VICP Registry Case Source Bundle
Canonical URL: https://vicp-registry.org/case/USCOURTS-cofc-1_23-vv-00635
Package ID: USCOURTS-cofc-1_23-vv-00635
Petitioner: Mikako Welborn
Filed: 2023-05-03
Decided: 2024-12-02
Vaccine: influenza
Vaccination date: 2021-10-20
Condition: Shoulder Injury Related to Vaccine Administration (SIRVA)
Outcome: compensated
Award amount USD: 115000

AI-assisted case summary:
On May 3, 2023, Mikako Welborn filed a petition for compensation under the National Vaccine Injury Compensation Program, alleging a Shoulder Injury Related to Vaccine Administration (SIRVA) resulting from an influenza vaccine received on October 20, 2021. Petitioner stated the vaccine was administered in the United States and that her injury lasted for more than six months. Respondent denied that the flu vaccine caused a SIRVA Table Injury or any other injury. Despite these positions, the parties filed a joint stipulation on October 29, 2024, agreeing to settle the case. Chief Special Master Brian H. Corcoran adopted the stipulation, awarding Mikako Welborn a lump sum of $115,000.00 for all damages. This amount represents compensation for all items of damages available under Section 15(a) of the Vaccine Act. Petitioner was represented by Daniel Alholm of Alholm Law PC, and Respondent was represented by Adam Nemeth Muffett of the U.S. Department of Justice.

Theory of causation field:
Petitioner Mikako Welborn received an influenza vaccine on October 20, 2021, and alleged a Shoulder Injury Related to Vaccine Administration (SIRVA) that lasted more than six months. Respondent denied that the vaccine caused a SIRVA Table Injury or any other injury. The parties filed a joint stipulation agreeing to settle the case. Chief Special Master Brian H. Corcoran adopted the stipulation, awarding Petitioner a lump sum of $115,000.00 for all damages under Section 15(a) of the Vaccine Act. The public decision does not describe the specific medical experts, clinical details of the injury, onset, symptoms, diagnostic tests, treatments, or the precise mechanism of injury. The case was settled via stipulation, and the public text does not specify if a Table theory was pursued or if the settlement reflects a compromise of liability and damages. Petitioner was represented by Daniel Alholm, and Respondent was represented by Adam Nemeth Muffett.

Public staged source text:

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DOCUMENT 1: USCOURTS-cofc-1_23-vv-00635-0
Date issued/filed: 2024-12-02
Pages: 7
Docket text: PUBLIC DECISION (Originally filed: 10/29/2024) regarding 31 DECISION Stipulation/Proffer, Signed by Chief Special Master Brian H. Corcoran. (ppa) Service on parties made.
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Case 1:23-vv-00635-UNJ Document 39 Filed 12/02/24 Page 1 of 7
In the United States Court of Federal Claims
OFFICE OF SPECIAL MASTERS
No. 23-0635V
MIKAKO WELBORN, Chief Special Master Corcoran
Petitioner, Filed: October 29, 2024
v.
SECRETARY OF HEALTH AND
HUMAN SERVICES,
Respondent.
Daniel Alholm, Alholm Law PC, Chicago, IL, for Petitioner.
Adam Nemeth Muffett, U.S. Department of Justice, Washington, DC, for Respondent.
DECISION ON JOINT STIPULATION1
On May 3, 2023, Mikako Welborn 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”) resulting from an influenza (“flu”) vaccine received on October
20, 2021. Petition at 1; Stipulation, filed October 29, 2024, at ¶¶ 2-4. Petitioner further
alleges that the flu vaccine was administered in the United States, her injury has lasted
for more than six months, and neither Petitioner, nor any other party, has ever filed any
action for Petitioner’s vaccine-related injury. Petition at ¶¶ 2, 16, 17; Stipulation at ¶¶ 3-
5. “Respondent denies that petitioner sustained a SIRVA Table Injury, denies that
petitioner’s alleged shoulder injury was caused-in-fact by the flu vaccine, and denies that
the flu vaccine caused petitioner any other injury or her current condition.” 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 1:23-vv-00635-UNJ Document 39 Filed 12/02/24 Page 2 of 7
Nevertheless, on October 29, 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:
A lump sum of $115,000.00 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.
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 1:23-vv-00635-UNJ Document 39 Filed 12/02/24 Page 3 of 7
IN THE UNITED STATES COURT OF FEDERAL CLAIMS
OFFICE OF SPECIAL MASTERS
)
MIKA KO WELBORN, )
)
Petitioner, )
) No. 23-635V (ECF)
V, ) Chief Special Master Corcoran
)
SECRETARY OF HEALT H )
AND HUMAN SERVICES. )
)
Rcspon<lcnl. )
STIPULATION
The parties hereby stipulate to the following matters:
I. Mikako Welborn. 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'!:i receipt
of the influenz<1 ("tlu") vaccine, which vaccine is contained in the Vaccine Injury Table
(''Table''), 42 C.F.R. § 100.3(a).
2. Petitioner received the Jlu vaccination in her lc!i shoulder on October 20, 2021.
3. The vaccine was administered within the United States.
4. Petitioner alleges that she suffered a Shoulder Injury Related to Vaccine
Administration (''SI RV A'') within the time period set forth in the Table, and that she experience<l
residual effects of this injury for more than six months.
5. Petitioner represents thar there has been no prior award or settlement of a civil action
for damages on her behalf as a result of her condition.

Case 1:23-vv-00635-UNJ Document 39 Filed 12/02/24 Page 4 of 7
6. Respondent denies that petitioner sustained a SIRVA Table lnjL1ry, denies that
petitioner's alleged shoulder injury was caused-in-fact by the flu vaccine, and denies that the flu
vaccine caused petitioner any other inju1y or her current condition.
7. Maintaining their above-stated positions, the parties neve1thcless 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 an entry ofj udgment 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-2l(a)(I), the Secretary of Health and Human Services will issue
the following vaccine compensation payment:
A lump sum of $11 5,000.00 in the form of a check payable to petitioner. This
amount represents 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 ofjudgrncnt 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-2 l (,1)( I), and an application, the patties will submit to further proceedings before
the special master to award reasonable attorney fees and costs incurred in proceeding upon this
petition.
I 0. Petitioner and her attorney represent that compensation to be provided pursuant to
this Stipulation is not for any items or services for which the Program is not primarily liable
under 42 U.S.C. § 300aa-l5(g), to the extent that payment has been made or can reasonably be
expected to be made under any State cClmpensation programs, insurance policies, Federal or
Stale health benefits programs (other tbau Title XIX of the Social Security Act (42 U.S.C.
§ 1396, et seq.)), or by entities that provide health services on a pre-paid basis.
2

Case 1:23-vv-00635-UNJ Document 39 Filed 12/02/24 Page 5 of 7
11. Payment made pursuant to paragraph 8 of this Stipulation, and any amounts awarded
pursuant to paragraph 9 of this Stipulation, will be made in accordance with 42 U.S.C. § 300aa-
l 5(i), subject to the availability of sufficient statutory funds.
12. The parties and their attorneys further agree and stipulate that, except for any award
for attorney foes and litigation costs, and past unrcimbursable expenses, the money provided
pursuant tu this Stipulation will be used solely for the benefit of petitioner. as contemplated by a
strict construction of 42 U. S.C. ~ 300aa-l 5(a) and (d ), and subject to the conditions of 42 U. S.C.
§ 300aa-15(g) and (h).
13. In return for the payments described in paragraphs 8 and 9, petitioner, in her
individual capacity and on behalf of her heirs, executors, administrators, successors or assigns,
docs forever irrevocably and unconditionally release, acquit and clischarge the United States and
the Sccreta1y of Health and Human Services from any and all actions, causes of action (including
agreements,judgmcnts, 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 rederal Claims, under the National Vaccine lnju1y Compensation Program, 42
U.S.C. ~ 300aa-J0, et se,,., on account of, or in any way growing out at: 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 flu vaccine administered on or about October 20, 2021, as
alleged by peliLioner in a petition for vaccine compensation filed on May 3, 2023, in the United
States Court of Federal Clairns as petition No. 23-635V.
14. If petitioner should die prior to ent1y of judgment, this agreement shall be voidable
upon proper notice lo Lhe Court on behalf of either or both of the parties.
3

Case 1:23-vv-00635-UNJ Document 39 Filed 12/02/24 Page 6 of 7
15. If the Chief 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 j1.1dgment in conformity
with a decision that is in complete conformity with the terms or 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 paragr<1ph 9 above. There is absolutely no <1greement on the part of the
parties hereto to make any payment or to do any act or thing other than is herein expressly stated
and clearly agreed to. The parties fu11bcr agree and understand that the aw;ird described in this
stipulation may reflect a compromise of the parties' respective positions as to liability and/or
<1mount or clamngcs. and fiirlher, th<1t a change in the nature or 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 Hunrnn Services that the flu vaccine caused petitioner's <1llcged shoulder
injury or any other injury.
18. All rights and obligations of petitioner hereunder shall apply equally to petitioner's
heirs, executors, administrators, successors, and/or assigns.
END OF STIPULATION
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Case 1:23-vv-00635-UNJ Document 39 Filed 12/02/24 Page 7 of 7
Respectfully submitted,
PETITIONER:
Mlkako wetbot11
Mlkako Welborn (Oct 25, 2024 09:0l PDT)
MIKAKO WELBORN
ATTORNEY OF RECORD FOR AUTHORIZED REPRESENTATIVE
PETITIONER: OF THE ATTORNEY GENERAL:
l
-..J-)J6=J-t--.u\ ~ 0c..UA ~
DANrEL G. ALHOLM HEATHER L. PEARLMAN ..
Alholm Law PC Deputy Director
150 South Wacker Drive, Suite 2400 Torts Branch
Chicago, IL 60606 Civil Division
(312) 291-4615 U.S. Department of Justice
dan@sirvainjury.com P.O. Box 146
Benjamin Franklin Station
Washington, DC 20044-0146
AUTHORIZED REPRESENTATIVE ATTORNEY OF RECORD FOR
OF THE SECRETARY OF HEALT H RESPONDENT:
AND HUMANs SE RVICES:
Jeffrey
Digitally signed by
• Jeffrey S. Beach -S
B e a C h - S 1 D 6 a : t 5 e 6 : : 2 4 0 3 2 - 4 04 .1 • 0 0 . 0 2 · 2 for ~ vvlA, A/. /VI _,~-..,\J~
CDR GEORGE REED GRlMES, MD, MPH A AMN. MUFFETT
Director, Division of Injury Trial Attorney
Compensation Programs Torts Branch
Health Systems Bureau Civil Division
Health Resources Anet Services U.S. Department of Justice
Administration P.O. Box 146
U.S. Department of Health Benjamin Franklin Station
and Human Services Washington, DC 20044-0146
5600 Fishers Lane, 08W-25A (202) 616-2895
Rockville. MD 20857 a<lam. inuffott@usdoj.gov
Dated: i 0· t q •· 2,, l-(
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