The following are general guidelines, which are adopted from and are intended
to be applied consistently with the Revised Settlement Program and
interpretations thereof, to be used in the submission and evaluation of a
Claim for compensation under Disease Payment Option I:
There are two ways to document a claim for Disease Payment Option I
(a) a Claimant can provide a statement or diagnosis from a physician Board-
certified in an appropriate specialty, together with the medical records upon
which that statement or diagnosis is based or
(b) a Claimant can provide the
medical records that, themselves, will enable the Claims Office to place the
Claimant on the Disease Payment Option I Schedule.
A Claimant should submit all records that contain information relevant to the
criteria for Disease Payment Option I, including
As used herein, the term "Qualified Medical Doctor" or "QMD" means a physician
who is Board-certified (not Board-eligible) in internal medicine, rheumatology
(a sub-specialty of internal medicine), neurology, neurological surgery, or
immunology who prepares the statement or diagnosis that the Claimant must file
in support of a Disease Payment Option I Claim. Only a Board-certified
physician can submit the statement or diagnosis of one of the compensable
diseases included in Disease Payment Option I.
The physician writing a statement or diagnosis of one of the compensable
diseases in Disease Payment Option I must be Board-certified in an appropriate
specialty. The type of specialty depends on the complaints and symptoms with
which a Claimant presents. A Claimant or her counsel who believes that another
specialty should appropriately be authorized to submit statements or diagnoses
for one or more of the listed diseases in Disease Payment Option I should
provide the Claims Office with sufficient information to substantiate the
The credentials of individual physicians should not be submitted because the
Claims Office can only approve medical specialties, not specific doctors.
Important information that should be submitted includes the subject matters
covered by that particular specialty examination, as well as the education and
training required for qualification. "Board-certified" means certification in
a particular medical specialty by the American Board of Medical Specialists. A
Doctor of Osteopathy can be a Qualified Medical Doctor if he or she is Board-
certified by the same Board that certifies Medical Doctors. A Doctor of
Osteopathy may also submit diagnoses or disease compensation claims so long as
his or her certification is within an appropriate specialty.
The Claims Office is authorized to determine whether physicians in other
countries have degrees or certifications that are the equivalent of those
accorded in the United States and should therefore be treated as Qualified
Medical Doctors. Physicians who believe that their credentials are the
equivalent of Board certification should submit material in support of that
belief to the Claims Office. As the Claims Office makes these decisions, the
information will be made available to all interested Claimants.
As used herein, the term "treating physician" is one who has seen, examined,
and treated the Claimant on several occasions, and not a doctor whom the
Claimant has seen only for purposes of getting an evaluation to make a claim
under this Disease Payment Option. Treating physician includes a Qualified
Medical Doctor if such Qualified Medical Doctor states that he or she has the
information necessary to form a professional opinion about the Claimant's
disability and sets forth in the statement or diagnosis (or in a supplemental
statement) the information upon which that opinion is based and the source of
As used herein, the term "documented" means that it is based on some reliable
information other than simply the Claimant's complaint or oral history. For
some symptoms, "documented" means that the physician has verified the symptom
on physical examination or through a lab test. For others, primarily those
that are entirely subjective, it can mean that the physician has performed a
physical examination and questioned the Claimant sufficiently to be able to
form a professional opinion, utilizing all that doctor's knowledge and
training, that the complaint is a valid one. (In this situation, it is
important that the physician relying on these complaints does not qualify the
diagnosis by stating that these "findings" are based solely on the patient's
history given at the time of the single visit to the Board-certified
The physician needs to feel confident in concluding that the problems do indeed exist.) "Documented" can also mean that written notations of that symptom are found several places in the Claimant's medical records. Thus, to show that a symptom is "documented," a Claimant can submit
To the extent the severity of a Claimant's disease is based on a disability
rating, as defined herein, the Claimant must submit all of the records that
the physician relied upon in making his or her disability determination. This
would include, as an example, any disability questionnaire that the Claimant
completed in order to assist in the physician's determination. A non-Board-
certified treating physician can provide a disability determination.
In preparing submissions for Disease and Disability Option 1 and in curing any
deficiencies that may be noted when the submission is processed, Claimants and
their physicians (and their counsel if applicable) should be aware that the
disability must be related to the compensable condition. That is, the pain
must be due to the Claimant's Atypical Connective Tissue Disease or Atypical
Neurological Disease. Thus, a threshold requirement in evaluating a disability
submission is whether the Claimant's qualifying symptoms are ones such as
alopecia, chronic fatigue, or loss of breast function that normally have no
A disability determination cannot be approved unless there is evidence that
the Claimant is experiencing pain from at least one of her qualifying symptoms
or unless the Claimant, in response to a deficiency determination, supplies
evidence that she has an additional qualifying symptom that does cause pain.
In addition, Claimants and their physicians (and their counsel if applicable)
should be aware that a "C" level disability requires that the pain be "regular
or recurring." Thus, if a Claimant's pain is described in her records as being
only "mild" or "slight," the disability determination will not be approved.
With respect to a claim for a "B" level disability, the claim must be based on
severe pain or an inability to do certain activities. In order to qualify,
there must be pain-producing symptoms that result in severe pain on a regular
or recurring basis. Generalized statements about "severe pain" may not be
enough. The Claims Office must be able to verify that the Atypical Connective
Tissue Disease or Atypical Neurological Disease symptoms themselves are the
cause of the severe pain.
If the "B" level disability claim is based on limitations on a Claimant's
activities, the claim submission must provide information concerning the
activities that are limited. A conclusory statement, with no information about
the Claimant and her limitations, will result in a deficiency being assigned.
The disability assessment must demonstrate a connection between the specific
activities that the Claimant can no longer perform. The disability must be due
to the compensable condition. The Claims Office must have enough information
about what the limitations are and the cause of those limitations to be able
to verify that the Claimant's condition indeed meets the requirements for a
"B" disability level.
In preparing a claim for an "A" level disability, Claimant's and their
physicians (and their counsel, if applicable) should be aware that the
definition of this assigned disability level is a difficult one to meet. A
Claimant must be unable to do any of her normal activities or only be able to
do a very few of them. In preparing a submission, it should be reviewed to
determine whether there is enough description of the Claimant's daily life and
limitations to allow a reader to know that she does indeed meet this strict
definition of total disability.
In addition, it must be clear that the Claimant's total disability is due to
the symptoms of the applicable disease or condition. Generalized statements by
the QMD that track the disease and disability language cannot replace the
responsibility of the Claims Office to review, on a detailed level, all of the
claim documentation provided. If the Breast Implant Claimant's Qualified
Medical Doctor determines that her death or total disability is clearly and
specifically caused by a disease or occurrence other than the compensable
disease, she will not be eligible for compensation in Severity/Disability
1. This category will provide compensation for Breast Implant Claimants
experiencing symptoms that are commonly found in autoimmune or rheumatic
diseases but which are not otherwise classified in any of the other
compensable disease categories. This category does not include individuals who
have been diagnosed with classical rheumatoid arthritis in accordance with ACR
criteria, but will include individuals diagnosed with undifferentiated
connective tissue disease (UCTD). However, such inclusion is not intended to
exclude from this category persons who do not meet the definition of UCTD, it
being intended that individuals not meeting the classic definitions of UCTD
will be compensated pursuant to the provisions contained herein relative to
ACTD, ARS, and NAC.
2. As with other individuals who fit within this disease compensation program,
the fact that a breast implant recipient has been in the past mis-diagnosed
with classic rheumatoid arthritis or the fact that the symptoms of classic
rheumatoid arthritis may coexist with other symptoms will not exclude the
individual from compensation herein. Persons who meet the criteria below and
may have a diagnosis of atypical rheumatoid arthritis will not be excluded
from compensation under this category.
3. Eligibility criteria and compensation levels for eligible Breast Implant
Claimants are set forth below in the Compensation Categories, which classify
individuals in accordance with the following groups of symptoms. If the Breast
Implant Claimant's Qualified Medical Doctor determines that a symptom is
clearly and specifically caused by a source other than breast implants, that
symptom will not be utilized in the diagnosis of Atypical Connective Tissue
Disease/Atypical Rheumatic Syndrome unless the Claims Office determines that
other submissions indicate that the symptom should be utilized. A symptom that
may be caused only in part by a source other than breast implants is not
excluded from such utilization.
4. A diagnosis of ACTD, ARS, or NAC must satisfy one of the following sets of
5. Symptom Groupings:
(a) Group I Signs and Symptoms:
(b) Group II Signs and Symptoms:
proximal or distal muscle weakness (loss of muscle strength in extremities or weakness of ankles, hands, or foot drop)
(c) Group III Signs and Symptoms:
C or 20% = $10,000 w/premium (if you believe tooth fairy; $12,000)
B or 25% = $20,000 ( " " $24,000)
A or 100% = $50,000 ( " " $60,000)
1. A diagnosis of Atypical Neurological Disease Syndrome (ANDS) shall be based upon the clinical findings and laboratory tests set forth below. The clinical and laboratory presentation of these neurological syndromes will have an atypical presentation from the natural disease and will also have additional neuromuscular, rheumatological or nonspecific autoimmune signs and symptoms.
2. Eligibility for Atypical Neurological Disease Syndrome requires both:
3. An individual will fit into this category if her primary symptoms are characteristic of a neurological disease as diagnosed by a Board-certified neurologist or by a physician Board-certified in internal medicine.
4. If the individual's Qualified Medical Doctor determines that a symptom is clearly and specifically caused by a source other than breast implants, that symptom will not be utilized in the diagnosis of Atypical Neurological Disease Syndrome unless the Claims Office determines that other submissions indicate that the symptom should be utilized. A symptom that may be caused only in part by a source other than breast implants is not excluded from such utilization.
5. Neurological disease types: Polyneuropathies.
This disease category requires either
Plus one or more of the following:
Disease of Neuromuscular Junction. This disease category requires either (1) a diagnosis of Myasthenia Gravis or Myasthenia Gravis-like syndrome or disorders of the NMJ, made by a Board-certified neurologist and confirmed by abnormal EMG showing typical findings of decrement on repetitive stimulation testing and/or elevated acetylcholine receptor antibodies or (2) submission of sufficient evidence of, and the required findings confirming, such condition.
6. Severity/Disability Compensation Categories.
The compensation level for ANDS will be based on the degree to which the individual is "disabled" by the condition, as the individual's treating physician determines in accordance with the following guidelines. The determination of disability under these guidelines will be based on the cumulative effect of the symptoms on the individual's ability to perform her vocational,
In evaluating the effect of the individual's symptoms, the treating physicians will take into account the level of pain and fatigue resulting from the symptoms. The disability percentages appearing below are not intended to be applied with numerical precision, but are, instead, intended to serve as a guideline for the physician in the exercise of his or her professional judgment.
A. Death or total disability due to the compensable condition. An individual shall be considered totally disabled if she demonstrates a functional capacity adequate to consistently perform none or only few of the usual duties or activities of vocation or self-care.
B. A Breast Implant Claimant will be eligible for category B compensation if she is 35 percent disabled due to the compensable condition. An individual shall be considered 35 percent disabled if she demonstrates a loss of functional capacity which renders her unable to perform some of her usual activities of vocation, avocation, and self-care, or if she can only perform them only with regular or recurring severe pain.
C. A Breast Implant Claimant will be eligible for category C compensation if she is 20 percent disabled due to the compensable condition. An individual shall be considered 20 percent disabled if she can perform some of her usual activities of vocation, avocation, and self-care only with regular or recurring moderate pain.
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