
Vaccination date: 2018-12-05
Condition: shoulder injury related to vaccine administration (SIRVA)
Outcome: entitlement_granted_pending_damages
Award amount USD: 

AI-assisted case summary:
Sandy Jubran filed a petition alleging she suffered a shoulder injury related to vaccine administration (SIRVA) after receiving an influenza vaccine on December 5, 2018. The primary issue was proving the vaccination occurred, as the direct record was missing. Petitioner provided an affidavit stating she received the flu vaccine on that date at her workplace, Memorial MRI & Diagnostic, administered by Memorial Clinical Associates, and that it hurt more than usual. A colleague, Delha Ramirez, also stated in an affidavit that MCA administered flu vaccinations to both her and Petitioner on December 5, 2018. Another colleague, Neda Moayeri, stated that on December 6, 2018, Petitioner complained of severe left shoulder pain following a vaccination the day before. Memorial MRI & Diagnostic's Clinical Manager, Anthony DeMoss, noted in an incident report that Petitioner stated she received a flu shot on December 5, 2018, and believed her shoulder pain was from it. Petitioner also consistently noted the December 5, 2018 date of vaccination with her treating physicians, Dr. Alan J. Rechter and Dr. Volkan B. Guzel, in medical records from March, April, May, and November of 2019. An employer email from December 3, 2018, confirmed flu shots would be given that week. Based on this circumstantial evidence, the Chief Special Master found it more likely than not that Petitioner received the flu vaccine on December 5, 2018. The case is proceeding to determine entitlement and damages.

Theory of causation field:
Table

Public staged source text:

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DOCUMENT 1: USCOURTS-cofc-1_21-vv-00677-0
Date issued/filed: 2024-12-02
Pages: 6
Docket text: PUBLIC ORDER/RULING (Originally filed: 10/30/2024) regarding 40 Findings of Fact & Conclusions of Law, Signed by Chief Special Master Brian H. Corcoran. (nh) Service on parties made.
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Case 1:21-vv-00677-UNJ Document 41 Filed 12/02/24 Page 1 of 6
In the United States Court of Federal Claims
OFFICE OF SPECIAL MASTERS
No. 21-0677V
SANDY JUBRAN, Chief Special Master Corcoran
Petitioner, Filed: October 30, 2024
v.
SECRETARY OF HEALTH AND
HUMAN SERVICES,
Respondent.
Sean Franks Greenwood, Greenwood Law Firm, Houston, TX, for Petitioner.
Naseem Kourosh, U.S. Department of Justice, Washington, DC, for Respondent.
FINDINGS OF FACT1
On January 12, 2021, Sandy Jubran 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 an influenza (“flu”) vaccine on December 5, 2018.
Petition at 1.
For the reasons discussed below, I find that it is more likely than not that Petitioner
received a flu vaccine on December 5, 2018, as alleged.
1 Because this Fact Ruling 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 Fact 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, 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).

Case 1:21-vv-00677-UNJ Document 41 Filed 12/02/24 Page 2 of 6
I. Relevant Procedural History
After initiating her claim, Petitioner filed the affidavit and medical records required
by the Vaccine Act. See Exs. 1 - 5, filed April 12, 2021, ECF No. 8. On the same date,
Petitioner also filed a status report indicating that she was still waiting to receive her
vaccination record. ECF No. 9. Despite her documented efforts to provide this record,
however, Petitioner later determined that it could not be found. ECF No. 23. On December
30, 2022, Respondent filed his Rule 4(c) Report opposing compensation because
“[Petitioner] has not provided a vaccination record and there is no documentation of a flu
vaccination on [December 5, 2018].” Rule 4(c) Report at 7.
In a Scheduling Order filed on April 25, 2023, I expressed the tentative view that
based on review of the existing record, a hearing would not be necessary, and that I could
issue a factual ruling regarding proof of vaccination after giving the parties an opportunity
to file briefs. ECF No. 30. Petitioner filed her brief on June 9, 2023, and Respondent filed
his response on July 13, 2023. ECF Nos. 34, 35. Petitioner filed a reply on July 20, 2023.
ECF No. 37.
II. Issue
At issue is whether Petitioner received a flu vaccine intramuscularly in her left
deltoid on December 5, 2018.
III. Authority
Pursuant to Vaccine Act Section 13(a)(1)(A), a petitioner must prove, by a
preponderance of the evidence, the matters required in the petition by Vaccine Act
Section 11(c)(1). A special master must consider, but is not bound by, any diagnosis,
conclusion, judgment, test result, report, or summary concerning the nature, causation,
and aggravation of petitioner’s injury or illness that is contained in a medical record.
Section 13(b)(1). “Medical records, in general, warrant consideration as trustworthy
evidence. The records contain information supplied to or by health professionals to
facilitate diagnosis and treatment of medical conditions. With proper treatment hanging in
the balance, accuracy has an extra premium. These records are also generally
contemporaneous to the medical events.” Cucuras v. Sec’y of Health & Hum. Servs., 993
F.2d 1525, 1528 (Fed. Cir. 1993).
Accordingly, where medical records are clear, consistent, and complete, they
should be afforded substantial weight. Lowrie v. Sec’y of Health & Hum. Servs., No. 03-
1585V, 2005 WL 6117475, at *20 (Fed. Cl. Spec. Mstr. Dec. 12, 2005). However, this is
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Case 1:21-vv-00677-UNJ Document 41 Filed 12/02/24 Page 3 of 6
not an iron-clad rule. “Written records which are, themselves, inconsistent, should be
accorded less deference than those which are internally consistent.” Murphy v. Sec’y of
Health & Hum. Servs., No. 90-882V, 1991 WL 74931, *4 (Fed. Cl. Spec. Mstr. April 25,
1991), quoted with approval in decision denying review, 23 Cl. Ct. 726, 733 (1991), aff'd
per curiam, 968 F.2d 1226 (Fed.Cir.1992)). And the Federal Circuit recently “reject[ed] as
incorrect the presumption that medical records are accurate and complete as to all the
patient’s physical conditions.” Kirby v. Sec’y of Health & Hum. Servs., 997 F.3d 1378,
1383 (Fed. Cir. 2021).
The United States Court of Federal Claims has outlined four possible explanations
for inconsistencies between contemporaneously created medical records and later
testimony: (1) a person’s failure to recount to the medical professional everything that
happened during the relevant time period; (2) the medical professional’s failure to
document everything reported to her or him; (3) a person’s faulty recollection of the events
when presenting testimony; or (4) a person’s purposeful recounting of symptoms that did
not exist. La Londe v. Sec’y of Health & Hum. Servs., 110 Fed. Cl. 184, 203-04 (2013),
aff’d, 746 F.3d 1335 (Fed. Cir. 2014).
The Court has also said that medical records may be outweighed by testimony that
is given later in time but that is “consistent, clear, cogent, and compelling.” Camery v.
Sec’y of Health & Hum. Servs., 42 Fed. Cl. 381, 391 (1998) (citing Blutstein v. Sec’y of
Health & Hum. Servs., No. 90-2808, 1998 WL 408611, at *5 (Fed. Cl. Spec. Mstr. June
30, 1998). The credibility of the individual offering such fact testimony must also be
determined. Andreu v. Sec’y of Health & Hum. Servs., 569 F.3d 1367, 1379 (Fed. Cir.
2009); Bradley v. Sec’y of Health & Hum. Servs., 991 F.2d 1570, 1575 (Fed. Cir. 1993).
A special master is obligated to fully consider and compare the medical records,
testimony, and all other “relevant and reliable evidence contained in the record.” La
Londe, 110 Fed. Cl. at 204 (citing Section 12(d)(3); Vaccine Rule 8); see also Burns v.
Sec’y of Health & Hum. Servs., 3 F.3d 415, 417 (Fed. Cir. 1993) (holding that it is within
the special master’s discretion to determine whether to afford greater weight to medical
records or to other evidence, such as oral testimony surrounding the events in question
that was given at a later date, provided that such determination is rational).
IV. Findings of Fact
I make these findings after a complete review of the record, including all medical
records, affidavits, and additional evidence filed. Specifically, I highlight the following
evidence:
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Case 1:21-vv-00677-UNJ Document 41 Filed 12/02/24 Page 4 of 6
• In a December 3, 2018 email to its employees, Memorial MRI and Diagnostic’s
human resource department stated that “[Memorial Clinical Associates] will be
here this week to give . . . employees [f]lu shots.” Ex. 9 at 2.
• In her January 8, 2020 affidavit, Petitioner represents that she received a flu
vaccine in her left arm on December 5, 2018 at Memorial MRI & Diagnostic
(“MMD”) – her place of employment – and confirms that it was administered by
Memorial Clinical Associates (“MCA”). Ex. 1 at 1.
• Petitioner also maintains that “[i]mmediately after the injection, I commented to the
nurse that this vaccination hurt more than any vaccination I previously had.” Ex. 1
at 1.
• In an affidavit dated July 6, 2021, Delha Ramirez states that “[o]n December 5,
2018, MMD contracted with [MCA] for flu vaccinations for all employees. MCA
administered flu vaccinations to both Petitioner and me.” Ex. 7 at 1.
• In a July 2, 2021 affidavit, Neda Moayeri states that “[o]n December 6, 2018,
Petitioner came into MMD complaining about severe pain in her left shoulder
following a flu vaccination she had received the day before.” Ex. 6 at 1.
• Anthony DeMoss, MMD’s Clinical Manager, completed an incident report form on
March 18, 2019 (a little more than three months post-vaccination). Ex. 10 at 1-2.
In it, he states that “[o]n 01/17/19 – [Petitioner] approached me and stated that she
had recently gotten a flu shot from MCA on 12/5/18 . . . [t]hat since then her left
shoulder hurt and she believed it was from the shot.” Id. at 1.
• Petitioner visited Dr. Alan J. Rechter at Orthopaedic Associates L.L.P. on March
26, 2019. Ex. 4 at 13-14. On the intake form, Petitioner noted that she suffered
from “[left] shoulder pain/[limited range of motion] right after flu shot injection 12-5-
18.” Id. at 15.
• Dr. Rechter’s notes from March 26, 2019 indicate that Petitioner “had a flu shot
into her left shoulder on 12/05/2018, and has had pain ever since.” Id. at 13.
• Petitioner visited Dr. Rechter for a follow-up evaluation on April 16, 2019. Ex. 4 at
12. The report states that Petitioner “had a flu shot on 12/05/2018, and she is just
not happy that she has not gotten better.” Id.
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Case 1:21-vv-00677-UNJ Document 41 Filed 12/02/24 Page 5 of 6
• On May 21, 2019, Petitioner again followed up with Dr. Rechter concerning her left
shoulder pain. Ex. 4 at 7. The medical notes indicate that her symptoms were “from
a flu shot injection that was delivered to her at work.” Id.
• On November 8, 2021, Petitioner visited Dr. Volkan B. Guzel concerning left
shoulder pain. Ex. 8 at 1-3. Petitioner stated “she received a flu vaccine that she
felt went into her skin incorrectly. She states the incident occurred in 12/2018 but
she is still having symptoms.” Id. at 1.
To prevail under the Vaccine Act a petitioner has one foundational evidentiary
obligation applicable to any claim: that she “received a vaccine set forth in the Vaccine
Injury Table.” Section 11(c)(1)(A). Additionally, when alleging a Table SIRVA injury as in
this case, a petitioner must show she received the vaccine intramuscularly in her injured
upper arm/shoulder. 42 C.F.R. § 100.3(c)(10) (2017) (Qualifications and Aids to
Interpretation for a Table SIRVA).
In many Program cases, direct proof of vaccine administration is missing. But when
presented with sufficient preponderant circumstantial evidence – such as consistent
references in contemporaneously created medical records and/or credible witness
testimony – special masters often determine that an alleged vaccination did likely occur
even without a written contemporaneous record directly memorializing the event. See,
e.g., Hinton v. Sec’y of Health & Hum. Servs., No. 16-1140V, 2018 WL 3991001, at *10-
11 (Fed. Cl. Spec. Mstr. Mar. 9, 2018); Gambo v. Sec’y of Health & Hum. Servs., No. 13-
0691V, 2014 WL 7739572, at *3-4 (Fed. Cl. Spec. Mstr. Dec. 18, 2014); Lamberti v. Sec’y
of Health & Hum. Servs., No. 99-0507V, 2007 WL 1772058, at *7 (Fed. Cl. Spec. Mstr.
May 31, 2007). Of course, not every case can succeed where such direct proof is lacking;
evidence relating to proof of vaccination has been found to be insufficient in cases where
there are inconsistencies related to Petitioner’s vaccination status and/or the events
surrounding vaccination. Matthews v. Sec’y of Health & Hum. Servs., No. 19-0414V, 2021
WL 4190265, at *6-7, 9 (Fed. Cl. Spec. Mstr. Aug. 19, 2021), aff’d, 157 Fed. Cl. 777
(2021) (petitioner’s reliance primarily on later notations of an allergic reaction).
Here, Petitioner has marshaled enough evidence for me to conclude that she more
likely than not received the flu vaccine on December 5, 2018. The records indicate that
Petitioner cited this precise date on four separate occasions, and within six months of
vaccination as well. See Ex. 4 at 15 (March 26, 2019 intake form on which Petitioner
reported a December 5, 2018 vaccination date); id. at 12-13 (March 26 and April 16, 2019
medical notes documenting Petitioner’s description of a vaccination that took place on
December 5, 2018); Ex. 10 at 1 (March 18, 2019 incident report form indicating that
Petitioner reported getting “a flu shot . . . on 12/15/12”). Moreover, the document
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Case 1:21-vv-00677-UNJ Document 41 Filed 12/02/24 Page 6 of 6
memorializing Petitioner’s March 18, 2019 appointment with Dr. Guzel indicates that
Petitioner “received a flu vaccine that . . . went into her skin incorrectly” and that “this
incident occurred in 12/2018.” Ex. 8 at 1.
Additionally, Petitioner has produced a December 3, 2018 email from her employer
stating that “MCA will be here this week to give . . . employees [f]lu shots” and witness
statements confirming that Petitioner received the vaccine in December 2018. Ex. 9 at 1;
Exs. 6, 7. Thus, even though the fact of vaccination cannot be conclusively established
with the actual vaccine administration record, the evidence convincingly preponderates
in favor of the finding.
V. Scheduling Order
In light of my findings regarding proof of vaccination, Petitioner should finalize a
reasonable demand which she should convey, along with any needed supporting
documentation, to Respondent at any time. Respondent should consider his tentative
position in this case.
Respondent shall file a status report indicating how he intends to proceed
following my Ruling by no later than Friday, December 13, 2024.
IT IS SO ORDERED.
s/Brian H. Corcoran
Brian H. Corcoran
Chief Special Master
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