Ratzlaff v. Secretary of Health and Human Services
18-1017
| Fed. Cl. | Apr 4, 2022Background
- Petitioner Stacy Ratzlaff received a left-arm Tdap vaccination on November 15, 2016 and alleges a SIRVA (shoulder injury related to vaccine administration).
- She first sought care for shoulder pain at physical therapy on November 23, 2016 (PT note ties pain to the shot but incorrectly records “shot to arm 3 days ago”); she later saw her PCP on December 14, 2016 who recorded left shoulder pain and suspected bursitis after an injection into the joint.
- Orthopedist evaluation (Dec. 5, 2017) recorded a 13-month history beginning with the Nov. 15, 2016 injection and diagnosed likely iatrogenic subacromial bursitis.
- Petitioner submitted a sworn affidavit saying the shot was painful and by the next day her shoulder was extremely painful and difficult to move; several unsworn family/friend statements corroborated rapid onset within hours to a day.
- Respondent argued onset was not shown within 48 hours (citing the PT note’s ‘‘3 days ago’’ entry and later, varying descriptions of immediate severity) and urged reliance on contemporaneous records.
- Special Master Horner held that, viewing the record as a whole, preponderant evidence supports onset within 48 hours of the November 15, 2016 vaccination; contemporaneous medical records and petitioner’s sworn statement were accorded controlling weight, while unsworn witness statements were considered but given limited weight due to potential bias and lack of cross-examination.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether petitioner’s shoulder pain began within 48 hours of the Nov. 15, 2016 Tdap | Ratzlaff: contemporaneous records plus sworn affidavit and witness statements show pain by next day | HHS: PT note reads "3 days ago" (suggesting later onset) and later records describe only typical immediate soreness; affidavits unreliable | Found: preponderant evidence supports onset within 48 hours |
| Weight of contemporaneous medical records | Ratzlaff: records attribute pain to the vaccination and support proximate onset | HHS: some contemporaneous entries contain errors/ambiguity so should be read cautiously | Found: contemporaneous records overall are persuasive and preponderate in favor of proximate onset |
| Reliance on unsworn family/friend statements | Ratzlaff: affidavits are relevant and corroborative evidence | HHS: unsworn, familial bias, inconsistent details, no cross-examination — limited reliability | Found: considered but given limited weight; would not suffice alone to overturn records |
| Need for an evidentiary hearing to resolve onset | Ratzlaff: did not request a hearing; argues record and affidavits are sufficient | HHS: inconsistencies could warrant a hearing | Found: no hearing required — the written record preponderantly establishes onset; master declined to decide entitlement beyond onset |
Key Cases Cited
- Cucuras v. Sec'y of Health & Human Servs., 993 F.2d 1525 (Fed. Cir. 1993) (contemporaneous medical records ordinarily entitled to significant weight)
- Camery v. Sec'y of Health & Human Servs., 42 Fed. Cl. 381 (1998) (lay testimony used to overcome records must be consistent, clear, cogent, and compelling)
- Andreu v. Sec'y of Health & Human Servs., 569 F.3d 1367 (Fed. Cir. 2009) (special masters may assess witness credibility when weighing testimony)
- Bradley v. Sec'y of Health & Human Servs., 991 F.2d 1570 (Fed. Cir. 1993) (credibility assessment of lay witnesses is within the special master’s purview)
- Burns v. Sec'y of Health & Human Servs., 3 F.3d 415 (Fed. Cir. 1993) (special master must make a rational determination when choosing between records and other evidence)
- La Londe v. Sec'y of Health & Human Servs., 110 Fed. Cl. 184 (2013) (special master must consider and compare medical records, testimony, and all relevant reliable evidence)
- James-Cornelius on Behalf of E. J. v. Sec'y of Health & Human Servs., 984 F.3d 1374 (Fed. Cir. 2021) (limits of lay opinion evidence on medical matters; factual lay testimony about events is admissible)
- Kreizenbeck v. Sec'y of Health & Human Servs., 945 F.3d 1362 (Fed. Cir. 2020) (record must be comprehensive and fully developed before ruling)
- Simanski v. Sec'y of Health & Human Servs., 671 F.3d 1368 (Fed. Cir. 2012) (parties must have full and fair opportunity to present and develop the record)
- Jay v. Sec'y of Health & Human Servs., 998 F.2d 979 (Fed. Cir. 1993) (same principle regarding record development and factfinding)