Hartman v. Secretary of Health and Human Services
19-1106
Fed. Cl.Oct 15, 2021Background:
- Petitioner Kimberly Hartman received a right deltoid influenza vaccine on October 29, 2018 and alleges a SIRVA (shoulder injury related to vaccine) with onset within 48 hours.
- She sought care starting November 26, 2018 and saw orthopedics and sports-medicine providers in December 2018 who recorded history of shoulder pain “since” or “following” the flu shot; physical therapy began January 2, 2019.
- Records document decreased range of motion, pain and weakness consistent with adhesive capsulitis/infraspinatus tendinopathy; she completed PT and later had largely improved function though intermittent anterior deltoid pain recurred with activity.
- Petitioner submitted a July 2019 affidavit asserting onset within 48 hours and lasting effects; Respondent disputed only the Table-required 48-hour onset window.
- The Chief Special Master credited the contemporaneous medical records together with the affidavit, found onset within 48 hours, held that other Table elements were satisfied (no prior shoulder pathology or alternate cause, correct arm/site, >6 months residual effects), and awarded entitlement; damages to be determined later.
Issues:
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether onset of shoulder pain occurred within 48 hours of vaccination (Table SIRVA timing) | Hartman: contemporaneous medical records state pain “since” the vaccine and her affidavit says onset within 48 hours | HHS: petitioner’s affidavit and recounting in records are insufficient alone; petitioner must show independent evidence beyond her own statements | Records from multiple providers contemporaneously reporting pain since vaccination plus affidavit were found preponderantly to support onset within 48 hours |
| Whether medical records that repeat the petitioner’s history can serve as independent corroboration | Hartman: records are trustworthy contemporaneous evidence supporting her history | HHS: records merely reflect petitioner’s statements and thus are not independent proof (invokes Lett) | Special Master distinguished Lett, applied presumption of trustworthiness for contemporaneous medical records, and found them probative when consistent and uncontradicted |
| Whether an alternative cause or preexisting shoulder pathology defeats a Table claim (e.g., MRI labral tear) | Hartman: no prior symptomatic shoulder pathology to explain injury; later imaging does not negate acute SIRVA history | HHS: MRI showed a posterior superior labral tear; not related to vaccine (raised but not pressed in briefing) | No evidence of prior symptomatic pathology or convincing alternative cause; MRI tear did not bar entitlement and was not pressed as dispositive |
| Whether petitioner satisfied all remaining Table SIRVA elements and is entitled to compensation | Hartman: met all Table elements (timing, site, no prior condition, >6 months residuals) | HHS: only contested timing; did not pursue other Table elements | Special Master found all Table requirements satisfied and awarded entitlement; damages to be determined later |
Key Cases Cited
- Cucuras v. Sec'y of Health & Human Servs., 993 F.2d 1525 (Fed. Cir. 1993) (medical records generally trustworthy and contemporaneous; accorded weight)
- Kirby v. Sec'y of Health & Human Servs., 997 F.3d 1378 (Fed. Cir. 2021) (rejects blanket presumption that medical records are complete and accurate as to all conditions)
- Camery v. Sec'y of Health & Human Servs., 42 Fed. Cl. 381 (1998) (medical records may be incomplete or inaccurate; credibility assessment required)
- La Londe v. Sec'y of Health & Human Servs., 110 Fed. Cl. 184 (2013) (identifies possible reasons for inconsistencies between records and later testimony)
- La Londe v. Sec'y of Health & Human Servs., 746 F.3d 1335 (Fed. Cir. 2014) (affirming standards for weighing records and testimony)
- Burns v. Sec'y of Health & Human Servs., 3 F.3d 415 (Fed. Cir. 1993) (special master has discretion to weigh medical records against other evidence)
- Lett v. Sec'y of Health & Human Servs., 39 Fed. Cl. 259 (1997) (when no medical record mentions an event and only petitioner’s statements exist, petitioner fails Section 13(a)(1) proof)
- James-Cornelius v. Sec'y of Health & Human Servs., 984 F.3d 1374 (Fed. Cir. 2021) (sworn testimony about facts within personal knowledge can be objective evidence bearing on factual issues)
- Andreu v. Sec'y of Health & Human Servs., 569 F.3d 1367 (Fed. Cir. 2009) (credibility of testimony and weighing of evidence are for the factfinder)
- Bradley v. Sec'y of Health & Human Servs., 991 F.2d 1570 (Fed. Cir. 1993) (discusses evaluation of evidence and testimony in Vaccine Program cases)