ORLANDO, Fla — A sudden medical issue put an Orlando couple’s lives on hold, and they believe an insurance decision is making this Tayler Gonzalez’ already tough road to recovery even harder.
“We got engaged before this, and we put off our wedding for this,” Tayler Gonzalez told Action 9 Consumer Investigator Jeff Deal.
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Gonzalez would love to get out of his specialty wheelchair and walk his fiancée, Lauren Hill, down the aisle. But as he battles a serious neurological condition, he’s also had to fight his insurance company for treatment.
The couple believes the inpatient therapy he was getting was really working and speeding up his recovery, but United Healthcare didn’t think it was enough. It denied continued inpatient coverage because it didn’t believe he was making what it called “notable continued progress.”
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32-year-old Tayler Gonzalez loves adventure; he loves to move and sweat.
He said, “I was an avid gym goer. I was healthy at sports, jump rope.”
When he asked the love of his life to marry him, their future couldn’t be brighter, but now life is different. Each movement and each moment for Tayler is a fight. The dream of marriage and children seems more distant with a diagnosis of a debilitating spinal condition.
Gonzalez recalled the conversation he had with his doctor, “Fluid in your cervical spine and Chiari malformation. And they recommended surgery as soon as possible.”
He said his condition worsened following a handful of surgeries, including an extensive one in February.
Lauren Hill said, “He had a stroke during that surgery.”
That set him on a new path starting with inpatient rehab in Jacksonville. The couple said that meant 4-hours a day working through movements. Tayler’s insurance plan with United Healthcare allows 120-days of inpatient care, but Hill quickly learned just because Gonzalez has those days, doesn’t mean he gets them. They must be approved by insurance and based on what his employer covers, and they said Gonzalez was not approved for more days. After a return home, he ended up in the emergency room and was approved for more inpatient therapy at Advent Health in Winter Park where they felt he continued to improve. Despite his belief in the progress and his lifted spirits, they said that coverage ended, too.
Hill explained, “Because he wasn’t making enough functional progress. When I asked the insurance company what that looked like, what were they looking for specifically, they couldn’t give me an answer.”
A request for coverage was denied in April for not “making notable continued progress in therapy.” A week later, their appeal was denied “because it is not medically needed” even though a neurosurgeon’s letter notes he’s “demonstrated encouraging signs of recovery” and “continues to require daily physician oversight” and “premature discharge to a lower level of care would place Tayler at significant risk.”
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Another request for coverage was denied in June.
Amber Padron with the non-profit group Patient Advocate Foundation sees all kinds of scenarios where patients are appealing coverage decisions.
“You know, one instance or diagnosis can be like changing for sure,” Padron said.
In her experience, disputes over inpatient care are rare.
She recommends, exhausting all appeals available, make each appeal as specific and as evidence-based as possible, and says to tailor responses to address the specific reason for the denial. It’s also a good idea to check with your doctor about what information they provided and about what steps they recommend you take.
Padron said, “Seeing it through all levels of appeal that you have the rights, don’t give up.”
Gonzalez and Hill are not giving up. There’s GoFundMe me page set-up for medical expenses and they are now paying out of pocket for more therapy while still looking to get coverage that they hope will give Gonzalez the boost he needs to live out their dreams.
Hill said, “I need him to walk me down the aisle.”
United Healthcare spent several weeks looking into the case after Action 9 brought Gonzalez’ concerns to their attention.
United Healthcare issued this statement:
We empathize with Mr. Gonzalez and his family during this challenging time, and we wish him continued recovery and health. Based on a thorough review of the clinical information submitted by his doctors, coverage decisions for both acute inpatient rehabilitation stays were determined to be appropriate. We remain available to help address any future coverage questions and review options.
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